VA and Defense Health Care: Military Medical Surveillance	 
Policies in Place, but Implementation Challenges Remain 	 
(27-FEB-02, GAO-02-478T).					 
								 
The Department of Defense (DOD) and the Department of Veterans	 
Affairs (VA) recently established a medical surveillance system  
to respond to the health care needs of both military personnel	 
and veterans. A medical surveillance system involves the ongoing 
collection and analysis of uniform information on deployments,	 
environmental health threats, disease monitoring, medical	 
assessments, and medical encounters and its timely dissemination 
military commanders, medical personnel, and others. GAO and	 
others have reported extensively on weaknesses in DOD's medical  
surveillance capability and performance during the Gulf War and  
Operation Joint Endeavor.  Investigations into unexplained	 
illnesses of Gulf War veterans disclosed DOD's inability to	 
collect, maintain, and transfer accurate data describing the	 
movement of troops, potential exposures to health risks, and	 
medical incidents during deployment. DOD improved its medical	 
surveillance system under Operation Joint Endeavor, which	 
provided useful information to military commanders and medical	 
personnel. However, a number of problems with this system still  
exist. DOD has several initiatives under way to improve the	 
reliability of deployment information and to enhance its	 
information technology capabilities. Although its recent policies
and reorganization reflect a commitment to establish a		 
comprehensive medical surveillance system, much needs to be done 
to implement the system. To the extent DOD's medical surveillance
capability is realized, VA will be better able to serve veterans 
and provide backup to DOD in times of war.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-02-478T					        
    ACCNO:   A02802						        
  TITLE:     VA and Defense Health Care: Military Medical Surveillance
Policies in Place, but Implementation Challenges Remain 	 
     DATE:   02/27/2002 
  SUBJECT:   Data bases 					 
	     Data integrity					 
	     Health care services				 
	     Information resources management			 
	     Interagency relations				 
	     Medical information systems			 
	     Medical records					 
	     Military personnel 				 
	     Strategic information systems planning		 
	     Systems compatibility				 
	     Bosnia						 
	     Croatia						 
	     DOD Force Health Protection Program		 
	     DOD Global Expeditionary Medical System		 
	     DOD Operation Joint Endeavor			 
	     DOD Theater Medical Information Program		 
	     DOD Transportation Command Regulating		 
	     and Command and Control Evacuation 		 
	     System						 
								 
	     DOD Vaccine Adverse Event Reporting		 
	     System						 
								 
	     DOD/IHS/VA Government Computer-Based		 
	     Patient Record Project				 
								 
	     Herzegovina					 
	     Hungary						 
	     Persian Gulf War					 

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GAO-02-478T
     
United States General Accounting Office

GAO Testimony

Before the Subcommittee on  Health, Committee on Veterans' Affairs, House of
Representatives

For Release on Delivery
Expected at 2:00 p.m.
Wednesday, February 27, 2002 VA AND DEFENSE

HEALTH CARE

Military Medical Surveillance Policies in Place, but Implementation
Challenges Remain

Statement of Cynthia A. Bascetta Director, Health Care-Veterans' Health and
Benefits Issues

GAO-02-478T

Mr. Chairman and Members of the Committee:

We are pleased to be here today to discuss the Department of Defense's (DOD)
efforts to establish a medical surveillance system that enables DOD-along
with the Department of Veterans Affairs (VA)-to respond to the health care
needs of our military personnel and veterans. A medical surveillance system
involves the ongoing collection and analysis of uniform information on
deployments, environmental health threats, disease monitoring, medical
assessments, and medical encounters. It is also important that this
information be disseminated in a timely manner to military commanders,
medical personnel, and others. DOD is responsible for developing and
executing this system and needs this information to help ensure the
deployment of healthy forces and the continued fitness of those forces. VA
also needs this information to fulfill its missions of providing health care
to veterans, backing up DOD in contingencies, and adjudicating veterans'
claims for service-connected disabilities. Scientists at VA, DOD, and other
organizations also use this information to conduct epidemiological studies
and research.1

Given current military actions responding to the events of September 11, and
what has been reported about DOD's medical surveillance activities, you
asked us to comment on DOD's medical surveillance during the Gulf War and
Operation Joint Endeavor.2 You also asked us to review the implementation
status of DOD's directives on military medical surveillance that have been
issued since the Gulf War. This statement is based on our reports3 and
reports issued by the Institute of Medicine (IOM), the Presidential Advisory
Committee on Gulf War Veterans' Illnesses,4 and others over the past several
years. This statement is also based on interviews we held in October 2001
and February 2002 with various

1Epidemiology is the scientific study of the incidence, distribution, and
control of disease in a population.

