Defense Health Care: Occupational and Environmental Health	 
Surveillance Conducted During Deployments Needs Improvement	 
(19-JUL-05, GAO-05-903T).					 
                                                                 
Following the 1991 Persian Gulf War, research and investigations 
into the causes of servicemembers' unexplained illnesses were	 
hampered by a lack of servicemember health and deployment data,  
including 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. This  
testimony is based on GAO's report, entitled Defense Health Care:
Improvements Needed in Occupational and Environmental Health	 
Surveillance during Deployment to Address Immediate and Long-term
Heath Issues (GAO-05-632). The testimony presents findings about 
how the deployed military services have implemented DOD's	 
policies for collecting and reporting OEHS data for Operation	 
Iraqi Freedom (OIF) and 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-05-903T					        
    ACCNO:   A30339						        
  TITLE:     Defense Health Care: Occupational and Environmental      
Health Surveillance Conducted During Deployments Needs		 
Improvement							 
     DATE:   07/19/2005 
  SUBJECT:   Data collection					 
	     Hazardous substances				 
	     Health hazards					 
	     Health services administration			 
	     Military personnel 				 
	     Military policies					 
	     Occupational health and safety programs		 
	     Occupational health standards			 
	     Occupational safety				 
	     Retired military personnel 			 
	     Risk assessment					 
	     Safety standards					 
	     Standards evaluation				 
	     Military health services				 
	     Preventive health care services			 
	     DOD Operation Iraqi Freedom			 
	     Persian Gulf War					 

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GAO-05-903T

     

     * Background
          * Federal OEHS Policy
          * DOD Entities Involved with Setting and Implementing OEHS Pol
          * Deployment OEHS Reports
          * OEHS Reporting and Archiving Activities during Deployment
          * Uses of Deployment OEHS Reports
     * Deployed Military Services Use Varying Approaches to Collect
          * Data Collection Standards and Practices Vary by Service, Alt
          * Deployed Military Services Have Not Submitted All Required O
     * Progress Made in Using OEHS Reports to Address Immediate Hea
          * DOD Has Made Progress in Using Deployment OEHS Data and Repo
          * Access to Most Archived OEHS Reports Is Limited by Security
          * Difficulties Exist in Linking Archived OEHS Reports to Indiv
          * No Federal Research Plan Exists for Using OEHS Reports to Fo
     * Concluding Observations
     * GAO Contact and Staff Acknowledgments
          * Order by Mail or Phone

Testimony

Before the Subcommittee on National Security, Emerging Threats, and
International Relations, Committee on Government Reform, House of
Representatives

United States Government Accountability Office

GAO

For Release on Delivery Expected at 10:30 a.m. EDT

Tuesday, July 19, 2005

DEFENSE HEALTH CARE

Occupational and Environmental Health Surveillance Conducted during
Deployments Needs Improvement

Statement of Marcia Crosse

Director, Health Care

GAO-05-903T

Mr. Chairman and Members of the Subcommittee:

I am pleased to be here today as you consider the efforts by the deployed
military services to implement policies for collecting and reporting
occupational and environmental health surveillance data for Operation
Iraqi Freedom (OIF) and the work under way to use these data to address
both the immediate and long-term health issues of servicemembers deployed
in support of OIF. The health effects from service in military operations
have been of increasing interest since the end of the 1991 Persian Gulf
War-an interest that was renewed when servicemembers were deployed in
early 2003 to the Persian Gulf in support of OIF. Following the 1991 Gulf
War, many servicemembers reported suffering from unexplained illnesses
that they attributed to their service in the Persian Gulf and expressed
concerns about 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.

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 for
use during deployments beginning in 1997. 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 specified
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.
Throughout this testimony, we identify the military services operating in
a deployment as "deployed military services."

My remarks will summarize our findings 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. My statement is based on our report, entitled Defense
Health Care: Improvements Needed in Occupatonal and Environmenta Heah
Surveance during Deployments o Address Immediae and Long-erm Health Issues
( GAO-05-632 ), which is being released today.

