Defense Health Care: Improvements Needed in Occupational and
Environmental Health Surveillance During Deployments to Address
Immediate and Long-Term Health Issues (14-JUL-05, GAO-05-632).
Following the 1991 Persian Gulf War, research and investigations
into the causes of servicemembers' unexplained illnesses were
hampered by inadequate occupational and environmental exposure
data. In 1997, the Department of Defense (DOD) developed a
militarywide health surveillance framework that includes
occupational and environmental health surveillance (OEHS)--the
regular collection and reporting of occupational and
environmental health hazard data by the military services. GAO is
reporting on (1) how the deployed military services have
implemented DOD's policies for collecting and reporting OEHS data
for Operation Iraqi Freedom (OIF) and (2) the efforts under way
to use OEHS reports to address both immediate and long-term
health issues of servicemembers deployed in support of OIF.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-05-632
ACCNO: A29877
TITLE: Defense Health Care: Improvements Needed in Occupational
and Environmental Health Surveillance During Deployments to
Address Immediate and Long-Term Health Issues
DATE: 07/14/2005
SUBJECT: Data collection
Health hazards
Military forces
Military personnel
Military policies
Noncompliance
Occupational health standards
Reporting requirements
Safety standards
Standards evaluation
Hazardous substances
DOD Operation Iraqi Freedom
Persian Gulf War
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GAO-05-632
United States Government Accountability Office
GAO Report to the Chairman, Subcommittee on National Security, Emerging Threats,
and International Relations, Committee on Government Reform, House of
Representatives
July 2005
DEFENSE HEALTH CARE
Improvements Needed in Occupational and Environmental Health Surveillance during
Deployments to Address Immediate and Long-term Health Issues
a
GAO-05-632
[IMG]
July 2005
DEFENSE HEALTH CARE
Improvements Needed in Occupational and Environmental Health Surveillance during
Deployments to Address Immediate and Long-term Health Issues
What GAO Found
Although OEHS data generally have been collected and reported for OIF, as
required by DOD policy, the deployed military services have used different
data collection methods and have not submitted all of the OEHS reports
that have been completed. Data collection methods for air and soil
surveillance have varied across the services, for example, although they
have been using the same monitoring standard for water surveillance.
Variations in data collection have been compounded by different levels of
training and expertise among service personnel responsible for OEHS. For
some OEHS activities, a cross-service working group has been developing
standards and practices to increase uniformity of data collection among
the services. In addition, while the deployed military services have been
conducting OEHS activities, they have not submitted all of the OEHS
reports that have been completed during OIF, which DOD officials attribute
to various obstacles, such as limited access to communication equipment to
transmit reports for archiving. Moreover, DOD officials did not have the
required consolidated lists of all OEHS reports completed during each
quarter in OIF and therefore could not identify the reports they had not
received to determine the extent of noncompliance. To improve OEHS
reporting compliance, DOD officials said they were revising an existing
policy to add additional and more specific OEHS requirements.
DOD has made progress in using OEHS reports to address immediate health
risks during OIF, but limitations remain in employing these reports to
address both immediate and long-term health issues. OIF was the first
major deployment in which OEHS reports have been used consistently as part
of operational risk management activities intended to identify and address
immediate health risks and to make servicemembers aware of the health
risks of potential exposures. While these efforts may help reduce health
risks, DOD has no systematic efforts to evaluate their implementation in
OIF. In addition, DOD's centralized archive of OEHS reports for OIF has
several limitations for addressing potential long-term health effects
related to occupational and environmental exposures. First, access to the
centralized archive has been limited due to the security classification of
most OEHS reports. Second, it will be difficult to link most OEHS reports
to individual servicemembers' records because not all data on
servicemembers' deployment locations have been submitted to DOD's
centralized tracking database. For example, none of the military services
submitted location data for the first several months of OIF. To address
problems with linking OEHS reports to individual servicemembers, the
deployed military services have made efforts to include OEHS monitoring
summaries in the medical records of some servicemembers for either
specific incidents of potential exposure or for specific locations within
OIF. Third, according to DOD and VA officials, no federal research plan
has been developed to evaluate the longterm health of servicemembers
deployed in support of OIF, including the effects of potential exposures
to occupational or environmental hazards.
United States Government Accountability Office
Contents
Letter
Results in Brief
Background
Deployed Military Services Use Varying Approaches to Collect
OEHS Data and Have Not Submitted All OEHS Reports for OIF
Progress Made in Using OEHS Reportsto Address Immediate Health Risks,
Though Limitations Remain for Addressing Both Immediate and Long-term
Health Issues
Conclusions
Recommendations for Executive Action
Agency Comments and Our Evaluation
1 3 5
15
18 26 27 28
Appendixes
Appendix I: Scope and Methodology 32
Example of an Occupational and Environmental
Appendix II: Health
Surveillance Summary Created by the Air Force
during
Operation Iraqi Freedom 35
Appendix III: Comments from the Department of Defense 37
Comments from the Department of Veterans 39
Appendix IV: Affairs
Table Table 1: Selected DOD Policies for the Collection and Reporting of
Deployment Occupational and Environmental Health Surveillance (OEHS) Data
Figures Figure 1: Entities Involved in Setting or Implementing
Occupational and Environmental Health Surveillance
(OEHS) Policy 9
Figure 2: Submittal of Deployment Occupational and
Environmental Health Surveillance (OEHS) Reports to
the Centralized Archive 12
Contents
Abbreviations
CENTCOM U.S. Central Command
CHPPM U.S. Army Center for Health Promotion and Preventive
Medicine DHSD Deployment Health Support Directorate DMDC Defense Manpower
Data Center DOD Department of Defense HHS Department of Health and Human
Services OEF Operation Enduring Freedom OEHS occupational and
environmental health surveillance OIF Operation Iraqi Freedom VA
Department of Veterans Affairs
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separately.
A
United States Government Accountability Office Washington, D.C. 20548
July 14, 2005
The Honorable Christopher Shays
Chairman
Subcommittee on National Security, Emerging Threats, and International
Relations Committee on Government Reform House of Representatives
Dear Mr. Chairman:
The health effects from service in military operations have been of
increasing interest, particularly since the end of the 1991 Persian Gulf
War. Following that war, many servicemembers reported suffering from
unexplained illnesses that they attributed to their service in the Persian
Gulf and expressed concerns regarding possible exposures to chemical or
biological warfare agents or environmental contaminants. Subsequent
research and investigations into the nature and causes of these illnesses
by the Department of Defense (DOD), the Department of Veterans Affairs
(VA), the Department of Health and Human Services (HHS), the Institute of
Medicine, and a Presidential Advisory Committee were hampered by a lack of
servicemember health and deployment data, including inadequate
occupational and environmental exposure data. During deployments-
particularly combat situations-the health of servicemembers can
potentially be affected by exposure to hazardous agents contained in or
produced by weapons systems, as well as exposure to environmental
contamination or toxic industrial materials.
In an effort to address continuing concerns about the health of
servicemembers during and after deployments and to improve health data
collection on potential exposures, DOD developed a militarywide health
surveillance framework in 1997 for use during deployments. A key component
of this framework is occupational and environmental health surveillance
(OEHS), an activity that includes the regular collection and reporting of
occupational and environmental health hazard data by the military services
during a deployment that can be used to monitor the health of
servicemembers and to prevent, treat, or control disease or injury. DOD
has created policies for OEHS data collection during a deployment and for
the submittal of OEHS reports to a centralized archive within certain time
frames. The military services are responsible for implementing these
policies in preparation for deployments. During a deployment, the military
services are unified under a deployment command structure and
are responsible for conducting OEHS activities in accordance with DOD
policy. For this report, we identify the military services operating in a
deployment as deployed military services.
In early 2003, servicemembers were deployed again to the Persian Gulf in
support of Operation Iraqi Freedom (OIF), and you and others raised anew
concerns about potential exposure to hazardous agents or environmental
contaminants. We are reporting on (1) how the deployed military services
have implemented DOD's policies for collecting and reporting OEHS data for
OIF and (2) the efforts under way to use OEHS reports to address both the
immediate and long-term health issues of servicemembers deployed in
support of OIF.
