Military Personnel: Top Management Attention Is Needed to Address
Long-standing Problems with Determining Medical and Physical	 
Fitness of the Reserve Force (27-OCT-05, GAO-06-105).		 
                                                                 
The Department of Defense's (DOD) operations in time of war or	 
national emergency depend on sizeable reserve force involvement  
and DOD expects future use of the reserve force to remain high.  
Operational readiness depends on healthy and fit personnel.	 
Long-standing problems have been identified with reserve members 
not being in proper medical or physical condition. Drilling	 
members in the reserve force by law are required to have a	 
medical exam every 5 years and an annual certificate of their	 
medical status. Also, DOD policies require an annual dental exam 
and an annual evaluation of physical fitness. Compliance with	 
these routine requirements is the first step in determining who  
is fit for duty. Public Law 108-375 required GAO to study DOD's  
management of the health status of reserve members activated for 
Operations Enduring Freedom and Iraqi Freedom. GAO assessed DOD's
(1) ability to determine reserve force compliance with routine	 
exams, and (2) visibility over reserve members' health status	 
after they are called to duty and the care, if any, provided to  
those deployed with preexisting conditions.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-105 					        
    ACCNO:   A40460						        
  TITLE:     Military Personnel: Top Management Attention Is Needed to
Address Long-standing Problems with Determining Medical and	 
Physical Fitness of the Reserve Force				 
     DATE:   10/27/2005 
  SUBJECT:   Armed forces reserves				 
	     Combat readiness					 
	     Medical examinations				 
	     Military forces					 
	     Military policies					 
	     Mobilization					 
	     Reporting requirements				 
	     Data integrity					 
	     Military reserve personnel 			 
	     Occupational health standards			 
	     DOD Operation Iraqi Freedom			 
	     Operation Enduring Freedom 			 

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GAO-06-105

                 United States Government Accountability Office

                     GAO Report to Congressional Committees

October 2005

MILITARY PERSONNEL

Top Management Attention Is Needed to Address Long-standing Problems with
         Determining Medical and Physical Fitness of the Reserve Force

                                       a

GAO-06-105

[IMG]

October 2005

MILITARY PERSONNEL

Top Management Attention Is Needed to Address Long-standing Problems with
Determining Medical and Physical Fitness of the Reserve Force

What GAO Found

DOD is unable to determine the extent to which the reserve force complied
with routine examinations due to lack of complete or reliable data.
Although each reserve component employs a tracking system capable of
monitoring compliance with medical exams, only one component has taken the
necessary quality assurance steps to ensure the reliability of its data.
While the Office of the Under Secretary of Defense for Personnel and
Readiness has the responsibility for overseeing medical and physical
fitness policy and processes, it has not established a management control
framework and executed a plan to oversee compliance with routine
examinations. Specifically, this office has not enforced holding all
responsible levels accountable, ensuring that all requirements are being
met, and that complete and reliable data are being entered into the
appropriate tracking system. For example, this office has not enforced its
own requirement for the services to report on the components' physical
fitness status. Without complete and reliable data, DOD is not in a sound
position to provide the Secretary of Defense or Congress assurances that
the reserve force is medically and physically fit when called to active
duty.

DOD has only limited visibility over the health status of reserve members
after they are called to duty and is unable to determine the extent of
care provided to those members deployed with preexisting medical
conditions despite the existence of various sources of medical
information. The components collect various types of medical data, but
vary in their ability to systematically identify, track, and report
information on those with temporary and permanent conditions that may
limit deployability. In addition, medical information is captured on
predeployment forms for all members and entered into a DOD-wide
centralized database. GAO has previously reported that the database has
missing and incomplete health data, and DOD is working to correct this
through its quality assurance program. GAO found during this review that
DOD has continued to make progress entering the data from the forms into
the database, but the data are still incomplete and the reasons why
members are determined medically nondeployable are not captured in a way
that is easily discernable. While the Under Secretary of Defense continues
to have responsibility for overseeing the medical and physical fitness of
reserve members after they are called to duty, the combatant commanders,
under the Joint Chief of Staff, have this responsibility for the theater.
DOD is unable to determine the care provided to those deployed with
preexisting medical conditions because DOD has not determined what
preexisting conditions may be allowed into a specific theater and, thus,
does not know what conditions to track. Evidence GAO developed suggests
that members are deployed into theater with preexisting conditions, such
as diabetes, heart problems, and cancer. The impact of those who are not
medically and physically fit for duty could be significant for future
deployments as the pool of reserve members from which to fill requirements
is dwindling and those who have deployed are not in as good health as they
were before deployment.

United States Government Accountability Office

Contents

  Letter

Results in Brief
Background
Lack of DOD Oversight Hinders DOD's Ability to Determine

Reserve Components' Compliance with Routine Medical and Physical Fitness
Examination Requirements, but Indications of Noncompliance Exist

DOD Lacks Visibility over the Health Status of Reserve Components after
Being Called to Active Duty and the Extent to which Members with
Preexisting Conditions Required Care during Deployment

Conclusions
Recommendations for Executive Action
Agency Comments and Our Evaluation

                                       1

                                      3 7

16

36 52 53 54

Appendix I Scope and Methodology

Appendix II Comments from the Department of Defense

Appendix III GAO Contact and Staff Acknowledgments

Related GAO Products

  Tables

Table 1: Service Decisions Concerning Reserve Components' Deployability,
November 2001 through June 2005 40 Table 2: Service Decisions Concerning
Active Components' Deployability, November 2001 through June 2005 41 Table
3: Total Predeployment Referral Rate by Reserve Component, November 2001
through June 2005 42 Table 4: Total Predeployment Referral Rate by Active
Component, November 2001 through June 2005 42

Table 5: Rate of Servicemembers Health Status as Recorded on Pre- and
Postdeployment Forms for Active and Reserve Components from November 2001
through June 2005 47

  Figures

Figure 1: Rate of Medical Referrals by Type for Active and Reserve
Components from November 2001 through June 2005 43

Figure 2: Medical Conditions of Army National Guard and Army Reserve
Members in a Medical Holdover Status as of August 11, 2005 45

Abbreviations

AFAA Air Force Audit Agency
AFFMS Air Force Fitness Management System
AMSA Army Medical Surveillance Activity
ANG Air National Guard
APFT Army Physical Fitness Test
CENTCOM U.S. Central Command
DIMHRS Defense Integrated Military Human Resources System
DNBI Disease Nonbattle Injury
DOD Department of Defense
GAO Government Accountability Office
HCP Health Care Provider
IMR Individual Medical Readiness
JMeWS Joint Medical Work Station
JMROC Joint Medical Readiness Oversight Committee
JPTA Joint Patient Tracking Application
MEDPROS Medical Protection System
MND-TM Medical Nondeployable Tracking Module
MODS Medical Operational Data System
MORDT Mobilization Operational Readiness Deployment Test
MRRS Medical Readiness Reporting System
NDAA National Defense Authorization Act
OSD Office of the Secretary of Defense
OUSD/P&R Office of the Under Secretary of Defense for Personnel and

Readiness PHA Preventive Health Assessment PHAM Periodic Health Assessment
Monitor PIMR Preventive Health Assessment and Individual Medical

Readiness PRIMS Physical Readiness Information Management System RCPHA
Reserve Component Periodic Health Assessment TRAC2ES TRANSCOM Regulating
Command and Control Evacuation

System TRANSCOM U.S. Transportation Command

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United States Government Accountability Office Washington, DC 20548

October 27, 2005

The Honorable John Warner
Chairman
The Honorable Carl Levin
Ranking Minority Member
Committee on Armed Services
United States Senate

The Honorable Duncan L. Hunter
Chairman
The Honorable Ike Skelton
Ranking Minority Member
Committee on Armed Services
House of Representatives

The Department of Defense's (DOD) operations in time of war or national
emergency are currently dependent upon sizeable National Guard and
Reserve involvement and DOD expects future use of the reserve force to
remain high. DOD policy acknowledges the importance that reserve
component1 members are medically and physically fit2 for deployment3
when called to active duty. As of June 2005, more than 323,000 reserve
component members had deployed in support of Operation Enduring
Freedom and Operation Iraqi Freedom,4 which is almost three times the
number of reserve component members deployed in support of Operations

1 DOD's reserve components include the collective forces of the National
Guard including the Army Guard and the Air Guard, as well as the forces
from the Army Reserve, the Navy Reserve, the Marine Corps Reserve, the Air
Force Reserve, and the Coast Guard Reserve. This report does not address
the Coast Guard Reserve.

2 For the purposes of this report, medical fitness equates to compliance
with routine or periodic medical (physical) examinations that identify the
diseases and medical conditions that may prevent members from performing
their military duties. Physical fitness equates to compliance with routine
or periodic examinations that test a member's physical skills needed to
perform the mission.

3 Deployment is a troop movement resulting from a Joint Chiefs of Staff
and Unified Command Deployment Order for 30 continuous days or greater to
a land-based location outside the United States.

4 Operation Enduring Freedom includes ongoing operations in Afghanistan
and in certain other countries; Operation Iraqi Freedom includes ongoing
operations in Iraq.

Desert Shield and Desert Storm. Reserve forces played a vital role in
Operations Desert Shield and Desert Storm. However, problems were revealed
with reserve component members not being in proper medical or physical
condition for these deployments. Some members could not deploy to the
Persian Gulf, and others had difficulty performing their missions while
there. In an effort to help obviate similar problems in the future,
Congress passed legislation during the 1990s to help monitor and track the
health status of deployed members of the Armed Forces, including reserve
component members.5

Public Law 108-375, the Ronald W. Reagan National Defense Authorization
Act for Fiscal Year 2005, requires GAO to study DOD's management of the
health status of reserve component members ordered to active duty in
support of Operation Enduring Freedom and Operation Iraqi Freedom.
Specifically, GAO assessed: (1) DOD's ability to determine the reserve
components' compliance with routine medical and physical fitness
examinations, and (2) DOD's visibility over reserve components' health
status after they are called to duty and the care, if any, provided to
those deployed with preexisting conditions.