To do this 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 Deployment
Manpower Data Center 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 to evaluate the long-term health of servicemembers
deployed in support of OIF using OEHS reports. We conducted our work from
September 2004 through June 2005 in accordance with generally accepted
government auditing standards.

In summary, 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 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, as required by 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 the services'
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. In addition, OEHS report submission may be
given a lower priority 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.

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.

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 is 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. Additionally, 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.

In the report we are issuing today, we recommend that the Secretary of
Defense ensure that cross-service guidance is developed to implement DOD's
revised policy for OEHS during deployments and ensure that the military
services jointly establish and implement procedures to evaluate the
effectiveness of risk management strategies during deployments. We also
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 OIF servicemembers over time that would include the use of OEHS
reports. In commenting on a draft of this report, DOD stated that
cross-service guidance meeting the intent of our recommendation would be
developed by the Joint Staff instead of the military services. 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

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
high-level exposures that result in immediate health effects.3 Health
hazards may also include low-level exposures that could result in delayed
or long-term health effects. Occupational and environmental health hazards
may include such things as contamination from the past use of a site, from
battle damage, from stored stockpiles, from military use of hazardous
materials, or from other sources.

Federal OEHS Policy

As a result of numerous investigations that found inadequate data on
deployment occupational and environmental exposure to identify the
potential causes of unexplained illnesses among veterans who served in the
1991 Persian Gulf War, the federal government 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 105-85 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 that have guided the collection and reporting of
deployment OEHS data.

3Harmful levels of environmental contaminants are determined by the
concentration of the substance and the duration of exposure.

4Presidential Review Directive/National Science and Technology Council - 5
(April 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").

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 OEHS health surveillance centers, the Joint Staff, other DOD
entities, and VA.

Each service has a health surveillance center-the 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 the
theater in order to carry out deployment OEHS activities in accordance
with DOD policy. In addition, these 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 developed by 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.)

6The 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.

7Each 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.

Figure 1: Entities Involved in Setting or Implementing Occupational and
Environmental Health Surveillance (OEHS) Policy

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
incident-driven.

           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 location 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 in combat and limits on the portability
           of OEHS equipment. In addition, DHSD officials said that
           preventive medicine units might not be aware of every potential
           health hazard and therefore might be unable to conduct appropriate
           OEHS activities.

           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 surgeons,12 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.)

           Figure 2: Submittal of Deployment Occupational and Environmental
           Health Surveillance (OEHS) Reports to the Centralized Archive

           aThe 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.

           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. This report also summarizes
           the status of OEHS report15 submissions by comparing the reports
           CHPPM receives with the quarterly consolidated lists from the
           command surgeons that list 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.

           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 the specific hazard. 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. 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 they may pose, the
           countermeasures to be employed to mitigate exposure or disease
           outcome, and any necessary medical measures or follow-up required
           during or after the deployment.

           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 on
           servicemembers in hazardous military deployments. 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.

           The deployed military services generally have collected and
           reported OEHS data for OIF, as required by DOD policy. However,
           the deployed military services have used different 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.

           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 because of 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.

           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.

           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 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. 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 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 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 the
           revision were not available.

           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.
           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.
           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, although DHSD officials said they
           considered the relatively low rates of disease and nonbattle
           injury in OIF 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 their security classification, incomplete data on
           servicemembers' deployment locations, and the lack of a
           comprehensive federal research plan incorporating the use of
           archived OEHS reports.

           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. 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 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.

           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, Kuwait, a
           deepwater port where a large number of servicemembers have been
           stationed, or 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.

           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 that DOD
           considers the rates of disease and nonbattle injury in OIF 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 archived OEHS reports by VA, medical professionals, and
           interested researchers has been limited by the security
           classification of most OEHS reports.28 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, because of these security concerns, they did not expect
           access to OEHS reports to improve until OIF has ended.

           Although access to OEHS reports has been restricted, VA officials
           said they have tried to anticipate likely occupational and
           environmental health concerns for OIF based on experience from the
           1991 Persian Gulf War and on CHPPM's research on the medical or
           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 2005.29 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.

