With a high operational tempo and the fewest personnel since the Air Force became an independent branch, airmen are increasingly stressed. It is the job of the Air Force surgeon general to monitor their health and try to improve it.

Air Force Times reporter Phillip Swarts sat down with Lt. Gen. Mark Ediger to discuss the strain on airmen, suicides, general fitness and health conditions on bases, like the mold problem at Al Udeid Air Base in Qatar. The conversation has been edited for clarity and length.

Q: What is the role of the Surgeon General's Ooffice's role in the Air Force?

Lt. Gen. Mark Ediger: Our role is to make sure that we stay in-step with the mission we are supporting and involve our medical capabilities to match that. Operations support is job one for us. In terms of our deployed medical capability, we have 683 medical airmen deployed today, at places around the world. , but mMany of them are in the CENTCOM area of operations, but also a significant number in AFRICOM.

Our primary deployable medical support comes in two forms: One is the field hospital. We call that the EMEDS,  — it stands for expeditionary medical system,  — and where we fit into the joint team with that, is that our focus is on an agile, flexible field hospital. It does not have great capacity, but our focus is on being able to get in and establish a capability quickly, and to be able to stabilize and then evacuate patients. It is adaptable to either to humanitarian assistance or combat support. In fact, it is the system that was set up in Monrovia last year, to support the Ebola crisis, and it adapted nicely to that use.

Our second main category of deployable capability is in aero-medical evacuation. We call that "en route care," and that takes the form of aero-medical evacuation crews, plus critical care transport teams. W, and we support the joint team, but oftentimes, coalition partners as well, with that capability. The nature of [the war with the Islamic State militant group] [the engagement with ISIS] means we have forces engaged in smaller packages, widely dispersed, often in places where we do not have field hospitals. That requires that we be able to provide surgical stabilization for trauma victims, often in places where there is no hospital. We do have a mobile field surgical team with that capability, and they are deployed, and providing that support. In mMany times in these scenarios, they may receive a battle casualty that they need to stabilize, and then that patient may be flown fly a great distance before reaching they reach the first hospital.

The nature of the Air Force mission is we have smaller installations at many locations, and so our military treatment facilities tend to be smaller than you would see in the Army and the Navy. Of our 75 treatment facilities, only 13 are hospitals, the rest are clinics. Of, and of those 13 hospitals, only eight are large enough to serve as deployment platforms, meaning, that we can embed EMEDS and Air EvVac crews in that hospital. Sso we fill 80 percent of our deployment taskings out of those eight hospitals.

Out of these 75 military treatment facilities, we also support the majority of our active duty families, and we think that is important to the readiness of the force. We firmly believe that the primary care support we provide to active duty families out of our facilities enables us to help Commander's support those families, particularly when they are under stress from deployment or the stress from being a young family in today's financial times, economic environment.

Q: We keep hearing airmen are stressed. What sorts of things do you look at to determine that?

A: The things we watch are certain kinds of occurrences and events that we really want to prevent. But it can show up in a variety of ways. It can show up sometimes in incidences like family member maltreatment. In can show up in substance abuse-related incidences, alcohol-related incidences. It can show up in suicide rates. In can show up in the types of care we are seeing demand for, in terms of mental health conditions. In can show up in certain physical maladies that can be aggravated by stress. So there are a variety of different indicators that we monitor.

So iIn the Air Force, every installation has something we have called a Community Action Information Board, CAIB. That is the body at an Air Force installation that monitors these kind of indicators of stress. It actually works with a community approach to try to address the sources of the stress and prevent the types of things that we prefer not to happen to our airmen and their families.

Q: What are some of the ways you can treat high-stress levels?

A: Sometimes it is through the Airman and Family Readiness Center, by providing counseling services to help with things that stress young families, often such as financial stress. Sometimes it is outreach from the mental health clinics to the units to make ourselves more accessible and to try to reduce the concerns about stigma that are sometimes associated with seeking mental health care. It can be the chaplin doing outreach or activities to help people with relationship issues. 

Sometimes it is on the mission’s side. If where if you notice that a particular unit is having some indicators of stress among the airmen, you could actually look at maybe how the mission could be adjusted. A good example of that is in the intel ops centers, where there were indicators that those airmen were having difficulty, and it was found to be subsequent to fatigue from the way their shifts and schedules were being managed. So tThe wing commander asked for a consultant to come and give them a human-performance evaluation, and that actually helped the wing commander adjust the scheduling in a way that helped those airmen balance their time on duty with their personal lives.

Q: Could you give an update on suicide prevention?