2United States and allied nations deployed peacekeeping forces to Bosnia
beginning in December 1995 in support of Operation Joint Endeavor, the
NATO-led Bosnian peacekeeping force.

3See list of related GAO products at the end of this statement.

4The President established this committee in May 1995 to conduct
independent, open, and comprehensive examinations of health care concerns
related to Gulf War service. The committee consisted of physicians,
scientists, and Gulf War veterans.

Defense Health Program officials, including officials from the Army Surgeon
General's Office.5

In summary, we, IOM, and others have reported extensively on weaknesses in
DOD's medical surveillance capability and performance during the Gulf War
and Operation Joint Endeavor and the challenges DOD faces in implementing a
reliable medical surveillance system. Investigations into the unexplained
illnesses of Gulf War veterans uncovered many deficiencies in DOD's ability
to collect, maintain, and transfer accurate data describing the movement of
troops, potential exposures to health risks, and medical incidents during
deployment. DOD improved its medical surveillance system under Operation
Joint Endeavor, which provided useful information to military commanders and
medical personnel. However, we and others reported a number of problems with
this system. For example, information related to service members' health and
deployment status-data critical to an effective medical surveillance
system-was incomplete or inaccurate. DOD's numerous databases, including
those that capture health information, are currently not linked, which
further challenges the Department's efforts to establish a single,
comprehensive electronic system to document, archive, and access medical
surveillance data.

DOD has several initiatives under way to improve the reliability of
deployment information and to enhance its information technology
capabilities, as we and others have recommended. Although its recent
policies and reorganization reflect a commitment by DOD to establish a
comprehensive medical surveillance system, much needs to be done to
implement the system. To the extent DOD's medical surveillance capability is
realized, VA will be better able to serve veterans and provide backup to DOD
in times of war.

An effective military medical surveillance system needs to collect reliable
information on (1) the health care provided to service members before,
during, and after deployment, (2) where and when service members were
deployed, (3) environmental and occupational health threats or exposures
during deployment (in theater) and appropriate protective and
countermeasures, and (4) baseline health status and subsequent health

5The Secretary of the Army is responsible for medical surveillance for DOD
deployments, consistent with DOD's medical surveillance policy.

Background

changes. This information is needed to monitor the overall health condition
of deployed troops, inform them of potential health risks, as well as
maintain and improve the health of service members and veterans.

In times of conflict, a military medical surveillance system is particularly
critical to ensure the deployment of a fit and healthy force and to prevent
disease and injuries from degrading force capabilities. DOD needs reliable
medical surveillance data to determine who is fit for deployment; to prepare
service members for deployment, including providing vaccinations to protect
against possible exposure to environmental and biological threats; and to
treat physical and psychological conditions that result from deployment. DOD
also uses this information to develop educational measures for service
members and medical personnel to ensure that service members receive
appropriate care.

Reliable medical surveillance information is also critical for VA to carry
out its missions. In addition to VA's better known missions-to provide
health care and benefits to veterans and medical research and education- VA
has a fourth mission: to provide medical backup to DOD in times of war and
civilian health care backup in the event of disasters producing mass
casualties. VA needs reliable medical surveillance data from DOD to treat
casualties of military conflicts, provide health care to veterans who have
left active duty, assist in conducting research should troops be exposed to
environmental or occupational hazards, and identify service-connected
disabilities to adjudicate veterans' disability claims.