           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.30 However, the
           Defense Manpower Data Center'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.31 Data center officials said the
           military services had not reported location data for all
           servicemembers for OIF. As of October 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.32 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 policy33
           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 have been affected. According to
           DOD officials, preventive medicine units have been investigating
           incidents involving potential exposure during the deployment. For
           a given incident, a narrative summary of events and the results of
           any medical procedures generally were included 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 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. I 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. Similarly, the Army and Navy jointly
           created a summary of potential exposure for the medical records of
           servicemembers stationed at Port Shuaiba, the deepwater port used
           for bringing in heavy equipment in support of OIF where a large
           number of servicemembers have been permanently or temporarily
           stationed. 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.

           According to DOD and VA officials, no federal research plan that
           includes the use of archived OEHS reports has been developed to
           evaluate the long-term 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.34 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.35 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.36 VA
           officials noted that because OIF 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.37

           Although no coordinated federal research plan has been developed,
           other separate federal research studies are underway 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. In another effort, 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.

           As we stated in our report, DOD's efforts to collect and report
           OEHS data could be strengthened. Currently, 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. Additionally, the
           deployed military services' uncertain compliance with OEHS report
           submission requirements casts doubt on the completeness of CHPPM's
           OEHS archive. These data shortcomings, combined with incomplete
           data in DOD's centralized tracking database of servicemembers'
           deployment locations, limit CHPPM's ability 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. DOD 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. Consequently, we recommended that the Secretary of
           Defense ensure that cross-service guidance is created to implement
           DOD's policy, once that policy has been revised, to improve the
           collection and reporting of OEHS data during deployments and the
           linking of OEHS reports to servicemembers. DOD responded that
           cross-service implementation guidance for the revised policy on
           deployment OEHS would be developed by the Joint Staff.

           While DOD's risk management efforts during OIF represent a
           positive step in helping to mitigate potential environmental and
           occupational risks of deployment, the lack of systematic
           monitoring of the deployed military services' implementation
           activities prevents full knowledge of their effectiveness.
           Therefore, we recommended that the military services jointly
           establish and implement procedures to evaluate the effectiveness
           of risk management efforts. DOD partially concurred with our
           recommendation and stated that it has procedures in place to
           evaluate OEHS risk management through a jointly established and
           implemented lessons learned process. However, in further
           discussions, DOD officials told us that they were not aware of any
           lessons learned reports related to OEHS risk management for OIF.

           Furthermore, 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. As a result, we recommended 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. DOD partially concurred with our
           recommendation, and VA concurred. 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.

           Mr. Chairman, this completes my prepared statement. I would be
           happy to respond to any question you or other Members of the
           Subcommittee may have at this time.

           For further information about this testimony, please contact
           Marcia Crosse at (202) 512-7119 or [email protected]. Contact points
           for our Offices of Congressional Relations and Public Affairs may
           be found on the last page of this testimony. In addition to the
           contacts named above, Bonnie Anderson, Assistant Director, Karen
           Doran, Beth Morrison, John Oh, Danielle Organek, and Roseanne
           Price also made key contributions to this testimony.

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8While in the deployment location, preventive medicine units create and
store reports both electronically and on paper.

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 testimony 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.

OEHS Reporting and Archiving Activities during Deployment

12The 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.

Uses of Deployment OEHS Reports

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.

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

Data Collection Standards and Practices Vary by Service, Although Preliminary
Efforts Are Under Way to Increase Uniformity

19OEHS standards generally set out technical requirements for monitoring,
including the type of equipment needed and the appropriate frequency of
monitoring.

Deployed Military Services Have Not Submitted All Required OEHS Reports for OIF,
and the Magnitude of Noncompliance Is Unknown

20This standard was approved in October 2003.

21Incident-driven reports reflect OEHS investigation 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.

 Progress Made in Using OEHS Reports to Address Immediate Health Risks, Though
  Limitations Remain for Addressing Both Immediate and Long-term Health Issues

DOD Has Made Progress in Using Deployment OEHS Data and Reports in Risk
Management but Does Not Monitor Implementation of These Efforts

25OEHS risk management activities 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.

