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Chapter VIII

Table of Contents

CHAPTER VIII

Summary and Conclusions

It is evident from the foregoing account that a great deal of progress was made during the Vietnam conflict in learning about the causes and means of prevention and treatment of common, potentially disabling dermatoses. Successful attacks were mounted on the important cutaneous disease problems through chemoprophylaxis, protective alterations of the cutaneous environment, and secondary prevention due to earlier and more effective diagnosis and treatment. In addition, the groundwork was laid for manifold laboratory, clinical, and field studies that some day may lead to conquering the problems altogether, perhaps through such technologically sophisticated means as vaccines, long-lasting topical and systemic prophylactic medications, and protective coatings for cutaneous surfaces derived from polymers ("artificial skins").

Altogether, then, the prospect for successfully combating cutaneous infections and other common, militarily important dermatoses was vastly greater at the end of the Vietnam war than at the beginning. This was due principally to the systematic and dedicated acquisition of the information detailed in the previous chapters, which can be summarized as follows:

1. Diseases of the skin were a leading cause of outpatient visits, hospitalization, and temporary disability among U.S. Army personnel in Vietnam. Superficial fungal and bacterial skin infections were the most important diseases in terms of both incidence and disability. Infantrymen operating in wet, lowland terrain during the rainy season were at highest risk.

2. Other diseases, including miliaria, contact dermatitis, and immersion injuries of the feet, also occurred with appreciable frequency and at times were important as sources of discomfort and disability. Diseases considered exotic or distinctly tropical in nature, such as cutaneous leishmaniasis, tropical acne, and tropical ulcer, were either rare or nonexistent.

3. The most common and disabling form of superficial fungal infection was an inflammatory dermatophytosis of the body and groin caused by a zoophilic, elastase-producing griseofulvin-sensitive strain of Trichophyton mentagrophytes Trichophyton rubrum, Epidermophyton floccosum, and Candida albicans were responsible for a significant proportion of groin and toeweb infections.

4. Bacterial skin infections occurred in the form of superficial pyodermas or ecthymatous ulcers. These lesions usually were located on the


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extremities, especially the legs and feet. Both Streptococcus pyogenes and Staphylococcus aureus could be recovered from the lesions in the majority of cases. Penicillin was found to be effective in treatment despite the presence of pencillin-resistant staphylococci in the lesions.

5. The most important factors contributing to the high rates of cutaneous infection and disability were heat, humidity, wet clothing, poor hygiene, and minor trauma to the skin. Differences in degree of exposure to these factors accounted for the marked differences which existed between combat and support troops in the prevalence and severity of cutaneous infections.

6. Antibiotics such as penicillin and griseofulvin were effective in the treatment of established infections and probably accounted for the relatively low rates of prolonged disability and medical evacuation compared to the experience of U.S. military forces in the Tropics during World War II. Relapses of infection were common because few troops were willing or able to adhere to a prolonged course of oral antibiotic therapy.

7. Virtually no effective measures for preventing disabling skin diseases existed other than reducing the length of combat operations. Research and development efforts were directed against infections and immersion injuries in infantrymen; however, American participation in ground combat operations ceased before any measures were completely field tested and introduced on a theaterwide basis. Among the items partially field tested in Vietnam were silicone ointment for prevention of immersion foot, prophylactic griseofulvin for prevention of inflammatory dermatophytosis, and lightweight, fast-drying boots and socks for prevention of immersion injuries and infections of the feet.

8. Skin infections in adult Vietnamese differed significantly from those in American soldiers, even when they wore similar types of clothing and had similar exposure to wet terrain. Streptococcal pyoderma was rare in Vietnamese adults, and dermatophytosis, although common, was almost always attributable to a distinctive sporulating strain of Trichophyton rubrum. Skin infections in Vietnamese children, on the other hand, were similar to those in American adults. The reasons for these differences were not determined, but it was clear that Vietnamese combat troops did not exhibit high rates of disability from skin diseases as did their American counterparts.