To conduct our work, we reviewed pertinent policies, guidance, and reports
related to collecting and reporting OEHS data obtained from officials at
the Deployment Health Support Directorate (DHSD), the military services,
and the Joint Staff, which supports the Chairman of the Joint Chiefs of
Staff.1 We also conducted site visits to the Army, Navy, and Air Force
health surveillance centers that develop standards and guidance for
conducting OEHS.2 We interviewed DOD officials and reviewed reports and
documents identifying occupational and environmental health risks and
outlining recommendations for addressing risks at deployment sites. We
interviewed officials at the U.S. Army's Center for Health Promotion and
Preventive Medicine (CHPPM), which archives OEHS reports, both classified
and unclassified, for all the military services. We also interviewed
officials and military service representatives at DOD's Defense Manpower
Data Center (DMDC) on the status of a centralized deployment tracking
database to identify deployed servicemembers and record their locations
within the theater of operations. Additionally, we interviewed VA
officials on their experience in obtaining and using OEHS reports from OIF
to address the health care needs of veterans. Finally, we interviewed DOD
and VA officials to examine whether the agencies have planned or initiated
health research using OEHS reports.
We determined that the data from CHPPM's OEHS archive and DMDC's
Contingency Tracking System were sufficiently reliable for the purposes of
1The Chairman of the Joint Chiefs of Staff is the principal military
adviser to the President, the National Security Council, and the Secretary
of Defense.
2The Navy supports OEHS activities for the Marine Corps.
this report. To assess the reliability of the data, we (1) confirmed that
the data included the elements that we requested and were consistent with
provided documentation and (2) conducted detailed fact-finding interviews
with CHPPM and DMDC officials to understand how the databases were created
and to determine the limitations of the data. We conducted our work from
September 2004 through June 2005 in accordance with generally accepted
government auditing standards. (See app. I for further detail on our scope
and methodology.)
Results in Brief Although OEHS data generally have been collected and
reported for OIF, as required by DOD policy, the deployed military
services have used different data collection methods and have not
submitted all of the OEHS reports that have been completed. Data
collection methods for air and soil surveillance have varied across the
services, for example, although they have been using the same monitoring
standard for water surveillance. Compounding these differences among the
services were the varying levels of training and expertise among the
deployed military service personnel who were responsible for conducting
OEHS activities, resulting in differing practices for implementing data
collection standards. For some OEHS activities, a cross-service working
group, called the Joint Environmental Surveillance Working Group, has been
developing standards and practices to increase uniformity of data
collection among the services. In addition, the deployed military services
have not submitted to CHPPM all OEHS reports that have been completed
during OIF, in accordance with DOD policy. While 239 of the 277 OIF bases
had at least one OEHS report submitted to CHPPM's centralized archive as
of December 2004, CHPPM could not measure the magnitude of noncompliance
because not all of the required consolidated lists that identify all OEHS
reports completed during each quarter in OIF had been submitted.
Therefore, CHPPM could not compare the reports that it had received
against the list of reports that had been completed. According to CHPPM
officials, obstacles to reporting compliance may have included a lack of
understanding by some within the deployed military services about the type
of OEHS reports that should have been submitted or the lower priority
given to report submission compared to other deployment mission
activities. Also, while CHPPM is responsible for OEHS archiving, it has no
authority to enforce report submission requirements. To improve OEHS
reporting compliance, DOD officials said they were revising an existing
policy to add additional and more specific OEHS requirements.
DOD has made progress using OEHS reports to address immediate health risks
during OIF, but limitations remain in employing these reports to address
both immediate and long-term health issues. OIF was the first major
deployment in which OEHS reports have been used consistently as part of
operational risk management activities intended to identify and address
immediate health risks. These activities included health risk assessments
that described and measured the potential hazards at a site, risk
mitigation activities intended to reduce potential exposure, and risk
communication efforts undertaken to make servicemembers aware of the
possible health risks of potential exposures. While these efforts may help
reduce health risks, there is no assurance that they have been effective
because DOD has not systematically evaluated the implementation of OEHS
risk management activities in OIF. Despite progress in the use of OEHS
information to identify and address immediate health risks, CHPPM's
centralized archive of OEHS reports for OIF has limitations for addressing
potential long-term health effects related to occupational and
environmental exposures for several reasons. First, access to CHPPM's OEHS
archive has been limited because most OEHS reports are classified-which
restricts their use by VA, medical professionals, and interested
researchers. Second, it will be difficult to link most OEHS reports to
individual servicemembers because not all data on servicemembers'
deployment locations have been submitted to DOD's centralized tracking
database. For example, none of the military services submitted location
data for the first several months of OIF. To address problems with linking
OEHS reports to individual servicemembers, the deployed military services
have made efforts to include OEHS summaries in the medical records of some
servicemembers for either specific incidents of potential exposure or for
specific locations within OIF, such as air bases. Third, according to DOD
and VA officials, no comprehensive federal research plan incorporating the
use of the archived OEHS reports has been developed to address the
long-term health consequences of service in OIF.
We are making recommendations to the Secretary of Defense to ensure that
cross-service guidance be developed to implement DOD's revised policy for
OEHS during deployments and to ensure that the military services jointly
establish and implement procedures to evaluate the effectiveness of risk
management strategies during deployments. We are also recommending that
the Secretary of Defense and the Secretary of Veterans Affairs work
together to develop a federal research plan to follow the health of OIF
servicemembers over time that would include the use of OEHS reports. In
commenting on a draft of this report, DOD did not concur with our original
recommendation that the military services jointly develop guidance to
implement DOD's revised policy for OEHS during deployments; rather, the
agency stated that cross-service guidance meeting the intent of our
recommendation would be developed by the Joint Staff instead of the
military services. In response, we modified the wording of our
recommendation to clarify our intent that joint guidance be developed. DOD
partially concurred with our other recommendations. VA concurred with our
recommendation to work with DOD to jointly develop a federal research plan
to follow the long-term health of OIF servicemembers.
Background On March 19, 2003, the United States launched military
operations in Iraq. As of the end of February 2005, an estimated 827,277
servicemembers had been deployed in support of OIF. Deployed
servicemembers, such as those in OIF, are potentially subject to
occupational and environmental hazards that can include exposure to
harmful levels of environmental contaminants such as industrial toxic
chemicals, chemical and biological warfare agents, and radiological and
nuclear contaminants. Harmful levels include highlevel exposures that
result in immediate health effects.3 Health hazards may also include
low-level exposures that could result in delayed or longterm health
effects. Occupational and environmental health hazards may include
contamination from the past use of a site, from battle damage, from stored
stockpiles, from military use of hazardous materials, or from other
sources.
3Harmful levels of environmental contaminants are determined by the
concentration of the substance and the duration of exposure.
Federal OEHS Policy As a result of numerous investigations that found
inadequate data on deployment occupational and environmental exposures to
identify the potential causes of unexplained illnesses among veterans who
served in the 1991 Persian Gulf War, the federal government has increased
efforts to identify potential occupational and environmental hazards
during deployments. In 1997, a Presidential Review Directive called for a
report by the National Science and Technology Council to establish an
interagency plan to improve the federal response to the health needs of
veterans and their families related to the adverse effects of deployment.4
The Council published a report that set a goal for the federal government
to develop the capability to collect and assess data associated with
anticipated exposure during deployments. Additionally, the report called
for the maintenance of the capability to identify and link exposure and
health data by Social Security number and unit identification code. Also
in 1997, Public Law 10585 included a provision recommending that DOD
ensure the deployment of specialized units to theaters of operations to
detect and monitor chemical, biological, and similar hazards.5 The
Presidential Review Directive and the public law led to a number of DOD
instructions, directives, and memoranda, which have guided the collection
and reporting of deployment OEHS data. See table 1 for a list of selected
DOD policies for collecting and reporting deployment OEHS data.