Investigations into the unexplained illnesses of service members and
veterans who had been deployed to the Persian Gulf uncovered the need for
DOD to implement an effective medical surveillance system to obtain
comprehensive medical data on deployed service members, including Reservists
and National Guardsmen. Epidemiological and health outcome studies to
determine the causes of these illnesses have been hampered by a lack of (1)
complete baseline health data on Gulf War veterans; (2) assessments of their
potential exposure to environmental health hazards; and (3) specific health
data on care provided before, during, and after deployment. The Presidential
Advisory Committee on Gulf War Veterans' Illnesses' and IOM's 1996
investigations into the causes of illnesses

Medical Recordkeeping and Surveillance During the Gulf War Was Lacking

experienced by Gulf War veterans confirmed the need for more effective
medical surveillance capabilities.6

The National Science and Technology Council, as tasked by the Presidential
Advisory Committee, also assessed the medical surveillance system for
deployed service members. In 1998, the council reported that inaccurate
recordkeeping made it extremely difficult to get a clear picture of what
risk factors might be responsible for Gulf War illnesses.7 It also reported
that without reliable deployment and health assessment information, it was
difficult to ensure that veterans' service-related benefits claims were
adjudicated appropriately. The council concluded that the Gulf War exposed
many deficiencies in the ability to collect, maintain, and transfer accurate
data describing the movement of troops, potential exposures to health risks,
and medical incidents in theater. The council reported that the government's
recordkeeping capabilities were not designed to track troop and asset
movements to the degree needed to determine who might have been exposed to
any given environmental or wartime health hazard. The council also reported
major deficiencies in health risk communications, including not adequately
informing service members of the risks associated with countermeasures such
as vaccines. Without this information, service members may not recognize
potential side effects of these countermeasures or take prompt precautionary
actions, including seeking medical care.

6Health Consequences of Service During the Persian Gulf War: Recommendations
for Research and Information Systems, Institute of Medicine, Medical
Follow-up Agency (Washington, D.C.: National Academy Press, 1996);
Presidential Advisory Committee on Gulf War Veterans' Illnesses: Interim
Report (Washington, D.C.: U.S. Government Printing Office, Feb. 1996);
Presidential Advisory Committee on Gulf War Veterans' Illnesses: Final
Report (Washington, D.C.: U.S. Government Printing Office, Dec. 1996).

7National Science and Technology Council Presidential Review Directive 5
(Washington, D.C.: Executive Office of the President, Office of Science and
Technology Policy, Aug. 1998).

Medical Surveillance Under Operation Joint Endeavor Improved but Was Not
Comprehensive

In response to these reports, DOD strengthened its medical surveillance
system under Operation Joint Endeavor when service members were deployed to
Bosnia-Herzegovina, Croatia, and Hungary. In addition to implementing
departmentwide medical surveillance policies, DOD developed specific medical
surveillance programs to improve monitoring and tracking environmental and
biomedical threats in theater. While these efforts represented important
steps, a number of deficiencies remained.

On the positive side, the Assistant Secretary of Defense (Health Affairs)
issued a health surveillance policy for troops deploying to Bosnia.8 This
guidance stressed the need to (1) identify health threats in theater, (2)
routinely and uniformly collect and analyze information relevant to troop
health, and (3) disseminate this information in a timely manner. DOD
required medical units to develop weekly reports on the incidence rates of
major categories of diseases and injuries during all deployments. Data from
these disease and non-battle-injury reports showed theaterwide illness and
injury trends so that preventive measures could be identified and forwarded
to the theater medical command regarding abnormal trends or actions that
should be taken.

DOD also established the U.S. Army Center for Health Promotion and
Preventive Medicine-a major enhancement to DOD's ability to perform
environmental monitoring and tracking. For example, the center operates and
maintains a repository of service members' serum samples-the largest serum
repository in the world-for epidemiological studies to examine potential
health issues for services members and veterans. The center also operates
and maintains a system for integrating, analyzing, and reporting data from
multiple sources relevant to the health and readiness of military personnel.
This capability was augmented with the establishment of the 520th Theater
Army Medical Laboratory-a deployable public health laboratory for providing
environmental sampling and analysis in theater. The sampling results can be
used to identify specific preventive measures and safeguards to be taken to
protect troops from harmful exposures and to develop procedures to treat
anyone exposed to health hazards. During Operation Joint Endeavor, this
laboratory was used in Tuzla, Bosnia-where most of the U.S. forces were
located-to conduct air, water, soil, and other environmental monitoring.