Research.-The facts detailed in this monograph clearly demonstrate that sophisticated, well-designed and -executed research with immediate practical results can be conducted during wartime, even under active combat circumstances. Essential to these endeavors are dedicated, appropriately trained and motivated people encouraged by high level command commit­ments and supported by ongoing research funding. Because of the U.S. Army Medical Research and Development Command's sustained commitment to dermatologic research in the years before the Vietnam war, it was no accident that in 1967 and 1968, when combat commanders reported


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up to 50 percent of their men unavailable for duty due to dermatologic problems, the best available civilian and military talent in the country was on hand to tackle the problem and to develop solutions. It is especially significant also that civilian as well as military physicians and scientists were prepared to go to Vietnam and be effective under the most disagree­able tropical combat conditions.

Without this high state of preparedness for a contingency that later developed into the Vietnam conflict, it is extremely doubtful whether the U.S. Army could have brought the critical mass of expertise to bear on the enormous military medical problem caused by skin diseases. Research teams need time and experience to develop well-coordinated responses to future needs because the necessary expertise cannot be instantly generated in response to unexpected circumstances. These facts are especially important to military planners who, faced with shrinking budgets and de­clining numbers of personnel during peacetime, may come to regard as luxuries the ongoing research programs that are crucial to the success of any organized attempt to solve major disease problems under the pressures and exigencies of war.

Prediction.-One of the most notable contributions to military medicine of the Vietnam war was the realization that the kinds and amounts of skin diseases in military populations can be predicted on the basis of knowledge of such factors as climate, terrain, and occupationally related exposures to various environmental conditions. Although precise prediction was not possible during the war, it became readily evident that the amount of disability from cutaneous diseases was directly related to command policies, combat conditions, and leadership, as well as medical capabilities organic to the fighting units. Of greatest significance in terms of the unhoped for but nevertheless finite possibility that U.S. military forces may again be called to action in the Tropics is the type of diseases which can be expected to occur-with few exceptions, the diseases will be the fungal and bacterial infections common to most of the rest of the world, varying only in incidence and severity. Contrary to the expectations and perhaps even the hopes of newcomers and tropical disease specialists, exotic tropical skin diseases can confidently be expected to be rare and therefore of relatively little military importance, even in the heart of tropical jungles and swamps. Thus, the efforts expended in preparing to combat the skin diseases that pose the significant problems in the Tropics are also useful in preparing for contingencies worldwide.

Training and doctrine.-Experience has shown that most of the hard-won lessons arising from military conflicts can be lost if not translated into administrative and educational reforms throughout the system. In reference to skin diseases, little will have been gained from Vietnam if the lessons are not converted into doctrine. Vietnam-related improvements in diagnosing, treating, and preventing the common, militarily important skin diseases are not likely to be widely used unless they are made known


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to medical personnel. It would be a mistake to assume that only dermatologists need to have this information imparted to them, since there are never likely to be enough of these specialists to see and treat any more than a small fraction of the common dermatoses arising in a wartime situation. General duty physicians, physician's assistants, and enlisted corpsmen could be made vastly more effective by teaching them how to deal with the half dozen most common dermatoses in soldiers. There also is a need to incorporate this material in training manuals for both medical and line personnel, for rapid dissemination to the field at times when training must be abbreviated to accommodate urgent demands for combat manpower.

Medical statistics.-In conclusion, mention must be made of the medical records and statistics systems as they apply to situations where skin diseases might be a major military medical problem. Because these systems have a marked tendency to focus almost exclusively on hospitalized patients, they are likely to reveal little about classes of disease that are dealt with principally in outpatient facilities. This was so applicable in Vietnam that one high-ranking medical officer in the major command headquarters flatly stated that there were no significant skin disease problems among U.S. combat forces in 1968 and brandished a fistful of computer-printed statistics to support his assertion. His error was easy to understand by anybody who had studied the information filtering process that took place as data moved from the field to successively higher headquarters. Development of new and improved information gathering and retrieval systems suitable for outpatients would not only improve patient care, but would also greatly enhance the chances of detecting and monitoring epidemics of skin diseases in military populations. Under these circumstances, preventive medicine and public health specialists could assist in the study and control of skin diseases of epidemic potential, and thereby partly relieve dermatologists of this overly large burden of responsibility.