4Presidential Review Directive, National Science and Technology Council -
5 (Apr. 21, 1997). The National Science and Technology Council is a
cabinet-level council that helps coordinate federal science, space, and
technology research and development for the President.
5National Defense Authorization Act for Fiscal Year 1998. Pub. L. No.
105-85, S:768, 111 Stat. 1629, 1828 (1997) ("Sense of Congress").
Table 1: Selected DOD Policies for the Collection and Reporting of
Deployment Occupational and Environmental Health Surveillance (OEHS) Data
Date Policy OEHS data collection OEHS reporting
Directs military
August 1997 Department of Defense services to
Instruction 6490.3, deploy specialized
units to
"Implementation and conduct environmental
Application health
of Joint Medical assessments of
Surveillance for potential
Deployment" (under exposure to
revision) occupational and
environmental
hazards.
February 2002 Office of the Chairman, The Joint Chiefs of Staff,
Memorandum MCM-0006-02, "Updated Procedures for Deployment Health
Surveillance and Readiness" Directs the combatant command-which is
responsible for the deployment-to develop and maintain an appropriate OEHS
program for the deployment. Directs deployed military commands to
continuously review and update environmental health assessments throughout
deployments using data collected in the theater. Directs deployed military
commands to ensure that requirements are met for reporting and archiving
OEHS data and sets out requirements for record keeping and reporting.
May 2003 Under Secretary of Defense for Directs the Joint Staff to issue
Personnel and Readiness, additional guidance for more
Memorandum, "Improved comprehensive OEHS reporting
Occupational and Environmental requirements for Operation Iraqi
Health Surveillance Reporting Freedom and provides specific
and Archiving" guidance for required reports
that should be submitted for
archiving, and time frames for
submittal.
June 2003 The Joint Staff, Memorandum DJSM-0613-03, "Improved Occupational
and Environmental Health Surveillance (OEHS) Reporting and Archiving"
Directs personnel involved in OEHS to submit all deployment OEHS reports
to the U.S. Army Center for Health Promotion and Preventive Medicine
(CHPPM) and to provide complete lists (on a quarterly basis) of all
deployment OEHS reports that were completed to CHPPM as well as to the
medical commander of the deployment.
Source: DOD.
DOD Entities Involved with Setting and Implementing OEHS Policy
DHSD makes recommendations for DOD-wide policies on OEHS data collection
and reporting during deployments to the Office of the Assistant Secretary
of Defense for Health Affairs. DHSD is assisted by the Joint Environmental
Surveillance Working Group, established in 1997, which serves as a
coordinating body to develop and make recommendations for DOD-wide OEHS
policy.6 The working group includes representatives from the Army, Navy,
and Air Force health surveillance centers, the Joint Staff, other DOD
entities, and VA.
Each service has a health surveillance center-CHPPM, the Navy
Environmental Health Center, and the Air Force Institute for Operational
Health-that provides training, technical guidance and assistance,
analytical support, and support for preventive medicine units7 in theater
in order to carry out deployment OEHS activities in accordance with DOD
policy. In addition, these consulting centers have developed and adapted
military exposure guidelines for deployment using existing national
standards for human health exposure limits and technical monitoring
procedures (e.g., standards of the U.S. Environmental Protection Agency
and the National Institute for Occupational Safety and Health) and have
worked with other agencies to develop new guidelines when none existed.
(See fig. 1.)
6 The working group makes recommendations for deployment OEHS policy to
the Deputy Assistant Secretary of Defense for Force Health Protection and
Readiness, who serves as the director of DHSD.
7 Each military service has preventive medicine units, though they may be
named differently. Throughout this report, we use the term preventive
medicine unit to apply to the units fielded by all military services.
Deployment OEHS Reports DOD policies and military service guidelines
require that the preventive medicine units of each military service be
responsible for collecting and reporting deployment OEHS data.8 Deployment
OEHS data are generally categorized into three types of reports: baseline,
routine, or incidentdriven.
o Baseline reports generally include site surveys and assessments of
occupational and environmental hazards prior to deployment of
servicemembers and initial environmental health site assessments once
servicemembers are deployed.9
o Routine reports record the results of regular monitoring of air, water,
and soil, and of monitoring for known or possible hazards identified in
the baseline assessment.
o Incident-driven reports document exposure or outbreak investigations.10
There are no DOD-wide requirements on the specific number or type of OEHS
reports that must be created for each deployment location because reports
generated for each reflect the specific occupational and environmental
circumstances unique to that location. CHPPM officials said that reports
generally reflect deployment OEHS activities that are limited to
established sites such as base camps or forward operating bases; 11 an
exception is an investigation during an incident outside these locations.
Constraints to conducting OEHS outside of bases include risks to
servicemembers encountered while in combat and limits on the portability
of OEHS equipment. In addition, DHSD officials said that preventive
8While in the deployment location, preventive medicine units create and
store reports both electronically and using paper-based formats.
9Some bases can have more than one baseline report.
10DOD officials said the analysis of servicemembers' responses to a
post-deployment health assessment questionnaire is another means to
identify potential exposures that should be investigated. These
assessments, designed to identify health issues or concerns that may
require medical attention, use a questionnaire that is to be completed in
theater and asks servicemembers if they believe they have been exposed to
a hazardous agent.
11Throughout the report we refer to both base camps and forward operating
bases collectively as bases. A forward operating base is usually smaller
than a base camp in troop strength and infrastructure and is normally
constructed for short-duration occupation.
medicine units might not be aware of every potential health hazard and
therefore might be unable to conduct appropriate OEHS activities.
OEHS Reporting and Archiving Activities during Deployment
According to DOD policy, various entities must submit their completed OEHS
reports to CHPPM during a deployment. The deployed military services have
preventive medicine units that submit OEHS reports to their command
surgeons12 who review all reports and ensure that they are sent to a
centralized archive that is maintained by CHPPM.13 Alternatively,
preventive medicine units can be authorized to submit OEHS reports
directly to CHPPM for archiving. (See fig. 2.)
12 The command surgeons of deployed preventive medicine units are either
Joint Task Force command surgeons or military service component command
surgeons. In OIF, there are two Joint Task Forces, each with a command
surgeon. In addition, the Army, Navy, Air Force, and Marine Corps have
their own subordinate component commands in a deployment, each with a
command surgeon.
13DOD has designated CHPPM as the entity responsible for archiving all
OEHS reports from deployments.
each with a command surgeon. In addition, the Army, Navy, Air Force, and
Marine Corps have their own subordinate component commands in a
deployment, each with a command surgeon.
According to DOD policy, baseline and routine reports should be submitted
within 30 days of report completion.14 Initial incident-driven reports
should be submitted within 7 days of an incident or outbreak. Interim and
final reports for an incident should be submitted within 7 days of report
completion. In addition, the preventive medicine units are required to
provide quarterly lists of all completed deployment OEHS reports to the
command surgeons. The command surgeons review these lists, merge them, and
send CHPPM a quarterly consolidated list of all the deployment OEHS
reports it should have received.
To assess the completeness of its centralized OEHS archive, CHPPM develops
a quarterly summary report that identifies the number of baseline,
routine, and incident-driven reports that have been submitted for all
bases in a command. Additionally, this report summarizes the status of
OEHS report15 submissions by comparing the reports CHPPM received with the
quarterly consolidated lists from the command surgeons that outline each
of the OEHS reports that have been completed. For OIF, CHPPM is required
to provide a quarterly summary report to the commander of U.S. Central
Command16 on the deployed military services' compliance with deployment
OEHS reporting requirements.
Uses of Deployment OEHS Reports
During deployments, military commanders can use deployment OEHS reports
completed and maintained by preventive medicine units to identify
occupational and environmental health hazards17 and to help guide their
risk management decision making. Commanders use an operational risk
management process to estimate health risks based on both the severity of
the risks to servicemembers and the likelihood of encountering specific
14DOD policy does not prescribe a time frame for how long preventive
medicine units have to complete a report.