8Health Affairs Policy 96-019 (DOD Assistant Secretary of Defense
Memorandum, Jan. 4, 1996).

Despite the Department's progress, we and others have reported on DOD's
implementation difficulties during Operation Joint Endeavor and the
shortcomings in DOD's ability to maintain reliable health information on
service members. Knowledge of who is deployed and their whereabouts is
critical for identifying individuals who may have been exposed to health
hazards while deployed. However, in May 1997, we reported that inaccurate
information on who was deployed and where and when they were deployed-a
problem during the Gulf War-continued to be a concern during Operation Joint
Endeavor.9 For example, we found that the Defense Manpower Data Center
(DMDC) database-where military services are required to report deployment
information-did not include records for at least 200 Navy service members
who were deployed. Conversely, the DMDC database included Air Force
personnel who were never actually deployed. In addition, we reported that
DOD had not developed a system for tracking the movement of service members
within theater. IOM also reported that during Operation Joint Endeavor,
locations of deployed service members were still not systematically
documented or archived for future use.10

We also reported in May 1997 that for the more than 600 Army personnel whose
medical records we reviewed, DOD's centralized database for postdeployment
medical assessments did not capture 12 percent of those assessments
conducted in theater and 52 percent of those conducted after returning
home.11 These data are needed by epidemiologists and other researchers to
assess at an aggregate level the changes that have occurred between service
members' pre-and postdeployment health assessments. Further, many service
members' medical records did not include complete information on the
in-theater postdeployment medical assessments that had been conducted. The
Army's European Surgeon General attributed missing in-theater health
information to DOD's policy of having service

9Defense Health Care: Medical Surveillance Improved Since Gulf War, but
Mixed Results in Bosnia (GAO/NSIAD-97-136, May 13, 1997).

10See Institute of Medicine, Protecting Those Who Serve: Strategies to
Protect the Health of Deployed U.S. Forces (Washington, D.C., National
Academy Press, 2000).

11In many cases, we found that these assessments were not conducted in a
timely manner or were not conducted at all. For example, of the 618
personnel whose records we reviewed, 24 percent did not receive in-theater
postdeployment medical assessments and 21 percent did not receive home
station postdeployment medical assessments. Of those who did receive home
station postdeployment medical assessments, the assessments were on average
conducted nearly 100 days after they left theater-instead of within 30 days,
as DOD requires.

Current Policies and Programs Not Fully Implemented

members hand-carry paper assessment forms from the theater to their home
units, where their permanent medical records were maintained. The
assessments were frequently lost en route.

We have also reported that not all medical encounters in theater were being
recorded in individual records. Our 1997 report indicated that this problem
was particularly common for immunizations given in theater. Detailed data on
service members' vaccine history are vital for scheduling the regimen of
vaccinations and boosters and for tracking individuals who received
vaccinations from a specific vaccine lot in the event that health concerns
about the lot emerge. We found that almost one-fourth of the service
members' medical records that we reviewed did not document the fact that
they had received a vaccine for tick-borne encephalitis. In addition, in its
2000 report, IOM cited limited progress in medical recordkeeping for
deployed active duty and reserve forces and emphasized the need for records
of immunizations to be included in individual medical records.

Responding to our and others' recommendations to improve information on
service members' deployments, in-theater medical encounters, and
immunizations, DOD has continued to revise and expand its policies related
to medical surveillance, and the system continues to evolve. In addition, in
2000, DOD released its Force Health Protection plan, which presents the
Department's vision for protecting deployed forces and includes the goal of
joint medical logistics support for all services by 2010.12 The vision
articulated in this capstone document emphasizes force fitness and health
preparedness, casualty prevention, and casualty care and management. A key
component of the plan is improved monitoring and surveillance of health
threats in military operations and more sophisticated data collection and
recordkeeping before, during, and after deployments. However, IOM criticized
DOD's progress in implementing its medical surveillance program as well as
its failure to implement several recommendations that IOM had made. In
addition, IOM raised concerns about DOD's ability to achieve the vision
outlined in the Force Health Protection plan. We have also reported that
some of DOD's programs designed to improve medical surveillance have not
been fully implemented.