27Risk assessments can designate identified occupational or environmental
health risks as posing a low, moderate, high, or extremely high risk to
servicemembers.

Access to Most Archived OEHS Reports Is Limited by Security Classification

28Individuals 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.

29Pub. L. No. 108-375, S:735, 118 Stat. 1811, 1999 (2004).

Difficulties Exist in Linking Archived OEHS Reports to Individual
Servicemembers, but Some Efforts Are Under Way to Include Information in Medical
Records

30GAO, Defense Health Care: Medical Surveillance Improved Since Gulf
Warbut Mxed Results in Bosnia, GAO/NSIAD-97-136 (Washington D.C.: May 13,
1997).

31DOD policy requires the Defense Manpower Data Center 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 the Defense Manpower Data Center 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," February 1, 2002.

32The military services submitted location data for both OIF and Operation
Enduring Freedom in Central Asia; Defense Manpower Data Center officials
said they were unable to separate the data from the two operations.

33DOD Instruction 6490.3, "Implementation and Application of Joint Medical
Surveillance for Deployment," Aug. 7, 1997.

No Federal Research Plan Exists for Using OEHS Reports to Follow the Health of
OIF Servicemembers over Time

34GAO, Gulf War Illnesses: Federal Research Strategy Needs Reexamination,
GAO/T-NSIAD-98-104 (Washington D.C.: Feb. 24, 1998).

35The Deployment Health Working Group includes representatives from DOD,
VA, and HHS.

36This effort also includes identifying research for Operation Enduring
Freedom.

37Epidemiologic studies generally have a fixed study population that does
not vary over time, according to VA officials.

                            Concluding Observations

                     GAO Contact and Staff Acknowledgments

Appendix I: Example of an Occupational and Environmental Health
Surveillance Summary Created by the Air Force

(290480)

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Highlights of GAO-05-903T , a testimony before the Subcommittee on
National Security, Emerging Threats, and International Relations,
Committee on Government Reform, House of Representatives

July 19, 2005

DEFENSE HEALTH CARE

Occupational and Environmental Health Surveillance Conducted during
Deployments Needs Improvement

Following the 1991 Persian Gulf War, research and investigations into the
causes of servicemembers' unexplained illnesses were hampered by a lack of
servicemember health and deployment data, including 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.

This testimony is based on GAO's report, entitled Defense Health Care:
Improvements Needed inOccupational and Environmental Heah Surveillance
duringDeployment to Address Immediaeand Long-term Heath Issues
(GAO-05-632). The testimony presents findings about how the deployed
military services have implemented DOD's policies for collecting and
reporting OEHS data for Operation Iraqi Freedom (OIF) and the efforts
under way to use OEHS reports to address both immediate and long-term
health issues of servicemembers deployed in support of OIF.

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. 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. Moreover, DOD officials could
not identify the reports they had not received to determine the extent of
noncompliance.

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. OEHS reports have been
used consistently during OIF as part of operational risk management
activities intended to identify and address immediate health risks and to
make servicemembers aware of the risks of potential exposures. While these
efforts may help in reducing health risks, DOD has not systematically
evaluated their implementation during OIF. 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. To address problems with
linking OEHS reports to individual servicemembers, the deployed military
services have tried 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. Additionally, according to
DOD and Veterans Affairs (VA) officials, no federal research plan has been
developed to evaluate the long-term health of servicemembers deployed in
support of OIF, including the effects of potential exposures to
occupational or environmental hazards.

GAO's report made several recommendations, including that the Secretary of
Defense improve deployment OEHS data collection and reporting and evaluate
OEHS risk management activities and that the Secretaries of Defense and
Veterans Affairs jointly develop a federal research plan to address
long-term health effects of OIF deployment. DOD plans to take steps to
meet the intent of our first recommendation and partially concurred with
the other recommendations. VA concurred with our recommendation for a
joint federal research plan.
*** End of document. ***