To address our first objective, we reviewed federal statutes and Office of
the Secretary of Defense (OSD) applicable directives and instructions to
identify and understand the roles and responsibilities of the offices
within DOD for management of the health status of the reserve components.
We discussed these statutes and guidance with senior officials in the
Office of the Under Secretary of Defense for Personnel and Readiness. We
discussed service policies for medical and physical fitness with military
officials within the service surgeon general offices and officials
responsible for physical fitness in the service personnel and operations
functions. We also analyzed reserve component regulations and policies and
discussed these with responsible reserve component officials. We took
steps to assess the reliability of these reserve component compliance data
and we discuss the results of our assessment in the report. We also
visited several unit-level commands in all six reserve components. In
addition, we conducted a limited medical and personnel file review and
group discussions at an Army National Guard unit in the Mid-Atlantic and
an Army Reserve unit in the Mid-west for the purposes of understanding
some of the issues confronting the Army components in terms of compliance.

5 10 U.S.C. S: 1074f.

To address our second objective, we interviewed reserve component
headquarters officials and active component officials responsible for
mobilizing the reserve components and observed an Army mobilization of
Army National Guard and Army Reserve members at Fort Bliss, Texas to
obtain information on processes used to screen members for their medical
deployability. We obtained and analyzed data provided on medical
deployability from DOD's centralized database on pre-and postdeployment
health assessments, maintained at the Army Medical Surveillance Activity
(AMSA) and discussed available data with AMSA officials. We also obtained
and analyzed data on Army reserve component members held at mobilization
stations for medical reasons and discussed these data with officials from
the Office of the Assistant Secretary of the Army for Manpower and Reserve
Affairs and the Army Office of the Surgeon General. Based on our review of
the AMSA database we used, we determined that the data from it were
reliable for the purposes of this report. To address the extent of medical
care provided in theater for preexisting medical conditions, we reviewed
the Joint Chiefs of Staff policy for Deployment Health Surveillance and
Readiness and information provided by the U.S. Central Command (CENTCOM)
Surgeon General office regarding medical deployment criteria for Operation
Enduring Freedom and Operation Iraqi Freedom and discussed these policies
with the appropriate DOD officials. We met with medical officials who
served in theater and discussed situations they witnessed related to
reserve members who had deployed with preexisting conditions. We conducted
our review from October 2004 through September 2005 in accordance with
generally accepted government auditing standards. A more thorough
description of our scope and methodology is provided in appendix I.

DOD is unable to determine the extent to which the reserve components
comply with routine medical and physical fitness examination requirements
due to a lack of OSD guidance and oversight, and incomplete or unreliable
compliance data supplied by the components. Although the Office of the
Under Secretary of Defense for Personnel and Readiness (OUSD/P&R) has the
responsibility for overseeing medical and physical fitness policy and
processes, this office has not established a management control framework
and executed a plan to oversee compliance with routine examinations. For
example, OUSD/P&R has not provided guidance to the reserve components
regarding requirements for the 5-year medical examination and an annual
medical certificate. Thus, each reserve component has developed its own
implementing policies with differences in scope, frequency, and
administration of the medical examination. Lack of OSD guidance makes
oversight difficult because uniform criteria

  Results in Brief

against which to measure compliance do not exist. DOD's ability to
determine the extent of compliance has been hindered because OSD does not
track reserve components' compliance with routine medical examinations. In
addition, the data reported at the reserve component level have been
incomplete and unreliable for purposes of determining compliance with
routine medical and physical fitness examination requirements, and
responsibility for compliance has not been enforced. For example, although
each reserve component employs a tracking system capable of monitoring
compliance with medical examinations, only one reserve component-the Navy
Reserve-has taken the necessary quality assurance steps to ensure the
reliability of its data on compliance.

Further, DOD has not enforced its own requirement for the services to
report on the status of the reserve and active components' physical
fitness. No reserve component has a tracking system that can report
complete and reliable data on compliance with physical fitness
examinations on a componentwide basis. Moreover, although the reserve
components place the responsibility for tracking compliance with medical
and physical fitness examinations on the unit commander, the reserve
components do not always hold the unit commanders accountable and the unit
commanders do not always enforce the compliance of their members. OUSD/P&R
has not enforced holding all responsible levels accountable, ensuring that
all requirements are being met, and complete and reliable data are being
entered into the appropriate tracking system. Despite DOD's inability to
determine the extent of reserve component compliance with routine medical
and physical fitness examinations, we found indications of noncompliance.
For example, a limited review of medical files at one Army National Guard
and one Army Reserve location, data from a Navy report, test results of
two units in a Marine Corps battalion, and data from a review conducted by
the Air Force Audit Agency indicate some noncompliance at all components
with routine examination requirements. OSD's lack of oversight could
negatively impact operational readiness for future deployments as the
number of needed personnel may not be medically and physically fit when
called to active duty.

DOD has limited visibility over the health status of reserve component
members after they are called to duty and is unable to determine the
extent of care provided to those members deployed with preexisting medical
conditions despite the existence of various sources of medical
information. For example, the reserve components all collect various types
of medical data, but vary in their ability to systematically identify,
track, and report information on members with both temporary and permanent
conditions that limit medical deployability. In addition, medical

information is captured on predeployment forms for all reserve members and
entered into a DOD-wide centralized database, but the data are incomplete
and the reasons why members were found nondeployable are not captured in a
way that is easily discernable. Furthermore, DOD is unable to determine
the care provided to those deployed with preexisting medical conditions
because DOD has not determined what preexisting conditions may be allowed
into a specific theater of operations and therefore does not know what
conditions to track. The medical deployment criteria specific to
Operations Iraqi Freedom and Enduring Freedom are still evolving, and
although DOD has a number of systems for tracking medical conditions in
theater, the current databases do not capture data on known preexisting
conditions. Developing and updating specific medical criteria for a
theater of operations are the responsibilities of the combatant command.
In the absence of specific theater guidance, the services relied on their
own deployment criteria. For the Army, specific deployment medical
criteria did not exist until February 2005. Evidence we developed suggests
that reserve members did deploy with preexisting medical conditions that
could not be adequately addressed in theater, such as diabetes, heart
problems, and cancer. The impact on operations of those determined
nondeployable or those deployed with mission-limiting medical conditions
is unknown. However, the impact could be significant for future
deployments as the pool of Guard and Reserve members from which to fill
requirements is dwindling and those who have deployed are not in as good
health as they were before deployment.

We are making several recommendations in this report. For DOD to have
visibility over the reserve components' compliance with routine
examinations, we recommend that DOD establish a management control
framework and execute a plan for improving oversight and take steps to
enforce the service reporting requirement on the status of their members'
physical fitness. To improve DOD's visibility over reserve component
members' health status after they are called to duty, we recommend that
DOD oversee the development of the reserve components' tracking systems to
identify and track members' temporary and permanent medical conditions
that limit deployability and modify the predeployment forms to better
capture the reasons for nondeployment and medical referrals. To help
prevent the deployment of members with preexisting medical conditions that
could adversely affect the mission and strain resources in theater, we
recommend that DOD develop medical criteria for specific theaters and
explore using existing tracking systems to track those with treatable
preexisting medical conditions.

In written comments on a draft of this report, DOD did not concur with our
first and fourth recommendation, partially concurred with our fifth
recommendation, and concurred with our second, third and sixth
recommendations. DOD did not concur with our first recommendation that it
establish a management control framework and execute a plan for issuing
guidance, establishing quality assurance for data reliability, and
tracking compliance with routine medical examinations. DOD did not state
that it disagreed with our findings; however, DOD stated that it had
initiatives underway that addressed our recommendation. We disagree with
DOD's conclusion because, based on our review, we do not believe that
DOD's initiatives are far enough along to dismiss further action, and we
continue to believe that our recommendation has merit. DOD concurred with
our second recommendation that DOD take steps to enforce the services'
reporting requirement on the status of their members' physical fitness.
During our review none of the reports had been submitted to the Principal
Deputy as required. We raised concerns in this report about the data
reliability of the tracking systems for physical fitness. Just as we found
with routine medical examinations, we also found that DOD lacked quality
assurance of the data on compliance with physical fitness examinations in
its tracking systems. We note that the responsible office for physical
fitness oversight, the Office of Morale, Welfare, and Recreation, does not
participate on the Joint Medical Readiness Oversight Committee that is
directed to oversee improvements in medical readiness, nor are we aware of
any DOD plans to include improvements in the oversight of physical fitness
in its comprehensive medical readiness plan. Therefore, we have expanded
our first recommendation to include routine physical fitness examinations
in the actions to be addressed.

DOD concurred with our recommendation that DOD oversee the development of
the reserve components' tracking systems to identify and track members'
temporary and permanent medical conditions that limit deployability. DOD
did not concur with our recommendation that DOD modify the medical
predeployment form to better capture reasons for nondeployment and medical
referrals. DOD stated that the best sources of accurate information about
what medical reasons kept service members from deploying are the permanent
medical records. We continue to believe our recommendation has merit
because DOD has no way to systematically analyze the information to
determine why servicemembers are medically nondeployable. DOD partially
concurred with our recommendation that DOD determine what preexisting
medical conditions should be allowed into a specific theater of
operations, especially during the initial stages of operations, and take
steps to consistently utilize these criteria for determining medical
deployability. DOD also noted that due to the ever-

changing nature of a theater of operations and the inexact nature of
medicine, a list of nondeployable preexisting conditions will never be
fully comprehensive or fully enforceable. We agree that a list of
nondeployable preexisting medical conditions can never be fully
comprehensive; however, we still believe DOD could establish a list of
what preexisting medical conditions should be allowed into specific
theaters of operations, especially during the initial stages of
operations, so that in future deployments DOD would not experience
situations such as those that occurred with members being deployed into
Iraq who clearly had preexisting conditions that should have prevented
their deployment. DOD concurred with our recommendation that DOD explore
using existing tracking systems to track those who have treatable
preexisting medical conditions in theater. DOD noted that refinements to
medical tracking system are ongoing. We wish to note that before DOD's
tracking systems can be used to track those who have treatable preexisting
medical conditions in theater, DOD must determine what preexisting medical
conditions should be allowed into a specific theater of operations as
called for in our fifth recommendation.

As required by law,6 each reserve component is to make available qualified
personnel for active duty in the armed forces in time of war or national
emergency and at such other times as national security requires. With this
requirement comes the responsibility that each reserve component provides
personnel who are medically and physically fit for active duty. As noted
in DOD guidance,7 fitness specifically includes the ability to accomplish
the task and duties unique to a particular operation, and ability to
tolerate the environmental and operational conditions of the deployed
location, including wear of protective equipment.