12Joint Staff, Medical Readiness Division, Force Health Protection (2000).

Recent IOM Report Concludes That DOD Has Made Slow Progress in Implementing
Recommendations

IOM's 2000 report presented the results of its assessment of DOD's progress
in implementing recommendations for improving medical surveillance made by
IOM and several others. IOM stated that, although DOD generally concurred
with the findings of these groups, DOD had made few concrete changes at the
field level. In addition, environmental and medical hazards were not yet
well integrated in the information provided to commanders.

The IOM report notes that a major reason for this lack of progress is that
no single authority within DOD has been assigned responsibility for the
implementation of the recommendations and plans. IOM said that because of
the complexity of the tasks and the overlapping areas of responsibility
involved, the single authority must rest with the Secretary of Defense.

In its report, IOM describes six strategies that in its view demand further
emphasis and require greater efforts by DOD:

* Use a systematic process to prospectively evaluate non-battle-related
risks associated with the activities and settings of deployments.

* Collect and manage environmental data and personnel location, biological
samples, and activity data to facilitate analysis of deployment exposures
and to support clinical care and public health activities.

* Develop the risk assessment, risk management, and risk communication
skills of military leaders at all levels.

* Accelerate implementation of a health surveillance system that completely
spans an individual's time in service.

* Implement strategies to address medically unexplained symptoms in deployed
populations.

* Implement a joint computerized patient record and other automated
recordkeeping that meets the information needs of those involved with
individual care and military public health.

Our Work Also Indicates Some DOD Programs for Improving Medical Surveillance
Are Not Fully Implemented

DOD guidance established requirements for recording and tracking
vaccinations and automating medical records for archiving and recalling
medical encounters. While our work indicates that DOD has made some progress
in improving its immunization information, the Department faces numerous
challenges in implementing an automated medical record. DOD also recently
established guidelines and additional policy initiatives for improving
military medical surveillance.

In October 1999, we reported that DOD's Vaccine Adverse Event Reporting
System-which relies on medical staff or service members to provide

needed vaccine data-may not have included some information on adverse
reactions because these personnel had not received guidance needed to submit
reports to the system.13 According to DOD officials, medical staff may also
report any other reaction they think might be caused by the vaccine, but
because this is not stated explicitly in DOD's guidance on vaccinations,
some medical staff may be unsure about which reactions to report.

Also, in April 2000, we testified that vaccination data were not
consistently recorded in paper records and in a central database, as DOD
requires.14 For example, when comparing records from the database with paper
records at four military installations, we found that information on the
number of vaccinations given to service members, the dates of the
vaccinations, and the vaccine lot numbers were inconsistent at all four
installations. At one installation, the database and records did not agree
78 percent to 92 percent of the time. DOD has begun to make progress in
implementing our recommendations, including ensuring timely and accurate
data in its immunization tracking system.

The Gulf War revealed the need to have information technology play a bigger
role in medical surveillance to ensure that information is readily
accessible to DOD and VA. In August 1997, DOD established requirements that
called for the use of innovative technology, such as an automated medical
record device that can document inpatient and outpatient encounters in all
settings and that can archive the information for local recall and format it
for an injury, illness, and exposure surveillance database.15 Also, in 1997,
the President, responding to deficiencies in DOD's and VA's data
capabilities for handling service members' health information, called for
the two agencies to start developing a comprehensive, lifelong medical
record for each service member. As we reported in April 2001, DOD's and VA's
numerous databases and electronic

13 Medical  Readiness:  DOD Faces  Challenges  in  Implementing Its  Anthrax
Vaccine Immunization Program (GAO/NSIAD-00-36, Oct. 22, 1999).