15CHPPM also receives some deployment OEHS data that have not been
incorporated into a report, such as tables of water sampling measurements.
16The U.S. Central Command is the combatant command responsible for all
OIF operations.
17Along with deployment OEHS reports, commanders also examine medical
intelligence, operational data, and medical surveillance (such as reports
of servicemembers seen by medical units for injury or illness) to identify
occupational and environmental health hazards.
hazards. The operational risk management process, which varies slightly
across the services, includes
o risk assessment, including hazard identification, to describe and
measure the potential hazards at a location;
o risk control and mitigation activities intended to reduce potential
exposures; and
o risk communication efforts to make servicemembers aware of possible
exposures, any risks to health that the exposures may pose, the
countermeasures to be employed to mitigate exposure or disease, and any
necessary medical measures or follow-up required during or after the
deployment.
Commanders balance the risk to servicemembers of encountering occupational
and environmental health hazards while deployed, even following mitigation
efforts, against the need to accomplish specific mission requirements.
Along with health encounter18 and servicemember location data, archived
deployment OEHS reports are needed by researchers to conduct epidemiologic
studies on the long-term health issues of deployed servicemembers. These
data are needed, for example, by VA, which in 2002 expanded the scope of
its health research to include research on the potential long-term health
effects of hazardous military deployments on servicemembers. In a letter
to the Secretary of Defense in 2003, VA said it was important for DOD to
collect adequate health and exposure data from deployed servicemembers to
ensure VA's ability to provide veterans' health care and disability
compensation. VA noted in the letter that much of the controversy over the
health problems of veterans who fought in the 1991 Persian Gulf War could
have been avoided had more extensive surveillance data been collected. VA
asked in the letter that it be allowed access to any unclassified data
collected during deployments on the possible exposure of servicemembers to
environmental hazards of all kinds.
18Examples of health encounter data are medical records of in-patient and
out-patient care, health assessments completed by servicemembers before
and after a deployment, and blood serum samples.
Deployed Military Services Use Varying Approaches to Collect OEHS Data and
Have Not Submitted All OEHS Reports for OIF
The deployed military services generally have collected and reported OEHS
data for OIF, as required by DOD policy. However, the deployed military
services have not used all of the same OEHS data collection standards and
practices, because each service has its own authority to implement broad
DOD policies. To increase data collection uniformity, the Joint
Environmental Surveillance Working Group has made some progress in
devising cross-service standards and practices for some OEHS activities.
In addition, the deployed military services have not submitted all of the
OEHS reports they have completed for OIF to CHPPM's centralized archive,
as required by DOD policy. However, CHPPM officials said that they could
not measure the magnitude of noncompliance because they have not received
all of the required quarterly consolidated lists of OEHS reports that have
been completed. To improve OEHS reporting compliance, DOD officials said
they were revising an existing policy to add additional and more specific
OEHS requirements.
Data Collection Standards and Practices Vary by Service, Although
Preliminary Efforts Are Under Way to Increase Uniformity
OEHS data collection standards19 and practices have varied among the
military services because each service has its own authority to implement
broad DOD policies and the services have taken somewhat different
approaches. For example, although one water monitoring standard has been
adopted by all military services, the services have different standards
for both air and soil monitoring. As a result, for similar OEHS events,
preventive medicine units may collect and report different types of data.
Each military service's OEHS practices for implementing data collection
standards also have differed, due to the varying levels of training and
expertise among the service's preventive medicine units. For example,
CHPPM officials said that Air Force and Navy preventive medicine units had
more specialized personnel with a narrower focus on specific OEHS
activities than Army preventive medicine units, which included more
generalist personnel who conducted a broader range of OEHS activities. Air
Force preventive medicine units generally have included a flight surgeon,
a public health officer, and bioenvironmental engineers. Navy preventive
medicine units generally have included a preventive medicine physician, an
industrial hygienist, a microbiologist, and an entomologist. In contrast,
Army preventive medicine unit personnel generally have consisted of
environmental science officers and technicians.
19OEHS standards generally set out technical requirements for monitoring,
including the type of equipment needed and the appropriate frequency of
monitoring.
DOD officials also said other issues could contribute to differences in
data collected during OIF. DHSD officials said that variation in OEHS data
collection practices could occur as a result of resource limitations
during a deployment. For example, some preventive medicine units may not
be fully staffed at some bases. A Navy official also said that OEHS data
collection can vary as different commanders set guidelines for
implementing OEHS activities in the deployment theater.
To increase the uniformity of OEHS standards and practices for
deployments, the military services have made some progress-particularly in
the last 2 years-through their collaboration as members of the Joint
Environmental Surveillance Working Group. For example, the working group
has developed a uniform standard, which has been adopted by all the
military services, for conducting environmental health site assessments,
which are a type of baseline OEHS report.20 These assessments have been
used in OIF to evaluate potential environmental exposures that could have
an impact on the health of deployed servicemembers and determine the types
of routine OEHS monitoring that should be conducted. Also, within the
working group, three subgroups-laboratory, field water, and equipment-have
been formed to foster the exchange of information among the military
services in developing uniform joint OEHS standards and practices for
deployments. For example, DHSD officials said the equipment subgroup has
been working collaboratively to determine the best OEHS instruments to use
for a particular type of location in a deployment. Another effort by the
working group included devising a joint standard for the amount of OEHS
data needed to sufficiently determine the severity of potential health
hazards at a site. However, DOD officials estimated in late 2004 that it
would take 2 years or more for this standard to be completed and approved.
20This standard was approved in October 2003.
Deployed Military Services Have Not Submitted All Required OEHS Reports for
OIF, and the Magnitude of Noncompliance Is Unknown
The deployed military services have not submitted all the OEHS reports
that the preventive medicine units completed during OIF to CHPPM for
archiving, according to CHPPM officials. Since January 2004, CHPPM has
compiled four summary reports that included data on the number of OEHS
reports submitted to CHPPM's archive for OIF. However, these summary
reports have not provided information on the actual magnitude of
noncompliance with report submission requirements because CHPPM has not
received all consolidated lists of completed OEHS reports that should be
submitted quarterly. These consolidated lists were intended to provide a
key inventory of all OEHS reports that had been completed during OIF.
Because there are no requirements on the specific number or type of OEHS
reports that must be created for each base, the quarterly consolidated
lists are CHPPM's only means of assessing compliance with OEHS report
submission requirements. Our analysis of data supporting the four summary
reports21 found that, overall, 239 of the 277 bases22 had at least one
OEHS baseline (139) or routine (211) report submitted to CHPPM's
centralized archive through December 2004.23
DOD officials suggested several obstacles that may have hindered OEHS
reporting compliance during OIF. For example, CHPPM officials said there
are other, higher priority operational demands that commanders must
address during a deployment, so OEHS report submission may be a lower
priority. In addition, CHPPM officials said that some of the deployed
military services' preventive medicine units might not understand the
types of OEHS reports to be submitted or might view them as an additional
paperwork burden. CHPPM and other DOD officials added that some preventive
medicine units might have limited access to communication equipment to
send reports to CHPPM for archiving.24 CHPPM officials also said that
while they had the sole archiving responsibility, CHPPM did not
21Incident-driven reports reflect OEHS investigations of unexpected
incidents and would not be submitted to CHPPM's archive according to any
identified pattern. Therefore, we did not comment on the services'
submission of incident-driven reports.
22The U.S. Central Command has established and closed bases throughout the
OIF deployment; therefore, the number of bases for each summary report
varied.
23A base may have had both baseline and routine reports submitted to the
OEHS archive.
24DOD officials said that during a deployment, preventive medicine units
share the military's classified communication system with all other
deployed units and transmission of OEHS reports might be a lower priority
than other mission communications traffic. Also, preventive medicine units
might not deploy with communications equipment.
have the authority to enforce OEHS reporting compliance for OIF; this
authority rests with the Joint Staff and the commander in charge of the
deployment.
DOD has several efforts under way to improve OEHS reporting compliance.