Background

Reserve Components and DOD reserve components include the Army Reserve,
the Army National Routine Medical and Guard, the Air Force Reserve, the
Air National Guard, the Navy Reserve, Physical Fitness and the Marine
Corps Reserve. Reserve forces consist of three categories: Examinations
the Ready Reserve, the Standby Reserve, and the Retired Reserve. The

Ready Reserve had approximately 1.1 million National Guard and Reserve

members at the end of fiscal year 2004, and its members were the only

6 10 U.S.C. S: 10102.

7 Minimal Standards of Fitness for Deployment to the CENTCOM Area of
Responsibility, January 2005.

reservists who were subject to involuntary mobilization under the partial
mobilization authorized by President Bush following the attacks of
September 11, 2001. Within the Ready Reserve, there are three
subcategories: the Selected Reserve, the Individual Ready Reserve, and the
Inactive National Guard. Members of all three subcategories are subject to
a mobilization under a partial mobilization but routine medical and
physical fitness policies apply primarily to the Selected Reserve,
consisting of about 850,000 members at the end of fiscal year 2004.8

DOD administers medical examinations to military personnel for various
reasons at different intervals. These include examinations at accession,
mobilization,9 for special duty assignments, and at separation and
retirement. The examinations that are required routinely for Selected
Reserve members to ensure ongoing medical and physical fitness include two
that are prescribed by federal statute and the second two prescribed by
DOD regulations and policy. Compliance with these routine requirements is
the first step toward determining who is fit for duty.

Federal statute10 prescribes that each member of the Selected Reserve11
who is not on active duty is required to:

o  	be examined as to the member's physical (medical) fitness every 5
years, or more often as the respective Secretary considers necessary; and

o  complete an annual certificate of medical condition.

DOD policy prescribes that each member of the Selected Reserve:

o  receive an annual dental examination; and

8 The Selected Reserve's members include individual mobilization
augmentees-individuals who train regularly, for pay, with active component
units-as well as members who participate in regular training as members of
National Guard or Reserve units.

9 Mobilization is the process of assembling and organizing personnel and
equipment, activating or federalizing units and members of the National
Guard or Reserves for active duty, and bringing the armed forces to a
state of readiness for war or other national emergency.

10 10 U.S.C. S: 10206(a).

11 Prior to 2002, this statute applied to members of the Individual Ready
Reserve and Inactive National Guard as well. Currently, the law requires
that the Individual Ready Reserve be examined as to their medical fitness
as a condition of military duty or promotion, or attendance at a military
school or other career-related action. 10 U.S.C. S: 10206(b).

o

Reserve Components Within the constraints of the existing mobilization
authorities12 and DOD Differ in Approaches to guidance, the services have
flexibility as to how, where, and when they Mobilize and Medically conduct
mobilization processing. As a result, the services differ in how Screen
Members for they mobilize and consequently medically screen members upon

notification that a unit or individual will be called to active duty. The
ArmyDeployment and Navy use centralized approaches, mobilizing their
reserve component

be evaluated annually for physical fitness for duty, to include an
assessment of aerobic capacity, muscular strength, muscular endurance, and
desirable fat composition.

forces at a limited number of locations. The Army uses 15 primary sites
that it labels "power projection platforms" and 12 secondary sites called
"power support platforms." The Navy has 15 geographically dispersed Navy
Mobilization Processing Sites but is currently using only 5 of these sites
because of the relatively small numbers of personnel who are mobilizing.

By contrast, the Air Force uses a decentralized approach, mobilizing its
reserve component members at their home stations-135 for the Air Force
Reserve and 90 for the Air National Guard-where all medical screening is
performed. The Marine Corps uses a hybrid approach. It has five
Mobilization Processing Centers to centrally mobilize individual
reservists and is currently using three of these centers. However, the
Marine Corps uses a decentralized approach to mobilize its units. Selected
Marine Corps Reserve units do most of their mobilization processing at
their home stations, including medical screening, and then report to their
gaining commands.

    Roles and Responsibilities for Developing and Implementing Examination
    Requirements

Within the Office of the Under Secretary of Defense for Personnel and
Readiness, the Office of the Assistant Secretary of Health Affairs is
responsible for developing medical policies and processes; the Principle
Deputy to the Under Secretary oversees the Office of Morale, Welfare, and
Recreation for developing physical fitness policies; and the Office of the
Assistant Secretary for Reserve Affairs serves in an advisory capacity to
the Under Secretary to determine how the reserve components can better
implement these requirements. Each service's Assistant Secretary for

12 Most reserve members who were called to active duty for other than
normal training after September 11, 2001, were mobilized under one of
three legislative authorities: 10 U.S.C. S: 12304, 12302, 12301(d).

Manpower and Reserve Affairs provides force management policy for both the
active and reserve components. It is then the responsibility of each
National Guard and Reserve Command-the Chief, Army Reserve, the Director
of the Army National Guard, the Chief of the Navy Reserve (Commander of
Navy Reserve Forces and Commander of Marine Corps Reserve Forces), Chief
of the Air Force Reserve, and the Director of the Air National Guard-that
the policies for medical and physical fitness examinations are properly
implemented for their respective commands. Each National Guard and Reserve
unit commander is responsible for ensuring that the members under his or
her command are provided routine medical and physical examinations in a
timely manner, and for identifying and processing members who are not
medically qualified or physically fit for active duty. The reserve
component member is responsible for meeting scheduled medical examination
requirements, obtaining any recommended follow-up medical and dental care
from his or her personal (civilian) medical provider, and truthfully
reporting any changes in his or her medical or dental condition to
military unit commanders and military medical personnel. Upon
mobilization, responsibility for the medical and physical fitness of the
reserve component members transfers to the active duty counterparts.

    Problems Identified with Medical Deployability during Operations Desert
    Shield and Desert Storm

Several studies identified medical issues with the reserve component
members called to duty for Operations Desert Storm and Desert Shield. A
1991 Army Inspector General report13 estimated that as many as 8,000
reserve component personnel were found to be medically nondeployable upon
arrival at mobilization stations. Even though all but 1,100 eventually
deployed, the nondeployable soldiers disrupted the mobilization process
because units had to undergo extensive efforts to replace nondeployable
reserve members with those who could be deployed. The report also noted
that some soldiers who had coronary bypass surgery, cancer, and
amputations had not been identified at their home stations and reported to
their mobilization station. In 1991, we reported14 that medical screenings
conducted at mobilization stations identified numerous problems that
impaired soldiers' ability to deploy, including ulcers, chronic asthma,

13 Special Assessment of Operations Desert Shield/Storm Mobilization,
Department of the Army, Inspector General, December 1991.

14 GAO, National Guard: Peacetime Training Did Not Adequately Prepare
Combat Brigades for the Gulf War, GAO/NSIAD-91-263 (Washington, D.C.:
Sept. 24, 1991).

spinal arthritis, hepatitis, seizures, and diabetes. In 1992, we
reported15 that because many medical personnel were found nondeployable
for various reasons, including medical reasons, many units deployed with
medical personnel shortages and were not fully mission capable upon
arrival in the Persian Gulf. For example, two reserve component
surgeons-one who was unable to stand for more than 30 minutes and another
who had Parkinson's disease-reported for duty but were unable to deploy
due to their conditions. A 1992 Sixth U.S. Army Inspector General report16
stated that many soldiers deployed to Southwest Asia had to return to the
United States because of medical conditions that had not been previously
diagnosed. This report noted that home unit commanders were not
identifying soldiers with severe medical problems, some permanent, to
determine if they were medically fit to perform their duties and job
assignments before deploying.

In 1994,17 we did a comprehensive review of the medical and physical
fitness policies for reserve component members serving in Operations
Desert Storm and Desert Shield and found that at one Army mobilization
station nearly 4 percent of the reserve component members reporting for
duty had serious medical conditions including cancer and heart disease.
One soldier had double kidney failure, one had muscular dystrophy, and
another had a gunshot wound to the head. We found that DOD medical policy,
which permits the services to retain nondeployable reservists, was
inconsistent with a military strategy that requires forces to be capable
of responding quickly to unexpected military contingencies anywhere in the
world and we recommended that DOD revise its policy that allows members
not to be worldwide deployable, but DOD disagreed and did not take action.
We also found that DOD was not aware of the physical fitness problems
because the services were not reporting fitness information as DOD
required and GAO recommended that DOD revise its directive to require
services to report on their members' physical fitness status. DOD
concurred with our recommendations and agreed to take actions. Other
related GAO products are found at the end of this report.

15GAO, Operation Desert Storm: Full Army Medical Capability Not Achieved,
GAO/NSIAD-92-175 (Washington, D.C.: Aug. 18, 1992).

16 Sixth U.S. Army Inspector General Nondeployable Soldiers Special
Inspection, August 1992.

17GAO, Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet
Medical and Physical Fitness Standards, GAO/NSIAD-94-36 (Washington, D.C.:
Mar. 23, 1994).

    DOD's System to Assess Active and Reserve Component Members' Health Status
    Prior to Deployments

Section 1074f of Title 10, United States Code requires that the Secretary
of Defense establish a system to assess the medical condition of members
of the armed forces (including members of the reserve components) who are
deployed outside of the United States or its territories or possessions as
part of a contingency operation or combat operation. It further requires
that records be maintained in a centralized location to improve future
access to records, and that the secretary establish a quality assurance
program to evaluate the success of the system in ensuring that members
receive pre-and postdeployment medical examinations and that recordkeeping
requirements are met.

DOD policy requires that the services collect pre-and postdeployment
health information from their members, and submit copies of the forms that
are used to collect this information to the Army Medical Surveillance
Activity (AMSA).18 Initially, deployment health assessments were required
for all active and reserve component personnel who were on troop movements
resulting from deployment orders of 30 continuous days or greater to
land-based locations outside the United States that did not have permanent
U.S. military treatment facilities. However, on October 25, 2001, the
Assistant Secretary of Defense for Health Affairs updated DOD's policy and
required deployment-related health assessments for all reserve component
personnel called to active duty for 30 days or more. The policy
specifically stated that the assessments were to be done "whether or not
the personnel were deploying outside the United States." Both assessments
use a questionnaire designed to help military healthcare providers in
identifying health problems and providing needed medical care. The
predeployment health assessment is generally administered at the service
mobilization site or unit home station before deployment.

On February 1, 2002, the Chairman of the Joint Chiefs of Staff issued
updated deployment health surveillance procedures. Among other things,
these procedures specified that active and reserve component personnel
must complete or revalidate the health assessment within 30 days prior to
deployment. The procedures also stated that the original completed health
assessment forms were to be placed in the military member's permanent
medical record and a copy "immediately forwarded to AMSA."