14Medical  Readiness: DOD  Continues to Face Challenges  in Implementing Its
Anthrax Vaccine Immunization Program (GAO/T-NSIAD-00-157, Apr. 13, 2000).

15DOD Directive 6490.2, "Joint Medical Surveillance" (Aug. 30, 1997).

systems for capturing mission-critical data, including health information,
are not linked and information cannot be readily shared.16

DOD has several initiatives under way to link many of its information
systems-some with VA. For example, in an effort to create a comprehensive,
lifelong medical record for service members and veterans and to allow health
care professionals to share clinical information, DOD and VA, along with the
Indian Health Service (IHS),17 initiated the Government Computer-Based
Patient Record (GCPR) project in 1998. GCPR is seen as yielding a number of
potential benefits, including improved research and quality of care, and
clinical and administrative efficiencies. However, our April 2001 report
described several factors- including planning weaknesses, competing
priorities, and inadequate accountability-that made it unlikely that DOD and
VA would accomplish GCPR or realize its benefits in the near future. To
strengthen the management and oversight of GCPR, we made several
recommendations, including designating a lead entity with a clear line of
authority for the project and creating comprehensive and coordinated plans
for sharing meaningful, accurate, and secure patient health data.

For the near term, DOD and VA have decided to reconsider their approach to
GCPR and focus on allowing VA to access selected health data on service
members captured by DOD. According to DOD and VA officials, full operation
is expected to begin the third quarter of this fiscal year, once testing of
the near-term system has been completed. DOD health information is an
especially critical information source given VA's fourth mission to provide
medical backup to the military health system in times of national emergency
and war. Under the near-term effort, VA will be able to access laboratory
and radiology results, outpatient pharmacy data, and patient demographic
information. This approach, however, will not provide VA access to
information on the health status of personnel when they enter military
service; on medical care provided to Reservists while not on active duty; or
on the care military personnel received from providers outside DOD,
including TRICARE providers. In addition, because VA will only be able to
view this information, physicians will not

16Computer-Based Patient Records: Better Planning and Oversight by VA, DOD,
and IHS Would Enhance Health Data Sharing (GAO-01-459, Apr. 30, 2001).

17IHS was included in the effort because of its population-based research
expertise and its long-standing relationship with VA.

be able to easily organize or otherwise manipulate the data for quick review
or research.

DOD has several other initiatives for improving its information technology
capabilities, which are in various stages of development. For example, DOD
is developing the Theater Medical Information Program (TMIP), which is
intended to capture medical information on deployed personnel and link it
with medical information captured in the Department's new medical
information system.18 As of October 2001, officials told us that they
planned to begin field testing for TMIP in spring 2002, with deployment
expected in 2003. A component system of TMIP- Transportation Command
Regulating and Command and Control Evacuation System-is also under
development and aims to allow casualty tracking and provide in-transit
visibility of casualties during wartime and peacetime. Also under
development is the Global Expeditionary Medical System (GEMS), which DOD
characterizes as a stepping stone to an integrated biohazard surveillance
and detection system.

In addition to its ongoing information technology initiatives, DOD recently
issued two major policies for advancing its military medical surveillance
system. Specifically, in December 2001, DOD issued clinical practice
guidelines, developed collaboratively with VA, to provide a structure for
primary care providers to evaluate and manage patients with
deployment-related health concerns.19 According to DOD, the guidelines were
issued in response to congressional concerns and IOM's recommendations. The
guidelines are expected to improve the continuity of care and health-risk
communication for service members and their families for the wide variety of
medical concerns that are related to military deployments. Because the
guidelines became effective January 31, 2002, it is too early for us to
comment on their implementation.

18Composite Health Care System II (CHCS II), currently being field tested,
is expected to capture information on immunizations; allergies; outpatient
encounters, such as diagnostic and treatment codes; patient hospital
admission and discharge; patient medications; laboratory results; and
radiology. CHCS II is expected to support best business practices, medical
surveillance, and clinical research.

19Department of Defense and Veterans Health Administration, Clinical
Practice Guideline for Post-Deployment Health Evaluation and Management
(Sept. 2000, updated Dec. 2001).