CHPPM officials said they have increased communication with deployed
preventive medicine units and have facilitated coordination among each
service's preventive medicine units prior to deployment. CHPPM has also
conducted additional OEHS training for some preventive medicine units
prior to deployment, including both refresher courses and information
about potential hazards specific to the locations where the units were
being deployed. In addition, DHSD officials said they were revising an
existing policy (DOD Instruction 6490.3; see table 1) to add additional
and more specific OEHS requirements. However, at the time of our review, a
draft of the revision had not been released and, therefore, specific
details about these revisions were not available.
Progress Made inUsing OEHS Reports to Address Immediate Health Risks, Though
Limitations Remain for Addressing Both Immediate and Long-term Health Issues
DOD has made progress using OEHS reports to address immediate health risks
during OIF, but limitations remain in employing these reports to address
both immediate and long-term health issues. During OIF, OEHS reports have
been used as part of operational risk management activities intended to
assess, mitigate, and communicate to servicemembers any potential hazards
at a location. While there have been no systematic efforts by DOD or the
military services to establish a system to monitor the implementation of
OEHS risk management activities, DHSD officials said relatively low rates
of disease and nonbattle injury in OIF were considered an indication of
OEHS effectiveness. In addition, DOD's centralized archive of OEHS reports
for OIF is limited in its ability to provide information on the potential
long-term health effects related to occupational and environmental
exposures for several reasons, including limited access to most OEHS
reports because of security classification, incomplete data on
servicemembers' deployment locations, and the lack of a comprehensive
federal research plan incorporating the use of archived OEHS reports.
Progress Made in Using Deployment OEHS Data and Reports in Risk Management,
but DOD Does Not Monitor Implementation of These Efforts
To identify and reduce the risk of immediate health hazards in OIF, all of
the military services have used preventive medicine units' OEHS data and
reports in an operational risk management process. A DOD official said
that while DOD had begun to implement risk management to address
occupational and environmental hazards in other recent deployments, OIF
was the first major deployment to apply this process throughout the
deployed military services' day-to-day activities, beginning at the start
of the operation.25 The operational risk management process includes risk
assessments of deployment locations, risk mitigation activities to limit
potential exposures, and risk communication to servicemembers and
commanders about potential hazards.
o Risk Assessments. Preventive medicine units from each of the services
have generally used OEHS information and reports to develop risk
assessments that characterized known or potential hazards when new bases
were opened in OIF. CHPPM's formal risk assessments have also been
summarized or updated to include the findings of baseline and routine OEHS
monitoring conducted while bases are occupied by servicemembers, CHPPM
officials said. During deployments, commanders have used risk assessments
to balance the identified risk of occupational and environmental health
hazards, and other operational risks, with mission requirements.
Alternatively, some preventive medicine units have addressed hazards
identified through risk assessments without initially involving a
commander. A Navy official said that, for example, if a preventive
medicine unit found elevated bacteria levels when monitoring a drinking
water purification system, the unit would likely order that the system be
shut down and corrected and then notify the commander of the action in a
summary report of OEHS activities. Generally, OEHS risk assessments for
OIF have involved analysis of the results of air, water, or soil
monitoring.26 CHPPM officials said that most risk assessments that they
have received
25OEHS risk management began to be employed during previous deployments,
such as Operation Joint Guardian in Kosovo and Operation Enduring Freedom
in Central Asia, but it was not formally adopted as a tool to assess
deployment health hazards until 2002. See Office of the Chairman, The
Joint Chiefs of Staff, Memorandum MCM-0006-02, "Updated Procedures for
Deployment Health Surveillance and Readiness," Feb. 1, 2002.
26An Army operational risk management field manual describes the steps in
determining risk level, including identifying the hazard, assessing the
severity of the hazard, and determining the probability that the hazard
will occur. DOD has also developed technical guides that detail toxicity
thresholds and associated potential health effects from exposure to
hazards.
characterized locations in OIF as having a low risk of posing health
hazards to servicemembers.27
o Risk Control and Mitigation. Using risk assessment findings, preventive
medicine units have recommended risk control and mitigation activities to
commanders that were intended to reduce potential exposures at specific
locations. For OIF, risk control and mitigation recommendations at bases
have included such actions as modifying work schedules, requiring
individuals to wear protective equipment, and increasing sampling to
assess any changes and improve confidence in the accuracy of the risk
estimate.
o Risk Communication. Risk assessment findings have also been used in
risk communication efforts, such as providing access to information on a
Web site or conducting health briefings to make servicemembers aware of
occupational and environmental health risks during a deployment and the
recommended efforts to control or mitigate those risks, including the need
for medical follow-up. Many of the risk assessments for OIF we reviewed
recommended that health risks be communicated to servicemembers.
The experience at Port Shuaiba, Kuwait, provides an illustration of the
risk management process. Officials determined that Port Shuaiba, which had
a moderate risk rating in numerous OEHS risk assessments, had the highest
assessed risk for potential environmental exposures identified in OIF. The
site is a deepwater port used for bringing in heavy equipment in support
of OIF, and a large number of servicemembers have been permanently or
temporarily stationed at this site. CHPPM officials said reported concerns
about air quality problems, such as sulfur dioxide emissions and windblown
dust and sand particles, and the concentration of a large number of
industrial facilities28 at Port Shuaiba led to this risk characterization
as a result of multiple OEHS risk assessments conducted before and during
OIF.29 Risk mitigation recommendations that have been
27Risk assessments are used to designate identified occupational or
environmental health risks as posing a low, moderate, high, or extremely
high risk to servicemembers.
28Industrial facilities located at Port Shuaiba include a fertilizer
plant; natural gas processing and liquid petroleum gas storage facilities;
a concrete company; petrochemical, hydrochloric acid, chlorine, caustic
soda, and methanol plants; and three petroleum refineries.
29OEHS activities have been conducted at Port Shuaiba since 1999.
implemented at Port Shuaiba include increasing air monitoring to
continuous, 24-hour sampling; implementing the use of standard protective
equipment, such as goggles and face kerchiefs; and using dust suppression
measures, such as laying gravel over the entire location to reduce dust.
CHPPM officials said they were uncertain whether some other risk
mitigation recommendations for Port Shuaiba had been implemented, such as
requiring servicemembers to stay inside buildings or tents as much as
possible when air pollution levels are high or increasing the number of
servicemembers available for operations to reduce the duration of shifts.
On the basis of recommendations from the risk assessments, military
officials have been attempting to transfer the activities at Port Shuaiba
to a nearby port that does not have industrial facilities,30 but
servicemembers have continued to live and work at the site, though in
greatly reduced numbers, CHPPM officials said. CHPPM officials said they
have recommended extensive risk communication activities at Port Shuaiba,
including providing information to servicemembers in town hall meetings
and through posters and handouts in dining facilities. In addition, CHPPM
officials said they have worked with commanders to allow CHPPM to provide
briefings about the identified and potential health hazards as soon as new
military units arrive at Port Shuaiba.
While risk management activities have become more widespread in OIF
compared with previous deployments, DOD officials have not conducted
systematic monitoring of deployed military services' efforts to conduct
OEHS risk management activities. As of March 2005, neither DOD nor the
military services had established a system to examine whether required
risk assessments had been conducted, or to record and track resulting
recommendations for risk mitigation or risk communication activities. In
the absence of a systematic monitoring process, CHPPM officials said they
conducted ad hoc reviews of implementation of risk management
recommendations for sites where continued, widespread OEHS monitoring has
occurred, such as at Port Shuaiba and other locations with elevated risks.
DHSD officials said they have initiated planning for a comprehensive
quality assurance program for deployment health that would address OEHS
risk management, but the program was still under development.
30Port Shuaiba has been the only deepwater port able to accommodate the
unloading of heavy military equipment in support of OIF; however, efforts
are under way to refurbish a nearby port to provide this capability.