Both forms include demographic information about the servicemember,
member-provided information about the member's general health, and

18 AMSA operates the Defense Medical Surveillance System, which was
established in 1997.

information about referrals that are issued when service medical providers
review the health assessments. The predeployment assessment also includes
a final medical disposition that shows whether the member was deployable
or not.

In September 2003,19 we reported that DOD did not maintain a complete,
centralized database of the active Army and Air Force components' member
health assessments and immunizations. Following our 2003 review, DOD
established a deployment health quality assurance program to improve data
collection and accuracy. The department's first annual report documenting
issues relating to deployment health assessments was issued in May 2005.

In September 2004,20 we reported similar findings for the reserve
component members. We reported that DOD's ability to effectively manage
the health status of its reserve component members is limited because its
centralized database has missing and incomplete health records and it has
not maintained full visibility over reserve component members with medical
problems. For example, the Marine Corps did not send predeployment health
assessments to DOD's database as required, due to unclear guidance and a
lack of compliance monitoring. The Air Force has visibility of
involuntarily mobilized members with health problems, but lacks visibility
of members with health problems who are on voluntary orders. As a result,
some Air Force reserve component personnel had medical problems that had
not been resolved for up to 18 months, but the full extent of this problem
was unknown since the Air Force did not have a mechanism for tracking
members who are on voluntary duty orders with medical problems. We made
several recommendations regarding improvements in this area and DOD
generally concurred with our recommendations and agreed to take actions.

19 GAO, Defense Health Care: Quality Assurance Process Needed to Improve
Force Health
Protection and Surveillance, GAO-03-1041 (Washington, D.C.: Sept. 19,
2003).

20 GAO, Military Personnel: DOD Needs to Address Long-term Reserve Force
Availability
and Related Mobilization and Demobilization Issues, GAO-04-1031
(Washington D.C.: Sept. 15, 2004).

    Recent DOD Efforts in Response to the 2005 National Defense Authorization
    Act

Section 731 of the Ronald W. Reagan National Defense Authorization Act for
Fiscal Year 2005 (NDAA) requires the Secretary of Defense to develop and
implement a comprehensive plan to improve medical readiness of members of
the Armed Services by focusing on areas such as health status, health
surveillance, and accountability for medical readiness. The mandate also
required that the Secretary of Defense establish a Joint Medical Readiness
Oversight Committee (JMROC) with a specified membership to oversee the
development and implementation of a comprehensive medical readiness
plan.21

In response to the act, the first meeting of the JMROC was held in
February 2005 during this review. The committee is chaired by the Under
Secretary of Defense for Personnel and Readiness and membership includes
the Assistant Secretaries of Defense for Reserve Affairs and Health
Affairs, the Joint Staff Surgeon, the Chief of the National Guard Bureau,
Army Reserve, Navy Reserve, Air Force Reserve and the Commander of the
Marine Corps Reserve, as well as the Vice Chiefs of Staff of the Army,
Vice Chief of Navy Operations, the Vice Chief of Staff of the Air Force
and the Assistant Commandant of the Marine Corps as well as their
respective Surgeon Generals and Assistant Secretaries for Manpower and
Reserve Affairs, and a representative of the Department of Veterans
Affairs.

A draft copy of the Comprehensive Medical Readiness Plan which addresses
all defense medical issues identified in the act was signed by the Under
Secretary of Defense for Personnel and Readiness on June 23, 2005.
Officials from the Force Health Protection Directorate in the OSD Office
of Health Affairs-which is providing the staff for drafting and overseeing
this effort-stated that financial and legislative constraints, which may
limit the implementation of the plan, will have to be identified and
addressed, and indicators for measuring progress will have to be developed
before the plan is finalized.

21 The mandate directed that the Secretary establish the committee 120
days after passage of the act, which was in October 2004.

Among other things, the draft plan specifies that DOD:

(l) institutionalize the Individual Medical Readiness22 (IMR) reporting
process by developing a DOD instruction for the IMR and requires that this
information be provided to commanders to assist them in improving the
health status of members of their units;

(2) expand and improve the pre-and postdeployment assessment process by
refining the predeployment survey to improve consistency with the
postdeployment survey and develop periodic postdeployment health
reassessments;

(3) develop a policy defining the circumstances under which treatment for
medical conditions may be provided in theater and circumstances under
which medical conditions are to be resolved prior to deployment; and

(4) review the results of this GAO study.

22 OSD's Office of Health Affairs has begun a process requiring each
active and reserve component to quarterly report the percentage of its
members who are in compliance with six medical readiness elements: (1)
dental class I or II; (2) immunizations; (3) medical readiness laboratory
tests, such as DNA blood sample; (4) no deployment-limiting conditions;
(5) periodic health assessment; and (6) medical equipment, such as
eyeglass inserts for gas masks.

  Lack of DOD Oversight Hinders DOD's Ability to Determine Reserve Components'
  Compliance with Routine Medical and Physical Fitness Examination Requirements,
  but Indications of Noncompliance Exist

DOD is unable to determine the extent to which the reserve components are
in compliance with routine medical and physical fitness examination
requirements primarily due to a lack of OSD guidance, oversight, and
incomplete or unreliable compliance data supplied by the components.
Although the Office of the Under Secretary of Defense for Personnel and
Readiness (OSD/P&R) has the responsibility for overseeing medical and
physical fitness policy and processes, this office has not established a
management control framework and executed a plan to oversee compliance
with routine examinations. For example, OSD/P&R has not provided guidance
to the reserve components regarding requirements for the 5-year medical
examination and an annual medical certificate. Thus, in the absence of OSD
guidance, each reserve component has developed its own implementing
policies, resulting in differences in scope, frequency, and administration
making it difficult because uniform criteria against which to measure
compliance do not exist; however, OSD has provided consistent guidance for
dental and physical fitness examinations. DOD's ability to determine the
extent of compliance has been hindered because OSD does not oversee
reserve component members' compliance with the routine physical fitness or
medical examination requirements. Furthermore, the data reported at the
reserve component level have been incomplete and unreliable for purposes
of determining compliance with routine medical and physical fitness
examinations, and responsibility for compliance has not been enforced. We
found indications of noncompliance during our site visits and reviews of
existing audit reports and investigations. OSD's lack of oversight could
negatively impact operational readiness for future deployments, as the
number of needed personnel may not be medically and physically fit for
active duty.

    Lack of OSD Guidance Contributes to Variations in Examination Policies among
    the Components

Although OSD/P&R has the responsibility for overseeing medical and
physical fitness policy and processes, this office has not established a
management control framework and executed a plan that includes issuing
guidance to the reserve components on compliance with the requirements for
the 5-year medical examination and an annual medical certificate. For
example, the statutory requirement for the 5-year medical examination has
not been defined by OSD, leaving each reserve component to develop
implementing guidance, resulting in differences in scope, frequency, and
administration of the examination among the components. In addition, there
has not been any OSD implementing guidance regarding the statutory
requirement for an annual medical certificate, and so different guidance
has been developed by the surgeons' general offices responsible for each
of the six reserve components. Lack of OSD guidance makes oversight
difficult to determine because the uniform criteria against which

5-Year Medical Examination Requirements Vary among the Components

to measure the components' compliance do not exist. OSD, through the
Office of the Assistant Secretary of Defense for Health Affairs, has
established a consistent requirement and implementation policy for an
annual dental examination. OSD has also established a consistent
requirement for a physical fitness examination, although the specific
content of the physical fitness examination varies among the components
and it is not coordinated with the medical examinations.

The requirement for a routine medical examination has been in effect for
all active and reserve components since at least 1960.23 Yet, as of
September 2005, OSD has not developed a plan or provided direction to the
components on how to implement this requirement.24 In the absence of OSD
guidance, the surgeons general responsible for the four services and six
reserve components have each developed their own separate implementing
guidance for the current requirement25 for a 5-year medical examination,
resulting in differences in scope, frequency, and administration among the
components as illustrated below.

Routine medical examinations include assessments in six areas: physical
capacity or stamina, upper extremities, hearing and ears, lower
extremities, eyes/vision, and psychiatric.26 For Army active and reserve
component members older than age 40, there are additional age-specific

23 10 U.S.C. S: 10206 states that "each member of the Selected Reserve who
is not on active duty shall be examined as to his physical fitness every
five years, or more often as the Secretary concerned considers necessary."
In 1993, the interval was changed from every 4 years to every 5 years.

24 In 2003, DOD asked the Armed Forces Epidemiological Board to review the
appropriate methodology and interval for routine medical examinations to
be applied similarly across all services. Based on the board's
recommendations, the Assistant Secretary of Defense for Health Affairs is
currently drafting a policy that would replace the 5-year medical
examination with an annual periodic health assessment. Congress is
currently considering changing the frequency requirement for a physical
examination from every 5 years to annually as part of the 2006 national
defense authorization act.

25 In 1993, Congress mandated that these examinations be conducted at
least once every 5 years. Prior to 1993, the requirement was once every 4
years.

26 Members are given a (PUHLES) physical capacity or stamina, upper
extremities, hearing, lower extremities, eyes, psychiatric score of 1 to 4
for each of the six assessment areas. P1 represents a nonduty-limiting
condition, meaning that the individual is fit for duty and possesses no
physical or psychiatric impairments. P2 means a condition may exist;
however, it is not duty-limiting. P3 or P4 means that the individual has a
duty-limiting condition in one of the six assessment areas. P4 means the
individual functions below the P3 level. A rating of either P3 or P4 puts
the servicemember in a nondeployable status or may result in the changing
of the reserve component member's job classification.

screenings such as prostate examination, a prostate-specific antigen test,
and a fasting lipid profile that includes testing for total cholesterol,
lowdensity lipoproteins, and high-density lipoproteins. The Department of
the Navy conducts routine medical examinations on all Navy and Marine
Corps active component and reserve members that include height and weight
measurements, blood pressure testing, urinalysis, serology, and mental
issues. Those being examined are also questioned about their past and
present medical history, including serious illnesses, injuries, chronic
conditions, and operations. The Air Force reserve components' medical
examination for nonflyers has been significantly reduced to minimize lost
training time due to annual medical requirements. The scope of the current
testing exam requirement is essentially limited to brief skin exams for
scars and cancer and limited laboratory blood work, and excludes EKGs,
cholesterol, lipid panels, depth perception, glaucoma, and mammograms. One
question asked on the questionnaire addresses mental status and whether
the member has a history of anxiety or depression.