Finally, DOD issued updated procedures on February 1, 2002, for deployment
health surveillance and readiness.20 These procedures supersede those laid
out in DOD's December 1998 memorandum. The 2002 memorandum adds important
procedures for occupational and environmental health surveillance and
updates pre- and postdeployment health assessment requirements. These new
procedures take effect on March 1, 2002.

According to officials from DOD's Health Affairs office, military medical
surveillance is a top priority, as evidenced by the Department's having
placed responsibility for implementing medical surveillance policies with
one authority-the Deputy Assistant Secretary of Defense for Force Health
Protection and Readiness. However, these officials also characterized force
health protection as a concept made up of multiple programs across the
services. For example, we learned that each service is responsible for
implementing DOD's policy initiatives for achieving force health protection
goals. This raises concerns about how the services will uniformly collect
and share core information on deployments and how they will integrate data
on the health status of service members. These officials also confirmed that
DOD's military medical surveillance policies will depend on the priority and
resources dedicated to their implementation.

Clearly, the need for comprehensive health information on service members
and veterans is compelling, and much more needs to be done. However, it is
also a very difficult task because of uncertainties about what conditions
may exist in a deployed setting, such as potential military conflicts,
environmental hazards, and the frequency of troop movements. Moreover, the
outlook for successful surveillance is complicated by scientific uncertainty
regarding the health effects of exposures and changes in technology that
affect the feasibility of monitoring and tracking troop movements. While
progress is being made, DOD will need to continue to make a concerted effort
to resolve the remaining deficiencies in its surveillance system and be
vigilant in its oversight. VA's ability to perform its missions to care for
veterans and compensate them for their service-connected conditions will
depend in part on the adequacy of DOD's medical surveillance system.

Concluding Observations

20Joint Staff Memorandum 0006-02, "Updated Procedures for Deployment Health
Surveillance and Readiness" (Office of the Chairman, Joint Chiefs of Staff,
Feb. 1, 2002).

Contact and For further information, please contact Cynthia A. Bascetta at
(202) 512-7101. Individuals making key contributions to this testimony
included Ann

Acknowledgments Calvaresi Barr, Diana Shevlin, Karen Sloan, and Keith Steck.

Related GAO Products

VA and Defense Health Care: Progress Made, but DOD Continues to Face
Military Medical Surveillance System Challenges (GAO-02-377T, Jan. 24,
2002).

Gulf War Illnesses: Similarities and Differences Among Countries in Chemical
and Biological Threat Assessment and Veterans' Health Status (GAO-02-359T,
Jan. 24, 2002).

Computer-Based Patient Records: Better Planning and Oversight by VA, DOD,
and IHS Would Enhance Health Data Sharing (GAO-01-459, Apr. 30, 2001).

Coalition Warfare: Gulf War Allies Differed in Chemical and Biological
Threats Identified and in Use of Defensive Measures (GAO-01-13, Apr. 24,
2001).

Medical Readiness: DOD Continues To Face Challenges in Implementing Its
Anthrax Vaccine Immunization Program (GAO/T-NSIAD-00-157, Apr. 13, 2000).

Medical Readiness: DOD Faces Challenges in Implementing Its Anthrax Vaccine
Immunization Program (GAO/NSIAD-00-36, Oct. 22, 1999).

Chemical and Biological Defense: Observations on DOD's Plans to Protect U.S.
Forces (GAO/T-NSIAD-98-83, Mar. 17, 1998).

Gulf War Veterans: Incidence of Tumors Cannot Be Reliably Determined From
Available Data (GAO/NSIAD-98-89, Mar. 3, 1998).

Gulf War Illnesses: Federal Research Strategy Needs Reexamination

(GAO-T-NSIAD-98-104, Feb. 24, 1998).

Gulf War Illnesses: Research, Clinical Monitoring, and Medical Surveillance
(GAO/T-NSIAD-98-88, Feb. 5, 1998).

Defense Health Care: Medical Surveillance Improved Since Gulf War, but Mixed
Results in Bosnia (GAO/NSIAD-97-136, May 13, 1997).

(290173)
*** End of document. ***