DHSD and military service officials said that developing a monitoring
system for risk management activities would face several challenges. In
response to recommendations for risk mitigation and risk communication
activities, commanders may have issued written orders and guidance that
were not always stored in a centralized, permanent database that could be
used to track risk management activities. Additionally, DHSD officials
told us that risk management decisions have sometimes been recorded in
commanders' personal journals or diaries, rather than issued as orders
that could be stored in a centralized, permanent database.
In lieu of a monitoring system, DHSD officials said the rates of disease
and nonbattle injury in OIF are considered by DOD as a general measure or
indicator of OEHS effectiveness. As of January 2005, OIF had a 4 percent
total disease and nonbattle injury rate-in other words, an average of 4
percent of servicemembers deployed in support of OIF had been seen by
medical units for an injury or illness in any given week. This rate is the
lowest DOD has ever documented for a major deployment, according to DHSD
officials. For example, the total disease and nonbattle injury rate for
the 1991 Gulf War was about 6.5 percent, and the total rate for Operation
Enduring Freedom in Central Asia has been about 5 percent. However, while
this indicator provides general information on servicemembers' health
status, it is not directly linked to specific OEHS activities and
therefore is not a clear measure of their effectiveness.
Access to Most Archived OEHS Reports Is Limited by Security Classification
Access to archived OEHS reports by VA, medical professionals, and
interested researchers has been limited by the security classification of
most OEHS reports.31 Typically, OEHS reports are classified if the
specific location where monitoring activities occur is identified. VA
officials said they would like to have access to OEHS reports in order to
ensure appropriate postwar health care and disability compensation for
veterans, and to assist in future research studies. However, VA officials
said that they did not expect access to OEHS reports to improve until OIF
has ended because of security concerns.
Although access to OEHS reports has been restricted, VA officials said
they have tried to anticipate likely occupational and environmental health
31Individuals desiring to review classified documents must have the
appropriate level of security clearance and a need to access the
information. VA officials have been able to access some OEHS data on a
case-by-case basis.
concerns for OIF based on experience from the 1991 Persian Gulf War and on
CHPPM's research on the medical and environmental health conditions that
exist or might develop in the region. Using this information, VA has
developed study guides for physicians on such topics as health effects
from radiation and traumatic brain injury and also has written letters for
OIF veterans about these issues.
DOD has begun reviewing classification policies for OEHS reports, as
required by the Ronald W. Reagan National Defense Authorization Act for
Fiscal Year 2005.32 A DHSD official said that DOD's newly created Joint
Medical Readiness Oversight Committee is expected to review ways to reduce
or limit the classification of data, including data that are potentially
useful for monitoring and assessing the health of servicemembers who have
been exposed to occupational or environmental hazards during deployments.
Difficulties Exist in Linking Archived OEHS Reports to Individual
Servicemembers, but Some Efforts Are Under Way to Include Information in
Medical Records
Linking OEHS reports from the archive to individual servicemembers will be
difficult because DOD's centralized tracking database for recording
servicemembers' deployment locations currently does not contain complete
or comparable data. In May 1997, we reported that the ability to track the
movement of individual servicemembers within the theater is important for
accurately identifying exposures of servicemembers to health hazards.33
However, DMDC's centralized database has continued to experience problems
in obtaining complete, comparable data from the services on the location
of servicemembers during deployments, as required by DOD policies.34 DMDC
officials said the military services had not reported location data for
all servicemembers for OIF. As of October
32Pub. L. No. 108-375, S:735, 118 Stat. 1811, 1999 (2004).
33GAO, Defense Health Care: Medical Surveillance Improved Since Gulf War,
but Mixed Results in Bosnia, GAO/NSIAD-97-136 (Washington D.C.: May 13,
1997).
34DOD policy requires DMDC to maintain a system that collects information
on deployed forces, including daily-deployed strength, in total and by
unit; grid coordinate locations for each unit (company size and larger);
and inclusive dates of individual servicemembers' deployment. See DOD
Instruction 6490.3, "Implementation and Application of Joint Medical
Surveillance for Deployment," Aug. 7, 1997. In addition, a 2002 DOD policy
requires combatant commands to provide DMDC with rosters of all deployed
personnel, their unit assignments, and the unit's geographic locations
while deployed. See Office of the Chairman, The Joint Chiefs of Staff,
Memorandum MCM-0006-02, "Updated Procedures for Deployment Health
Surveillance and Readiness," Feb. 1, 2002.
2004, the Army, Air Force, and Marine Corps each had submitted location
data for approximately 80 percent of their deployed servicemembers, and
the Navy had submitted location data for about 60 percent of its deployed
servicemembers.35 Additionally, the specificity of location data has
varied by service. For example, the Marine Corps has provided location of
servicemembers only by country, whereas each of the other military
services has provided more detailed location information for some of their
servicemembers, such as base camp name or grid coordinate locations.
Furthermore, the military services did not begin providing detailed
location data until OIF had been ongoing for several months.
DHSD officials said they have been revising an existing policy36 to
provide additional requirements for location data that are collected by
the military services, such as a daily location record with grid
coordinates or latitude and longitude coordinates for all servicemembers.
Though the revised policy has not been published, as of May 2005 the Army
and the Marine Corps had implemented a new joint location database in
support of OIF that addresses these revisions.
During OIF, some efforts have been made to include information about
specific incidents of potential and actual exposure to occupational or
environmental health hazards in the medical records of servicemembers who
may be affected. According to DOD officials, after preventive medicine
units have investigated incidents involving potential exposure, they
generally have developed narrative summaries of events and the results of
any medical procedures for inclusion in affected servicemembers' medical
records. Additionally, rosters were generally developed of servicemembers
directly affected and of servicemembers who did not have any acute
symptoms but were in the vicinity of the incident. For example, in
investigating an incident involving a chemical agent used in an improvised
explosive device, CHPPM officials said that two soldiers who were directly
involved were treated at a medical clinic, and their treatment and the
exposure were recorded in their medical records. Although 31
servicemembers who were providing security in the
35The military services submitted location data for both OIF and Operation
Enduring Freedom in Central Asia; DMDC officials said they were unable to
separate the data from the two operations.
36DOD Instruction 6490.3, "Implementation and Application of Joint Medical
Surveillance for Deployment," Aug. 7, 1997.
area were asymptomatic, doctors were documenting this potential exposure
in their medical records.
In addition, the military services have taken some steps to include
summaries of potential exposures to occupational and environmental health
hazards in the medical records of servicemembers deployed to specific
locations. The Air Force has created summaries of these hazards at
deployed air bases and has required that these be placed in the medical
records of all Air Force servicemembers stationed at these bases. (See
app. II for an example.) However, Air Force officials said no follow-up
activities have been conducted specifically to determine whether all Air
Force servicemembers have had the summaries placed in their medical
records. In addition, the Army and Navy jointly created a summary of
potential exposure for the medical records of servicemembers stationed at
Port Shuaiba. Since December 2004, port officials have made efforts to
make the summary available to servicemembers stationed at Port Shuaiba so
that these servicemembers can include the summary in their medical
records. However, there has been no effort to retroactively include the
summary in the medical records of servicemembers stationed at the port
prior to that time.
No Federal Research Plan Exists for Using OEHS Reports to Follow the Health
of OIF Servicemembers over Time
According to DOD and VA officials, no federal research plan that includes
the use of archived OEHS reports has been developed to evaluate the
longterm health of servicemembers deployed in support of OIF, including
the effects of potential exposure to occupational or environmental
hazards. In February 1998 we noted that the federal government lacked a
proactive strategy to conduct research into Gulf War veterans' health
problems and suggested that delays in planning complicated researchers'
tasks by limiting opportunities to collect critical data.37 However, the
Deployment Health Working Group, a federal interagency body responsible
for coordinating research on all hazardous deployments, recently began
discussions on the first steps needed to develop a research plan for
OIF.38 At its January 2005 meeting, the working group tasked its research
subcommittee to develop a complete list of research projects currently
under way that may be related to OIF.39 VA officials noted that because
OIF
37GAO, Gulf War Illnesses: Federal Research Strategy Needs Reexamination,
GAO/T-NSIAD-98-104 (Washington D.C.: Feb. 24, 1998).