A: We’ve been very concerned about this because the Air Force suicide rates, along with the national rates, have been rising for several years. And so last year the chief and the secretary initiated a comprehensive review of suicide prevention. Historically, we’ve had a very good suicide prevention program in the Air Force that was implemented in about 1996, and it’s actually been cited nationally as one of the best evidence-based suicide prevention programs in the country. But dDespite that, we saw that, about six to seven years ago, our rates started climbing, and they have climbed steadily along with the national rates. So that was of great concern to us.

And so wWe have a number of actions in progress. I can probably best summarize it by describing it as three layers of prevention. There is the primary layer, which reaches every airman and that is really about developing a culture of airmen with strong problem-solving skills, being mutually supportive as wingmen, and engendering that through strong interaction between the supervisor and every airman. We think that layer actually will have the greatest impact, but it’s also the one with the slowest onset. It takes time to do that sort of thing.

The second layer of prevention is to focus on getting problem-solving support to those airmen who show signs of needing a little extra help in terms of just getting through the stressors, whether it’s finances, relationships, or the workplace. And tThat’s sort of a counseling and assistance activity in that layer.

And then the third layer is focused on those that we know are in distress. And tThat’s where mental health and the Air Force medicine comes in, is in terms of working with commanders to kind of put our arms around those airmen who show signs of being in distress, and helping them resolve the issues and keeping them safe until they’re improved. And so we’ve identified a number of changes in all three of those layers and those are in progress now.

Q: Is the way that you go about suicide prevention different for deployed airmen versus home stationed missions?

A: It’s really the same approach. And we know that actually suicide among deployed airmen is very, very rare. Suicide is an uncommon event across the Air Force. But among our deployed airmen, it’s particularly uncommon. And that’s been the case for years. And wWe think that’s because when airmen deploy, there’s such a strong sense of mission, and such a strong sense of their role and responsibility. And tThey know that if they’re not there tomorrow, that their wingmen, their airmen around them, are going to have to keep that mission going somehow. And so, we think tThat sense of belonging, that sense of importance to the mission in a deployed site, is probably why, one big reason why, we rarely see suicide in a deployed mission..

But the basic approach is the same, we have mental health there, commanders work to understand what the stressors are at the deployed site. Commanders there don’t have all the tools they have at home station, but we try to put the right tools there. We have chaplains there, we have mental health there, so that we can give them those essential pieces of support that they need at the community level at the deployed site.

Q: Air Force Times reported about problems with mold and other health concerns at Al Udeid Air Base. How do you deal with such health issues on bases and the challenges presented by their locations?

A: In every Air Force medical group we have … a group of individuals called bio-environmental engineers [and]  . We also have public health professionals in there. Really, tTheir primary role is to help advise commanders and facility managers on the environment in which our airmen work so that we can prevent health impacts from what we ask our airmen to do.

Many times when we deploy, of course, we are operating in a very challenging and difficult environment. Often times, temporary facilities can be more difficult, in terms of maintaining them in a way that will prevent problems like mold growth — especially in environments like Al Udeid, where it is just incredibly hot and humid year-round.

So in workplaces where we know hazards exist, we have an industrial hygiene program where our bio-environmental engineers go out and routinely inspect those workplaces. But then wWhen other concerns are identified, such as mold is identified in a ventilation system in a building or anything that [might have] a there might be some concern about its health impact on the occupants or the people who work in the building, then the bio-environmental engineers respond. They go out and make an assessment and then they advise the commander in terms of what actions should be taken to help protect the health of the individuals who are involved.

Specifically, in regards to Al Udeid, they had a number of older, temporary facilities there that had mold growing inside the walls. So, as that became known, the command there — with support from headquarters Air Force — has a four-point program for addressing that. Really, the remedy for mold is to get rid of the mold. It actually does not matter a great deal what kind of mold, the action is the same: as Gget rid of the mold.

First and foremost, we make sure that anybody who might have a health condition related to the mold exposure gets appropriate care. So they are doing that at Al Udeid. We are also doing that in re-deploying airmen that go through their post-deployment health assessments. We have had a few that have identified symptoms that could be related to mold exposure, so those airmen have been referred for appropriate evaluations.

But the four-point program to really address the problem involves first of all, improving the maintenance of the temporary facilities so they are more effectively cleaned by the contractors that they had doing that. Another point of it is to repair any facility that has things such as plumbing leaks that may be aggravating the mold, and then renovate is another part of the program.

[Third is] to go in and renovate the temporary facilities that will continue to be in use to ensure that they clear out any mold that is in the facility. And then replace is the fourth point. They do have a construction project that is due to be completed by this summer that will move over 2,000 airmen out of temporary facilities in Al Udeid into permanent buildings that will be far easier to maintain and less susceptible to the mold problem.

That is something that will require continue vigilance at places like that where you have deployed people, temporary facilities, high-humidity, and high-heat. We want to put airmen in a climate controlled facility which means we air-condition a temporary facility, and that will sometimes encourage mold to grow.