In addition to the differing scope, the different implementing guidance
across the services has resulted in variations among the services in the
frequency and administration of the 5-year medical examinations. For
example, Army guidelines require that Selected Reserve members complete a
medical examination once every 5 years. During our review, the Navy and
Marine Corps personnel were examined at slightly different intervals:
every 5 years through age 50, every 2 years through age 60, and annually
after age 60. The Air Force is even more different, in that it no longer
requires a traditional medical examination physical be completed every 5
years for nonflyers.27 Instead, members are required to complete an annual
Preventive Health Assessment (PHA), the answers to which- combined with
the member's age, gender, health risk factors, medical history, and
occupations-will determine the types of screening and laboratory tests
required and if the member needs to be seen by a military health care
provider. At a minimum, however, Air Force reserve component members are
required to have a visit with a military health care provider, or Periodic
Health Assessment Monitor (PHAM),28 at least once every 3 years, while Air
National Guard members are required to visit

27 The Air Force Reserve and Air National Guard discontinued utilizing the
"complete or comprehensive" long physical exams in July 2001 and January
2003, respectively. However, annual physical exams for flying personnel
continue to be conducted in both components.

28 A PHAM is a credentialed health care provider, and may be a physician,
nurse practitioner, or physician's assistant. A PHAM performing
examinations for flying personnel must be a flight surgeon.

Annual Certification of Members Medical Condition Varies among Components

a Health Care Provider (HCP)29 at least once every 5 years. Thus,
differences exist between the two Air Force reserve components.

In the absence of any implementing guidance from OSD, guidance for the
annual certification of medical condition has been developed by the
surgeon general's offices responsible for each of the six reserve
components. Like the 5-year medical examination, the annual certificate of
medical condition is prescribed by statute30 which states that "each
member of the Selected Reserve who is not on active duty shall execute and
submit annually to the Secretary concerned a certificate of physical
condition." This requirement has been in law since at least 1960 and is
especially important for the reserve components, since they are not seen
by military health care providers as often as the active duty.

The different guidance from each of the services has resulted in differing
definitions from each service as to what is involved in the annual medical
certificate. For example, Department of Army regulations require that all
members of the Army Reserve and Army National Guard certify their medical
condition annually on a two-page certification form, where members report
physician and dentist visits since their last examination, describe
current medical or dental problems, and disclose any medications they are
currently taking. Navy and Marine Corps Selected Reserve members complete
an Annual Certificate of Physical Condition that provides information
including the location of their health and dental records, the dates and
purpose or type of their last complete physical and dental examinations,
and the date of their last HIV blood test among others. Reservists are
also expected to disclose any injury, illness, or disease that occurred
within the last 12 months and resulted in hospitalization, or caused them
to be absent from work, school, or duty for more than 3 consecutive days;
if they have been under a physician's care or taken prescription
medications during the past 12 months; and any physical defects, family
issues, or mental problems that would prevent them from being mobilized.
The Air Force has combined this annual requirement into its PHA screening
process. Within the Air Force Reserve, the PHA process involves all
members initially completing a Reserve Component Health Risk Assessment,
which was formerly known as the

29 An HCP is a credentialed health care provider, and may be a physician,
nurse practitioner, or physician's assistant. An HCP performing flying
personnel examinations must be a flight surgeon.

30 10 U.S.C. S: 10206(a)(2).

Dental Examination Requirements Are Consistent among Components

Annual Medical Certificate. In the Air National Guard, the PHA involves
all the members initially completing an annual Health History
Questions/Interval History, which was formerly known as the Annual Medical
Certificate.

The annual dental examination is a consistent requirement across the
reserve components that was established by DOD policy and provided
consistent standards for active duty and Selected Reserve members to
improve dental readiness.31 In 1998, the Office of the Assistant Secretary
of Defense for Health Affairs, under the Under Secretary of Defense for
Personnel and Readiness, directed that all active duty and Selected
Reserve members obtain an annual dental examination so that DOD would have
a clear picture of members' dental readiness and fitness for duty.32
Although the 1998 directive required all services to provide
implementation plans for completing all dental examinations by 2001,
Health Affairs recognized that the services were having difficulty
identifying both the mechanisms for compliance and the tracking system for
documentation, and extended the goal of 90 percent compliance until
February 2004. A year and half later, DOD still does not have complete and
reliable information on all reserve components' compliance.

According to Army regulation, all soldiers within the Army National Guard
are required to have a dental examination on an annual basis.33 The
current annual dental examination requires an assessment of the current
state of oral health; risk for future dental disease, including
periodontal assessment; and oral cancer screening. Prior to early 2004,
the Army

31 On December 19, 1996, the Assistant Secretary of Defense for Health
Affairs issued DOD policy in Health Affairs Memo 97-020, standardizing
dental classifications: Class I indicates no dental treatment or
reevaluation required within the next 12 months; Class II indicates
patients have the potential for dental emergencies with the next 12 months
but it is not likely if certain treatments are obtained; Class III
represents patients with oral conditions that if not treated are expected
to result in dental emergencies within the next 12 months; and Class IV
represents patients requiring a dental examination and whose dental
classification is unknown.

32 On February 19, 1998, the Assistant Secretary of Defense for Health
Affairs issued DOD policy, in Health Affairs Memo 98-021, requiring annual
dental examinations and stipulating that personnel shall not deploy in
Dental Class III or IV except under extreme circumstances.

33 While Army regulation, AR 40-501, only addresses an annual dental
examination for the Army National Guard, according to the Army Dental
Command and the Army Reserve, Army Reserve members adhere to the same
dental standard.

Physical Fitness Examination Requirements Consistent among the Components,
but Content Varies and It Is Not Coordinated with Medical Examination
Requirements

reserve components were still conducting only a dental screening.34 In
March 2000, the Navy issued instructions requiring Navy and Marine Corps
reservists to undergo an annual dental examination. Currently, both the
Air Force Reserve and Air National Guard require annual dental
examinations in line with DOD's requirement. The Air Force Reserve made
this a requirement in January 2003, but the Air National Guard did not
make it a requirement until September 2004. Prior to these times, the
required dental exam interval was once every 3 years for the Air Force
Reserve and once every 5 years for the Air National Guard.

Although the specific content of the physical fitness examination varies
among the components, the requirement for at least an annual physical
fitness examination is consistent across the components because it was
established by DOD policy which is to be monitored by the Principal Deputy
Under Secretary of Defense for Personnel and Readiness, Office of Morale,
Welfare, and Recreation.35 Specifically, the policy requires that all
military services and reserve components develop and use physical fitness
tests that evaluate aerobic capacity (e.g., a timed run), muscular
strength, and muscular endurance (e.g., push-ups, pull-ups, sit-ups), and
that all service members be formally evaluated and tested for the record
at least annually (unless they are under a medical waiver).

The specific content of the physical fitness examination varies among the
components because different physical abilities are needed to meet the
services' different missions. The Army Physical Fitness Test (APFT) is a
performance test that indicates a member's ability to perform physically
and handle his or her own body weight. The APFT is required annually for
the Army National Guard. As of October 2004, the Chief of the Army Reserve
required Army reservists to be tested twice a year, as are their active
component counterparts. The APFT consists of 2 minutes of pushups, 2
minutes of sit-ups, and a 2-mile run (the same test is administered to
both the active and reserve component). The number of push-ups and situps
and the 2-mile run time are based on the soldier's age range and sex (the
physical fitness test required to enter the Army has the same requirements
for all ages, but different requirements for gender). All Navy personnel,
regardless of age and component (active or reserve), are required to
participate semiannually in a Physical Fitness Assessment that

34 The dental screening was more limited than the current dental
examination. It included a mouth-mirror, and explorer or tongue depressor
evaluation only.

35 DOD Directive 1308.1, "DOD Physical Fitness and Body Fat Program".

includes a Body Composition Assessment and Physical Readiness Test unless
medically prohibited from doing so. Body composition is assessed by an
initial weight and height screening or an approved circumference technique
to estimate body fat percentage. Testing includes a series of physical
events designed to evaluate an individual's flexibility through a
sit-reach activity, muscular strength and endurance through curl-ups and
push-ups, and aerobic capacity through a 1.5-mile run/walk, or 500-yard or
450-meter swim. Individuals who fail either the Body Composition
Assessment or the Physical Readiness Test or both are considered to have
failed the entire assessment. The Marine Corps has also developed a Body
Composition Program and Physical Fitness Test to assess each Marine's
fitness level. Active component Marines are tested semiannually while
Marine Corps Reservists are tested annually. Body composition standards
are health-and performance-based limits for body weight and body fat.
Physical fitness testing includes pull-ups for males, flexed-arm hang for
females, a timed abdominal crunch event, and a timed 3-mile run. These
events are designed to test the strength and stamina of the upper body,
midsection, and lower body, as well as the cardiovascular system. The Air
Force fitness program requires an annual physical assessment to motivate
all members to participate in a year-round physical conditioning program,
including proper aerobic conditioning, strength/flexibility training, and
healthy eating. Fitness assessment results are based on a composite score
calculated from results of an aerobic assessment (1.5-mile run), muscular
fitness assessment (push-ups and crunches), and body composition
measurement (abdominal circumference measurement).

Although DOD has directed the military physical fitness programs to
complement the health promotion program within OSD's Office of Health
Affairs and senior medical officials have told us that medical and
physical fitness go "hand-in-hand," physical fitness policies are not
coordinated with medical fitness policies at the OSD, service, reserve
component, or unit levels. Furthermore, DOD did not consider physical
fitness a factor for determining the medical deployability of reserve
component members prior to deployment to Iraq and Afghanistan, even though
we reported in 199436 that several Army reports on Operations Desert
Shield and Desert Storm noted fitness-related problems that hindered
wartime operations. For example, one report noted that poor fitness
contributed to the deaths

36GAO, Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet
Medical and Physical Fitness Standards, GAO/NSIAD-94-36 (Washington, D.C.:
Mar. 23, 1994).

by heart attack of eight reserve component personnel deployed to the
Persian Gulf.

    OSD Does Not Oversee Compliance with Routine Medical and Physical Fitness
    Examinations

OSD Does Not Track Compliance with Routine Medical Examinations

OSD Has Not Enforced Its Directive Requiring the Services to Report on
Compliance with Physical Fitness Exams

OSD does not have a plan to oversee reserve components' compliance with
the routine medical or physical fitness examinations, which hinders DOD's
ability to determine the extent of compliance. For example, OSD does not
track reserve component members' compliance with routine medical
examinations. In addition, OSD does not enforce its own directive
requiring the services to report on their members' compliance with
physical fitness examinations.