38The Deployment Health Working Group includes representatives from DOD,
VA, and HHS.
is ongoing, the working group would have to determine how to address a
study population that changes as the number of servicemembers deployed in
support of OIF changes.40
Although no coordinated federal research plan has been developed, there
are some separate federal research studies under way that may follow the
health of OIF servicemembers. For example, in 2000 VA and DOD collaborated
to develop the Millennium Cohort study, a 21-year longitudinal study
evaluating the health of both deployed and nondeployed military personnel
throughout their military careers and after leaving military service.
According to the principal investigator, the Millennium Cohort study was
designed to examine the health effects of specific deployments if enough
servicemembers in that deployment enrolled in the study. However, the
principal investigator said that as of February 2005 researchers had not
identified how many servicemembers deployed in support of OIF had enrolled
in the study. Additionally, a VA researcher has received funding to study
mortality rates among OIF servicemembers. According to the researcher, if
occupational and environmental data are available, the study will include
the evaluation of mortality outcomes in relation to potential exposure for
OIF servicemembers.
Conclusions Since the 1991 Persian Gulf War, DOD has made progress in
improving occupational and environmental health data collection through
its development of a militarywide health surveillance framework for use
during deployments. However, these efforts still could be strengthened.
OEHS data that the deployed military services have collected during OIF
may not always be comparable because of variations among the services'
data collection standards and practices. As a result of these variations,
the amount and comprehensiveness of data for servicemembers from one
military service may be more extensive than for servicemembers from
another service. Additionally, the deployed military services' uncertain
compliance with OEHS report submission requirements casts doubts on the
completeness of CHPPM's OEHS archive. These data shortcomings, in
conjunction with the incomplete data in DOD's centralized tracking
database of servicemembers' deployment locations, limit CHPPM's ability
39This effort also includes identifying research for Operation Enduring
Freedom.
40Epidemiologic studies generally have a fixed study population that does
not vary over time, according to VA officials.
to respond to requests for OEHS information about possible exposure to
occupational and environmental health hazards of those who are serving or
have served in OIF. Other limitations may also impede the
comprehensiveness of the archived OEHS reports, including the inability to
collect OEHS data outside of base camps and a lack of knowledge of all
potential health hazards. Nonetheless, these limitations do not outweigh
the need to collect data on known or expected hazards in order to make
every effort to address potential health issues. DHSD officials have said
they are revising an existing policy on OEHS data collection and reporting
to add additional and more specific OEHS requirements. However, unless the
military services take measures to direct those responsible for OEHS
activities to proactively implement the new requirements, the services'
efforts to collect and report OEHS data may not improve.
DOD's risk management efforts during OIF represent a positive step in
helping to mitigate potential environmental and occupational risks of
deployment. But the effects of such efforts are unknown without systematic
monitoring of the deployed military services' implementation activities.
Rates of disease and nonbattle injury have been used as an overall
surrogate outcome measure for risk management in OIF, but DOD and the
military services currently are unable to ascertain how and to what extent
risk management efforts have contributed to the relatively low disease and
nonbattle injury rate for OIF.
Although OEHS reports alone are not sufficient to identify the causes of
potential long-term health effects in deployed servicemembers, they are an
integral component of research to evaluate the long-term health of
deployed servicemembers. However, efforts by a joint DOD and VA working
group to develop a federal research plan for OIF that would include
examining the effects of potential exposure to occupational and
environmental health hazards have just begun, despite similarities in
deployment location to the 1991 Persian Gulf War. Unless DOD addresses
OEHS data collection and reporting weaknesses and develops a federal
research plan for OIF with VA, the departments ultimately may face the
same criticisms they faced following the first Gulf War over their
inability to adequately address the long-term health issues of
servicemembers.
Recommendations for We are making recommendations aimed at improving the
collection and reporting of OEHS data during deployments and improving
OEHS risk
Executive Action management. To improve the collection and reporting of
OEHS data during deployments and the linking of OEHS reports to
servicemembers, we
recommend that the Secretary of Defense ensure that cross-service guidance
is created to implement DOD's policy, once that policy has been revised,
which addresses improvements to conducting OEHS activities and to
reporting the locations of servicemembers during deployment.
To improve the use of OEHS reports to address the immediate health risks
of servicemembers during deployments, we recommend that the Secretary of
Defense ensure that the military services jointly establish and implement
procedures to evaluate the effectiveness of risk management efforts.
To better anticipate and understand the potential long-term health effects
of deployment in support of OIF, we recommend that the Secretary of
Defense and the Secretary of Veterans Affairs work together to develop a
federal research plan to follow the health of these servicemembers that
would include the use of archived OEHS reports.
Agency Comments and Our Evaluation
We requested comments on a draft of this report from DOD and VA. Both
agencies provided written comments that are reprinted in appendixes III
and IV. DOD also provided technical comments that we incorporated where
appropriate.
In commenting on this draft, DOD did not concur with our recommendation
that the military services jointly develop implementation guidance for
DOD's policy on OEHS during deployments, once that policy has been
revised. However, DOD stated that officials are planning steps that will
meet the intent of our recommendation to improve the collection and
reporting of OEHS data during deployments. DHSD officials stated that
cross-service implementation guidance for the revised policy on deployment
OEHS would be developed by the Joint Staff instead of by the individual
military services, as we originally recommended. We believe that the
development of cross-service implementation guidance is a critical element
needed to improve OEHS data collection and reporting during deployments,
regardless of the entity responsible for developing this guidance.
Therefore, we modified the wording of our recommendation to clarify our
intent that joint guidance be developed.
DOD partially concurred with our recommendation that the military services
jointly establish and implement procedures to evaluate the effectiveness
of risk management efforts. DOD stated that OEHS reports would be of no
value for "immediate" health risks, except for incidentdriven reports, and
assumed that we were referring to health risks that may
occur once servicemembers return from a deployment. However, our findings
describe the OEHS operational risk management process that is specifically
conducted during a deployment, including risk assessment, risk mitigation,
and risk communication activities that are used to identify and reduce the
risk of immediate health hazards. Additionally, DOD stated that it has
procedures in place to evaluate OEHS risk management through a jointly
established and implemented lessons learned process. Because the lessons
learned process was not raised by agency officials during our review, we
did not determine whether it would systematically monitor or evaluate the
effectiveness of OEHS risk management activities. However, in further
discussions, DHSD officials told us that they were not aware of any
lessons learned reports related to OEHS risk management for OIF.
DOD partially concurs with our recommendation that DOD and VA work
together to develop a federal research plan to follow the health of
servicemembers deployed in support of OIF that would include the use of
archived OEHS reports. Although DOD states that it agrees with the
importance of following the health of its servicemembers, its response
focuses on initiatives for the electronic exchange of clinical health
information with VA. In further discussions, DHSD officials explained that
analysis of this clinical information could lead to the development of
research hypotheses and, ultimately, research questions that would guide
federal health research. Although DOD officials stated that they have not
yet linked any occupational or environmental exposures to specific adverse
health effects, there is no certainty that long-term health effects
related to these types of exposures will not appear in veterans of OIF.
Federal research has not clearly identified the causes of unexplained
illnesses reported by servicemembers who served in the 1991 Persian Gulf
War, and OIF servicemembers are serving in the same region for longer
periods of time.
Separately, VA concurred with our recommendation to work jointly with DOD
to develop a federal research plan to follow the health of OIF
servicemembers. VA confirmed that the Deployment Health Working Group,
which includes DOD officials, had initiated steps in January 2005 toward
developing a comprehensive joint federal surveillance plan to evaluate the
long-term health of servicemembers returning from both OIF and Operation
Enduring Freedom (OEF). However, more importantly, the difference in VA
and DOD's responses to this recommendation illustrates a disconnect
between each agency's understanding of whether and how such a federal
research plan should be established. Therefore, continued collaboration
between the agencies to formulate a mutually agreeable
process for proactively creating a federal research plan would be
beneficial in facilitating both agencies' ability to anticipate and
understand the potential long-term health effects related to OIF
deployment versus taking a more reactive stance in waiting to see what
types of health problems may surface.