Although OSD's Office of Health Affairs has begun to track medical
readiness indicators, it does not have a plan to track compliance with
routine medical examinations and does not attempt to track compliance with
physical fitness examinations. OSD's Office of Health Affairs has
initiated a process requiring that all reserve components report quarterly
the percentage of their members who are in compliance with the following
six indicators of medical readiness: dental class I or II; immunizations;
medical readiness laboratory tests, such as providing a blood sample; no
deployment-limiting conditions; periodic health assessment; and medical
equipment, such as eyeglass inserts for face masks. This process continues
to evolve as the Office of Health Affairs wrestles with inconsistencies in
requirements among the reserve components, especially in regard to the
periodic health assessment since each reserve component implements the
requirement for a periodic 5-year medical examination differently.37
Without centralized oversight and management for tracking compliance,
DOD's ability to determine the extent of compliance with routine medical
examinations may be impeded.

OSD has not enforced its own directive requiring the reserve and active
components to report on their members' compliance with physical fitness
examinations by March 2005. Although DOD policy states that physical
fitness is a vital element of combat readiness and is essential to the
general health and well-being of military personnel, OSD and the reserve
components have been lax in reporting compliance with physical fitness
examination requirements and do not fully utilize available systems that
could report physical fitness status on a servicewide basis. DOD

37 The Assistant Secretary of Defense for Health Affairs is currently
drafting a policy intended to help standardize implementation of the
medical examination requirements.

established a reporting requirement for physical fitness in November 2002,
in response to recommendations from our prior reports; however, it has not
enforced compliance with this new requirement.

The new physical fitness policy requires that each military service
establish and maintain a data repository that provides baseline statistics
and a tracking mechanism that monitors physical fitness and body fat for
both the active and reserve components. The policy was developed over the
course of many years. In response to a recommendation in our 1994
report,38 the Under Secretary of Defense for Personnel and Readiness
stated that revised DOD guidance39 would "require the services to provide
an annual report assessing their physical fitness and health promotion
programs, to include a brief summary on how physically fit and healthy
they view their military members, both active and reserve components." Not
only did the original directive fail to require the services to submit an
annual report on the status of servicemembers' physical fitness, but
senior military officials in the office responsible for developing these
directives told us that no service ever submitted a status report on their
physical fitness programs as required by the revised directive. In 1998,
we again reported that DOD's oversight of the physical fitness program was
inadequate and that DOD had not enforced the annual reporting
requirement.40 Officials in the Office of Morale, Welfare, and Recreation
stated that in response to our report, DOD guidance was again revised in
November 2002, to require the services to report annually to the Principal
Deputy Under Secretary of Defense for Personnel and Readiness41 on a
number of very specific physical fitness statistics, including the number
of personnel tested, the number of personnel who failed the test, and the
number placed in remedial training programs. The first report was due to
the Principal Deputy Under Secretary of Defense for Personnel and
Readiness by the military services by March 31, 2005. However, during our
review we were told by officials in the Office of Morale, Welfare, and
Recreation that none of the reports had been submitted to the Principal

38GAO, Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet
Medical and Physical Fitness Standards, GAO/NSIAD-94-36 (Washington, D.C.:
Mar. 23, 1994).

39 DOD Directive 1308.1.

40GAO, Gender Issues: Improved Guidance and Oversight Are Needed to Ensure
Validity and Equity of Fitness Standards, GAO/NSIAD-99-9 (Washington,
D.C.: Nov. 17, 1998).

41 This position was referred to as the Assistant Secretary of Defense
(Force Management Policy) at the time the directive was revised in 2002.

Deputy as required. The Air Force, Navy, and Marine Corps were developing
their information during this review. The Army had until March 2007 to
report because, according to a signed memorandum by the Principal Deputy
Under Secretary of Defense for Personnel and Readiness, the Army is taking
steps to report this information as part of the Defense Integrated
Military Human Resources System (DIMHRS). Until this reporting requirement
is enforced, DOD's ability to determine compliance with the physical
fitness examinations may continue to be hindered.

    Reporting of Compliance at Reserve Component Level Is Hindered by Incomplete
    and Unreliable Data and Lack of Enforcement

Most Reserve Component Data on Compliance with Routine Medical
Examinations Are Unreliable

Incomplete and unreliable data at the reserve component level regarding
compliance with routine medical and physical fitness examinations have
hindered DOD's ability to determine the extent of the reserve components'
compliance with the examination requirements. Each reserve component
employs a tracking system capable of monitoring compliance with medical
examinations, but only one reserve component-the Navy Reserve-has data
that are reliable for determining compliance with routine medical
examinations. Furthermore, even though DOD policy calls for each military
service to establish and maintain a physical fitness data repository, no
reserve component has demonstrated that its tracking system can report
complete and reliable compliance data on physical fitness. Although the
reserve components place the responsibility for tracking compliance with
medical and physical fitness examinations on the unit commander, the
reserve components do not always hold the unit commanders accountable and
the unit commanders do not always enforce the compliance of their members.
No centralized oversight exists to hold all levels accountable, thus
ensuring that all requirements are being met.

All of the reserve components are now employing systems that can track
compliance with medical examinations, but only one reserve component- the
Navy Reserve-has taken the necessary quality assurance steps to ensure the
reliability of its data on compliance with routine medical examinations.
In contrast, we found that the data captured by the systems used by the
Army and the Air Force were unreliable for determining compliance with
routine medical examinations. We did not assess the reliability of the
data used by the Marine Corps because it is in the process of implementing
and testing the use of the Navy's system.

Assessing data for their reliability includes quality assurance steps to
consider the completeness and currency of the data, i.e., determining
whether there are assurances that all members are included and the
information is up to date; quality control measures, such as conducting
periodic testing of the data against medical records, to ensure the
accuracy and reliability of the data; and examining who is using the data

and for what purposes, and how reliable the user thinks the data are. We
found that the Navy Reserve had taken such quality assurance steps. For
example, the Navy has directed its Readiness Commands to conduct routine
inspections to verify medical data accuracy in the Navy Reserve's Medical
Readiness Reporting System (MRRS) and required reserve units to review 10
percent of their medical records for accuracy after each drill weekend. In
addition, Navy Reserve units are also required to keep the Commander, Navy
Reserve Forces Command informed about medical and dental compliance on a
biweekly basis.

In contrast, we found that the compliance data on routine medical
examinations captured by the Army Medical Protection System (MEDPROS) were
unreliable for the purposes of determining compliance with routine medical
examinations. MEDPROS was developed in 1998 to track anthrax compliance
and has since matured to meet current mobilization requirements. All Army
components-active, reserve, and guard-are required to enter members'
medical compliance data into MEDPROS. We found the data captured by this
system are unreliable for monitoring compliance with routine requirements
for several reasons, including missing data, failure to include data for
all Army units, and lack of quality assurance assessments on data content
being performed to test the data's reliability. Until quality control
measures are instituted, the Army will not be able to reliably use MEDPROS
to track compliance with the requirements for the 5-year medical
examination, the annual medical certificate, and the annual dental
examination.

We also found that the Air National Guard's Preventive Health Assessment
and Individual Medical Readiness (PIMR) system and the Air Force Reserve's
Reserve Component Periodic Health Assessment (RCPHA) system were
unreliable for the purposes of determining compliance with routine medical
examinations. We found that neither system produces data that are reliable
for the purposes of determining compliance with routine medical
examinations because: (1) both the Air Force Audit Agency and Air Force
Inspection Agency have reported discrepancies in their review of medical
records and the data from these systems, and (2) there is a high reliance
on unit commands to test and verify the reliability of the data. In
addition, during our site reviews, we found medical staff at several
commands having difficulty entering large backlogs of medical data, which
raised concerns about the timeliness of the data. Often, this backlog took
several weeks to resolve and required the assistance of full-time
reservists. However, according to program managers and database
administrators, the quality of the data, in terms of their completeness
and accuracy, ranges from quite good to exceptional

Reserve Components Are Unable to Report Complete and Reliable Data on
Compliance with Routine Physical Fitness Examinations on a Componentwide
Basis

when subjected to internal system software checks. Until resources
necessary to input and verify the data in a timely manner are provided,
the Air Force will not be able to rely on PIMR and RCHPA data to determine
compliance with routine medical examination requirements.

We did not assess the reliability of the data used by the Marine Corps
because it is in the process of implementing and testing the use of Navy's
system. According to a Marine Corps official, once the new system is fully
implemented, the Marine Corps will have the same oversight capability over
medical compliance that the Navy Reserve currently has.

Even though DOD policy calls for each military service to establish and
maintain a physical fitness data repository, no reserve component has a
tracking system that can report complete and reliable data on compliance
with physical fitness examinations on a componentwide basis. In fact, the
Army Reserve, the Army National Guard, and the Marine Corps Reserve do not
have systems that are designed to track compliance with physical fitness
examinations on a componentwide basis.

The Navy Reserve, the Air National Guard, and Air Force Reserve each have
systems that can track compliance with physical fitness examinations on a
componentwide basis. The Navy Reserve system, however, may not be
producing reliable data at this time. Further, we have concerns regarding
the reliability of the data produced by the Air National Guard and the Air
Force Reserve because such data are not reviewed or validated on a regular
basis.

The Army does not report physical fitness on a componentwide basis.
According to a Department of Army memo, dated April 19, 2004, and
confirmed through our discussions with Army and OSD officials, physical
fitness and body composition data will eventually be tracked in DIMHRS, in
which the Army is the first component to participate. Until DIMHRS is
used, the Army will be unable to report complete and reliable data on
componentwide compliance with the physical fitness examination
requirements. According to Army Reserve officials, physical fitness data
can be tracked in the regional level application software database, but
the information may not be updated by the units in a timely or consistent
manner. This information is then updated in the Total Army Personnel
database, which updates the Individual Training and Readiness System. In
the Army National Guard, the states may use the personnel database to
record the scores and dates of physical fitness examinations, but not
consistently. The Army's first report on the status of its physical
fitness compliance for all its components will be due March 31, 2007,
because the

Office of the Under Secretary of Defense for Personnel and Readiness
granted the Army a 2-year extension for its requirement to report on the
physical fitness status of all members (active, reserve, and guard). The
data in this report, if complete and reliable, could enable DOD to
determine the Army's compliance with the physical fitness examination
requirement. According to the 2004 Department of the Army Memo, if DIMHRS
is not on line by September 2006, the Army will manually report these
data.

Compliance with physical fitness examination requirements is tracked at
headquarters level for the Navy Reserve, but we found that the Navy is
unable to report complete and reliable compliance data. The Navy requires
all commands to report their physical fitness assessment data, including
physical readiness test results, through the Physical Readiness
Information Management System (PRIMS). However, we found the data
generated by this system to be unreliable because, according to a Navy
Official, there are about 2,000 duplicate records that need to be purged
and about 25 percent of the Body Composition Assessment scores have not
been reported by unit commanders. Until internal controls are established
to eliminate duplication and ensure completeness of data, the Navy will be
unable to report complete and reliable data on componentwide compliance
with the physical fitness examination requirement. The Navy submitted its
annual report on physical fitness, due March 31, 2005, to DOD 3 months
late, on July 8, 2005. According to a DOD official, the Navy did not
request an extension or provide an explanation for the late submission.
Because the data in this report came from the PRIMS system that we found
to be unreliable, we do not believe that DOD can reliably use the
information in the report to determine the Navy's compliance with the
physical fitness examination requirement.

The Marine Corps is unable to report complete and reliable data on
compliance with the physical fitness examination because, in contrast to
the Navy, the Marine Corps does not have a dedicated physical fitness
reporting system. Instead, the Marine Corps requires unit commanding
officers to record physical fitness scores in unit diaries, personnel
records, and the Marine Corps Total Force System, a Marine Corps-wide
personnel system. Units that input data into this system are responsible
for reviewing the data and certifying that they are correct. However, a
Marine Corps official indicated that the data are assumed to be correct
when transmitted to higher commands, but no steps are taken to verify
accuracy of the data. As of August 2005, the Marine Corps had provided DOD
with a draft report addressing calendar year 2004 physical fitness scores.
According to a DOD official, the Marine Corps did not request an extension
or provide an

explanation for the late draft submission. Further, as of September 2005,
the Marine Corps had not responded to our official request for the annual
physical fitness report. Without an ongoing quality assurance program to
consistently and continuously ensure the completeness and reliability of
the data in the Marine Corps Total Force System, we did not rely on the
data in the draft Marine Corps Physical Fitness Report provided to DOD.

Although both the Air Force Reserve and Air National Guard each have a
dedicated system to track the physical fitness status of their members, we
found quality assurance procedures lacking, possibly leading to incomplete
and unreliable data with which to track physical fitness compliance. The
Air Force Reserve's software system Program-the Air Force Fitness
Management System (AFFMS)-only tracks fitness program results on a current
basis and only retains data entered from 2004 forward. However, quality
assurance procedures are not followed. For example, there are delays in
entering data; compliance of individual units is only reviewed if there is
a question; and headquarters does not routinely assess members' currency.
This program relies on a fitness program manager within each unit command
to monitor program metrics. According to an AFFMS system official, the
only true way of determining the reliability of the data in this system is
to compare these data with the data in the respective member's personnel
files, and this has not been done. The Air National Guard (ANG) tracking
system for compliance with physical fitness examinations is ANG's Fitness
Age and was first implemented in late 2003, although many ANG units lagged
in their use of Fitness Age until after April 2004. ANG's Fitness Age
database only reflects calendar year information as of a specific point in
time, and does not track or measure performance based on a running
12-month period. The ANG Fitness Program requires an assessment on all ANG
members once per calendar year. According to ANG officials, most physical
fitness testing is performed within the last few months of the calendar
year. Because the data are cumulative, the only time that physical fitness
information can be assessed for all members taking the test is at the end
of the calendar year. In other words, most reservists would appear out of
compliance until they take their annual exam even though they are probably
still within their 1year window for testing. Furthermore, information on
the number of reservists not tested at all or who are overdue is not
captured by the ANG Fitness Age database. According to an ANG official,
the responsibility for managing the physical fitness program rests with
the respective ANG installation's command. The respective ANG
installations (unit commands) have visibility over their respective
"overdue" members. However, ANG headquarters lacks sufficient oversight to
assess compliance. Without ongoing quality assurance programs to
consistently

Accountability to Comply with Routine Medical and Physical Fitness
Examination Is Not Always Enforced

and continuously ensure the completeness and reliability of the data in
the Air National Guard and Air Force Reserve systems, we did not rely on
the data in these systems.

In general, throughout the reserve components, the individual members are
responsible for maintaining their physical and medical fitness and the
unit commanders are responsible for ensuring members' compliance with
medical and physical fitness examinations; however, the reserve components
do not always hold the unit commanders accountable and the unit commanders
do not always enforce the members' compliance. Accountability for
compliance is fragmented at various levels of command. No centralized
oversight exists to hold all levels accountable ensuring that all
requirements are being met. Individual members are responsible for
attending all scheduled examinations and assessments, seeking timely
medical advice when necessary, reporting changes in their medical health
on the annual medical certificate, and successfully completing the
requirements of the physical fitness examinations. False statements may
result in reassignment, discharge, or other disciplinary action. Unit
commanders are responsible for implementing any administrative and command
provisions for examinations, informing members of the examination
requirements, establishing training programs for physical fitness, taking
actions against reserve members who fail to comply with the requirements,
and reporting the current medical and dental status of reservists through
the applicable tracking systems, and they are ultimately responsible for
the accuracy of medical and physical fitness information relied on by
higher commands. However, reserve components do not always hold the unit
commanders accountable for these responsibilities and the unit commanders
we interviewed expressed concern about the many competing responsibilities
they have, such as meeting training requirements, and how they must
prioritize the use of their limited resources. One unit commander also
expressed concern about enforcing medical and physical fitness policies if
it meant losing a "good soldier" who otherwise performs his duties well.
Without oversight and accountability at the OSD and respective service and
reserve component levels, unit commanders may not have the incentive or
resources to fully enforce the medical and physical fitness examination
requirements and compliance may suffer.

    Indications of Noncompliance with Medical and Physical Fitness Examination
    Requirements Exist

Indications of Noncompliance with 5-Year Medical Examination and Annual
Medical Certificate Exist at All Components

Although DOD can not determine the extent of reserve components'
compliance with routine medical and physical fitness examinations, we
found indications of noncompliance during our site visits and in our
reviews of existing audit reports and investigations. For example, a
limited review of medical files at one Army National Guard and one Army
Reserve location, data from a Navy report, test results of two units in a
Marine Corps battalion, and data from a review conducted by the Air Force
Audit Agency indicate some noncompliance at all components with the
routine medical examination, annual medical certificate, annual dental
examination, and annual physical fitness examination.

A review of available medical files at one Army National Guard and one
Army Reserve location, data from a Navy report, test results of two units
in a Marine Corps battalion, and data from a review conducted by the Air
Force Audit Agency indicate some noncompliance with the routine medical
examination and the annual medical certificate at all components. For
example, in April 2005 we conducted a review of 39 medical files at an
Army National Guard unit that was deployed to Iraq in 2003 for 1 year. We
found that 13 members were not in compliance with the routine medical
examination at the time of our review. Further, while 36 members were in
compliance with the annual medical certificate at the time of our review,
only 3 members were in compliance with the annual medical certificate
prior to the unit being alerted of their most recent mobilization date for
deploying to Iraq. According to the commander of this unit, there are a
number of actions that need to be accomplished during weekend drills, and
with limited time and resources available, completing routine medical
requirements is low on the long list of priorities. In addition, during
June 2005, we reviewed 175 medical files of an Army Reserve unit that
deployed to Afghanistan in 2003 for 10-month deployment. We found that all
but 2 members were in compliance with the 5-year medical examination.
While 150 members were in compliance with the annual medical certificate
at the time of our review, not a single member was in compliance with the
annual medical certificate prior to the unit receiving alert orders of
their mobilization. Furthermore, many of the soldiers that we spoke with
during our review stated that they were unfamiliar with the annual medical
certificate. In addition, a February 2005 Army Inspector General Report
noted that virtually all reserve component leaders they contacted during
their review expressed frustration with their inability to maintain the
medical deployability status of their soldiers using the annual medical

certificate process.42 Leaders noted the certificate only reflects what a
soldier is willing to share. Often the only medical personnel available to
review and sign the certificate is a unit medic, who can do little more
than ask if the data are correct.

In July 2005, the Navy reported that 96.8 percent of reserve members had
completed the routine 5-year medical examination and 94 percent of reserve
members had completed the annual medical certificate. These high rates are
due, in part, to the high priority placed on medical and dental compliance
throughout the Navy Reserve.

Although the Marine Corps Reserve does not currently have componentwide
automated information on medical compliance, it does conduct a periodic
site inspection called the Mobilization Operational Readiness Deployment
Test (MORDT). We reviewed the results of the MORDT at two units of a
Selected Reserve Battalion that had been mobilized. The first unit test
results we reviewed indicated that 98 percent of the reservists had
completed a routine physical examination within 5 years, and 90 percent
had submitted annual health certifications. The second unit test results
also indicated that 98 percent of the reservists had completed a routine
annual physical within 5 years, and 88 percent had submitted annual health
certifications. According to Marine Corps Reserve officials, all Marine
Corps Selected Reserve units are subjected to an unannounced test prior to
mobilization to ensure the unit can deploy.

The Air Force Audit Agency (AFAA) recently concluded its review of the
Service's Individual Deployment Process, during which it found significant
problems with the Guard's and Reserve's medical records. Ten Air National
Guard and Air Force Reserve installations included in a sample of 20
installations designed to be able to produce estimates for all Air Force
personnel who were eligible to be deployed during the 90-day window
between June 1, 2004, and August 31, 2004, were in compliance with medical
requirements such as, but not limited to, annual medical assessments and
dental examinations. The AFAA reviewed the medical records and associated
documentation for accuracy and completeness. Based on AFAA's review and
analysis of 14,121 eligible Guard and Reserve members combined, about 13
percent43 were found to have medical

42 Over 1,400 active and reserve component leaders, soldiers, and
civilians in 35 locations in the United States were contacted by the Army
Inspector General during its review.

43 We are 90 percent confident that the true percentage of medical
discrepancies is within +/-6.1 percentage points of our estimate.