In its response, VA also contends that we overstate problems related to
its ability to access DOD's classified occupational and environmental
health data. VA notes that it has staff with the necessary security
clearances to examine classified OEHS reports, so that there is no barrier
to access. However, during our review VA officials expressed concerns that
they did not have OEHS data and that access to the data was difficult.
Even if VA staff have security clearances that enable them to examine OEHS
data, any materials that arise from the use of classified documents, such
as research papers or other publications, would likely be restricted.
Therefore, these results would have limited use, as they cannot be broadly
shared with other researchers and the general public. Nonetheless, VA
maintains that development of a systematic method to tabulate and organize
the exposure data is needed, as is a complete roster of OIF and OEF
veterans, pre-and post-deployment health screening data, and a complete
roster of the most seriously injured veterans. We agree that a systematic
method to organize and share OEHS data is important. This issue could be
addressed within the efforts to develop a federal research plan.
As arranged with your office, unless you release its contents earlier, we
plan no further distribution of this report until 30 days after its
issuance date. At that time, we will send copies of this report to the
Secretary of Defense and the Secretary of Veterans Affairs. We will also
provide copies to others upon request. In addition, the report will be
available at no charge on GAO's Web site at http://www.gao.gov.
If you or your staff has any questions about this report, please call me
at (202) 512-7119. Bonnie Anderson, Karen Doran, John Oh, Danielle
Organek, and Roseanne Price also made key contributions to this report.
Sincerely yours,
Marcia Crosse Director, Health Care
Appendix I
Scope and Methodology
To describe how the military services have implemented the Department of
Defense's (DOD) policies for collecting and reporting occupational and
environmental health surveillance (OEHS) data for Operation Iraqi Freedom
(OIF), we reviewed pertinent DOD policies and military services' guidance
that delineated the requirements for OEHS data collection and reporting.
We interviewed officials at the Deployment Health Support Directorate
(DHSD) and the Joint Staff to obtain a broad overview of DOD's OEHS
activities in OIF. We also interviewed officials at each of the military
services' health centers-the U.S. Army Center for Health Promotion and
Preventive Medicine (CHPPM), the Navy Environmental Health Center, and the
Air Force Institute for Operational Health-to obtain information about
each service's OEHS data collection standards and practices, training of
preventive medicine units for OIF, obstacles that could hinder OEHS data
collection and reporting, and efforts to improve reporting compliance.
Additionally, we interviewed members of the Joint Environmental
Surveillance Working Group to discuss the purpose and structure of the
working group and efforts related to increasing the uniformity of OEHS
standards and practices for deployments.
To determine if the military services were submitting OEHS reports to
CHPPM's centralized archive, we obtained and reviewed CHPPM's quarterly
summary reports, which provided the total number of bases that have
submitted at least one report in each of the categories of baseline,
routine, or incident-driven reports for the U.S. Central Command's
(CENTCOM) area of responsibility, details about consolidated lists of
reports, and information about other OEHS reporting compliance issues. The
summary reports did not show report submission by individual bases or,
other than for the first summary report, separately identify OIF bases
from all others in the CENTCOM area of responsibility. For each of the
summary reports, CHPPM provided us with supporting documents that included
lists of the bases specific to OIF and, for each base, whether it had
submitted baseline, routine, or incident-driven reports. We attempted to
include only unique OIF bases in our analysis; however, CHPPM officials
told us that a few duplicate OIF bases may be included in our analysis due
to reasons such as frequent base openings and closures and base name
changes. We used these supporting documents to identify the number and
percentage of bases with and without baseline or routine reports during
the reporting periods. Incident-driven reports reflect OEHS investigations
of unexpected incidents and would not be submitted to CHPPM's archive
according to any identified pattern. Therefore, we did not review the
services' submission of incident-driven reports. Because OEHS reports
Appendix I Scope and Methodology
generally are classified, we did not report on the specifics contained in
these reports.
We determined that the data from CHPPM's OEHS archive were sufficiently
reliable for the purposes of this report by (1) confirming the data
included the elements that we requested and were consistent with provided
documentation and (2) conducting detailed fact-finding interviews with
CHPPM officials to understand how the data were obtained and to determine
the limitations of the data. To characterize the OEHS reports for OIF
submitted to CHPPM, we discussed the numbers of reports submitted and
characterized the categories of reports using percentages. While the OEHS
reports were contained in a computerized archive, there was no formal
database in which the information from the reports could have been
extracted into data fields. Instead, the archived reports were Microsoft
Word documents, Microsoft Excel spreadsheets, Adobe Acrobat files, scanned
images, or e-mail text that were organized by either military base or type
of report. Therefore, there was no specific database with data fields that
could be examined through a data reliability test.
To identify the efforts to use OEHS reports to address the more immediate
health issues of servicemembers deployed in support of OIF, we reviewed
DOD policies and documents describing the operational risk management
process. Additionally, we reviewed 28 risk assessment reports and the risk
mitigation efforts and risk communication activities that resulted from
these assessments. We also reviewed and summarized risk management
activities for Port Shuaiba, Kuwait. We interviewed officials from CHPPM
responsible for OEHS risk management activities at Port Shuaiba and
discussed quality assurance efforts related to these activities. We also
interviewed officials from DHSD about additional OEHS-related quality
assurance programs.
To identify the efforts under way to use OEHS reports to address the
longterm health issues of servicemembers deployed in support of OIF, we
interviewed Department of Veterans Affairs (VA) and DOD officials to
examine access to OEHS reports and use of OEHS reports for VA, and
reviewed laws relating to classification of documents. Additionally, we
reviewed relevant VA documents to determine the ways in which VA can use
OEHS reports and to determine its efforts to anticipate OEHS issues.
To determine the difficulties in linking OEHS reports to the individual
records of servicemembers, we interviewed officials and military
representatives at DOD's Defense Manpower Data Center (DMDC)
Appendix I Scope and Methodology
regarding the status of the Contingency Tracking System, a centralized
tracking database to identify deployed servicemembers and track their
movements within the theater of operations. To help identify problems with
this system, we asked DMDC to provide information about the amount of
location data submitted by each military service to this database. To
assess the reliability of the data submitted by each military service, we
(1) interviewed DMDC officials about limitations of the system and (2)
confirmed that the data included the elements we requested and were
consistent with provided documentation. We tested the data electronically
to ensure that the numbers were accurately calculated. Given our research
questions and discussions with DMCD officials regarding the centralized
system, we determined that these data were reliable for our purposes.
We interviewed CHPPM officials to examine efforts to include information
from investigations of potential exposures to occupational and
environmental health hazards in servicemembers' medical records, and
reviewed summary documents related to potential occupational and
environmental exposures. We also interviewed Army, Air Force, and Navy
officials to discuss these summary documents and determine efforts in
place to ensure that these documents were placed in the medical records.
We also examined other documents, including DOD policies, federal laws,
and interagency coordinating council meeting minutes relating to OEHS.
We interviewed DOD and VA officials to determine whether a federal
research plan using OEHS reports had been developed to evaluate the
longterm health of servicemembers deployed in support of OIF. We also
reviewed documents, including the meeting minutes of an interagency group
and documents relating to a current collaborative study between DOD and
VA. We performed our work from September 2004 through June 2005 in
accordance with generally accepted government auditing standards.
Appendix II
Example of an Occupational and Environmental Health Surveillance Summary
Created by the Air Force during Operation Iraqi Freedom
Appendix II
Example of an Occupational and
Environmental Health Surveillance Summary
Created by the Air Force during Operation
Iraqi Freedom
Appendix III
Comments from the Department of Defense
Appendix III
Comments from the Department of Defense
Appendix IV
Comments from the Department of Veterans Affairs
Appendix IV
Comments from the Department of Veterans
Affairs
Appendix IV
Comments from the Department of Veterans
Affairs
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