Indications of Noncompliance with Dental Examinations Exist at All Reserve
Components

discrepancies in their medical records. At 2 of the unit commands included
in AFAA's review that we also visited in our review, command officials
said that they agreed with the AFAA's findings and were taking corrective
action.

Indications of noncompliance with the dental examination requirement were
also present at all the reserve components. For example, as previously
noted, in April 2005, we conducted a review of 39 medical files of an Army
National Guard unit; of these, 33 were not in compliance with the annual
dental examination at the time of our review. Furthermore, 32 members were
not in compliance with the annual dental examination prior to alert. In
June 2005, we visited an Army Reserve unit to conduct a review of 175
medical files. Although only 13 members were not in compliance with the
annual dental examination at the time of our review, over 130 members were
not in compliance with the dental examination prior to alert.

Other evidence indicates that compliance with dental requirements has been
a particular matter of concern for the Army reserve components. According
to a February 2005 Army Inspector General Report,44 there are examples of
reserve component service members with multiple tooth extractions at
nearly every mobilization station. Furthermore, in cases where members
presented dental records during mobilization, often the only entries are
dated to the members' basic training and initial exams and procedures. We
found a stark example of what happens during mobilization when a member's
dental status is allowed to remain below Class I or II. In one unit we
visited, we interviewed a member who had 30 teeth extracted prior to
deployment. According to the member, although dental screenings were
conducted annually, indicating that he was a dental class III he took no
follow-up action to correct his dental problems because he had no dental
insurance and correcting the problem was not a priority. At the time this
servicemember was being mobilized, a Department of the Army memo dated
December 6, 2002, stated that soldiers assigned to designated units
scheduled to deploy within 75 days of mobilization and identified as being
within dental class III or IV have necessary dental treatment initiated to
bring them up to dental classification II, the deployment standard.

44 Department of the Army Inspector General Special Inspection of Army
Mobilization/Demobilization in Support of Recent and Ongoing Operations,
November 2003-June 2004, February 28, 2005.

Indications of Noncompliance with Physical Fitness Examination Requirement
Exist at All Reserve Components

Although we did not review individual medical and dental records at Navy
and Marine Corps Reserve sites we visited, we did review specific reports
to assess whether these components monitored members' dental status. We
found that the Navy Reserve compliance appears to be improving. For
example, in early July 2005, the Navy reported that 88.6 percent of
selected reservists were in a Dental Class I or II category, an increase
over the 69 percent reported in the Dental Class I or II category in
December 2002. We also reviewed MORDT results for two Marine Corps units
during a site visit to a Marine Corps Reserve Battalion that had been
mobilized. We found that test results for the first unit indicated that 85
percent were categorized as Dental Class I or II while 77 percent in the
second unit were categorized as Dental Class I or II.

Analysis provided by the AFAA from its review, mentioned earlier,
indicated that about 13 percent45 of the Air National Guard and Air
Reserve members who were eligible to be deployed between June 1, 2004, and
August 31, 2004, were found to have discrepancies in their dental records.
In addition to the AFAA review, in 2004 the Air Force Inspection Agency
conducted health services inspections and found discrepancies in dental
readiness classifications in 49 percent of the 37 installations reviewed.

As with the other examination requirements, we also found indications of
noncompliance with the physical fitness examination requirement at all six
components.

During our review in April 2005 we also reviewed 29 physical fitness files
of the Army National Guard unit that deployed to Iraq. Of the 29 physical
fitness files we reviewed, only 18 members showed compliance with the
physical fitness examination requirement during 2004. Of these 18 members,
11 passed the physical fitness test and 7 failed. According to the unit
commander, some soldiers possess skills that are greatly needed for unit
continuity and strength and usually outweigh the ramifications of having
to separate the member due to physical fitness test failures. We also
conducted a review in June 2005 of 227 physical fitness files of the Army
Reserve unit that deployed to Afghanistan. Of the 227 physical fitness
files we reviewed, only 117 members showed evidence of compliance with the
physical fitness examination requirement during 2005. Of these 117
members, 89 passed the physical fitness test and 16

45 We are 90 percent confident that the true percentage of medical
discrepancies is within +/-6.1 percentage points of our estimate.

failed.46 In group discussions held at this time, members stated that
there were no repercussions for failing the physical fitness test. As
previously reported in our 1994 report,47 we also found that physical
fitness scores had been inappropriately changed and servicemembers were
not discharged even after repeated test failures, primarily because
commanders placed more emphasis on maintaining unit strength.

While visiting a Navy Reserve Activity, we obtained a single unit's
physical fitness test results to ensure data were properly maintained in
the Physical Readiness Information Management System. However, when we
asked the Navy Personnel Command to provide a copy of the required
physical fitness report, we learned the report would be submitted to OSD
late. According to a Navy official, the Navy had identified over 2,000
duplicate record entries and estimated that nearly 25 percent of the body
fat scores were missing from the data totals. In its report to OSD, the
Navy reported that it had not mandated separation processing for
individuals who failed the physical fitness test since May 2001.

During a visit to a Marine Corps Reserve Center, we also obtained
information that indicated individual Marine Corps reservists' physical
fitness scores were recorded in the Marine Corps Total Force System.
Subsequent to our visit, however, we learned that the Marine Corps also
provided an unofficial "draft" physical fitness report to the OSD after
the deadline. In order to review Marine Corps physical fitness statistical
data, we requested a copy of the report on April 6, 2005. As of October
2005, the Marine Corps had not responded to our request.

The Air Force did not meet OSD's required due date in submitting its first
annual report on its assessment of the physical fitness, body fat, and
health promotion program for the active service, the Air National Guard,
and the Air Force Reserve. The Air Force did not submit its annual report
until May 4, 2005. Based on the data provided by the Air Force for the Air
National Guard and the Air Force Reserve, only 83 percent of the force
members were tested, with 13.2 percent of those tested falling into the

46 At the time of our review, 110 members did not have an APFT on file. In
addition, there were service members who did not take a physical fitness
test for the record during 2005, nor did they have a temporary or
permanent profile when completing the physical fitness test.

47GAO, Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet
Medical and Physical Fitness Standards, GAO/NSIAD-94-36 (Washington, D.C.:
Mar. 23, 1994).

  DOD Lacks Visibility over the Health Status of Reserve Components after Being
  Called to Active Duty and the Extent to which Members with Preexisting
  Conditions Required Care during Deployment

poor category. However, the Air Force's assessment of one of its reserve
component's statistical data may not be entirely correct. In its reported
statistical information of the numbers of members tested, those members
testing in the poor category are higher than those numbers directly
reported by the Air National Guard to the Air Force Medical Support
Agency, which consolidated the respective components' data and in turn
submitted the overall report to the Assistant Secretary of Defense for
Force Management Policy. In addition, as discussed earlier, we were unable
to determine that the data used from the Air National Guard and Air Force
Reserve databases that generated these data are reliable.

DOD does not have complete visibility over the health status of reserve
component members after they are called to duty and is unable to determine
the extent of care provided to those members deployed with preexisting
medical conditions. Despite the existence of various sources of medical
information, DOD has incomplete visibility over members' health status
when called to active duty, primarily because the reserve components vary
in their ability to systematically identify, track, and report members'
medical deployability and the DOD-wide centralized database cannot provide
complete information-both of which hinder DOD's ability to accurately
determine what forces remain for future deployments. In addition, DOD is
unable to determine the extent to which reserve component members received
care for preexisting medical conditions while deployed; however, evidence
suggests that reserve component members did deploy with preexisting
medical conditions that could not be adequately addressed in theater and
that some of these conditions may have stressed in-theater medical
capabilities.

    Visibility over Health Status of Reserve Members after They Are Called to
    Active Duty Is Limited

Although DOD has some visibility over reserve component members after they
are called to active duty or mobilized, this visibility is limited despite
several potential sources of information. For example, the reserve
components vary in their ability to systematically identify, track, and
report information about members' medical deployability, which limits
DOD's visibility over the health status of members. In addition, although
medical information is captured on predeployment forms for all reserve
component members and entered into a DOD-wide centralized database during
mobilization, some data are still missing and information regarding the
reasons why members were found nondeployable is not captured in a way that
can be easily searched through the database. Moreover, medical referral
data captured on the predeployment forms provide some insight into the
care that members may have required during mobilization, but this care is
not always related to why a member was determined to be

Reserve Components Vary in Ability to Identify, Track, and Report Medical
Nondeployable Members

medically nondeployable. Some data on the medical reasons why Army Guard
and Reserve members were not deployed after being activated can be
obtained from an analysis of the Army's medical holdover database, but
this information is insufficient to provide DOD with visibility over
members' health status since it is only gathered on the numbers of Army
reserve components held prior to deployment and this population is
diminishing due to positive changes in Army's medical holdover policy.
DOD's limited visibility over reserve component members' health status
when they are called to active duty could affect planning for future
deployments because the pool of available Guard and Reserve component
members from which to fill requirements for certain skills and grades is
dwindling, and members' health status is deteriorating following
deployments.

The reserve components vary in their ability to systematically identify,
track, and report members' medical deployability, and only three reserve
components-the Navy Reserve, the Air Force Reserve, and Air National
Guard-can currently identify and track members with both temporary and
permanent conditions that limit medical deployability. This limited
visibility over reserve component members' medical deployability status
hinders DOD's ability to identify the pool of available Guard and Reserve
members who are available for deployment.

The Navy Reserve uses the Medical Readiness Reporting System (MRRS) to
track and report the status of reservists classified as Temporarily Not
Physically Qualified for duty because of an illness, injury, or other
medical condition that should be resolved within 6 months. This system is
also used to track and report the status of reservists, classified as Not
Physically Qualified for duty, with more serious medical conditions such
as cancer or heart disease that will not be resolved in 6 months and may
lead to a medical review or board retention decision. As the Marine Corps
Reserve continues to fully implement the Navy's Medical Readiness
Reporting System, it too will have these same capabilities. Both the Air
National Guard and the Air Force Reserve's medical tracking systems- PIMR
and RCPHA, respectively-can identify and track members with specific
medical conditions that limit deployment; however, neither system can
distinguish between temporary and permanent limitations. In addition, the
Air Force has a system called Military Personnel Data System that captures
information on all medical profiles and can report specific queries on
specific categories such as temporary and permanent conditions. Although
the Army tracks active, guard, and reserve members with medical profiles
that limit deployment through their medical tracking system, MEDPROS, the
active Army and Army Reserve do not presently

Centralized DOD-wide Database Provides Some Visibility over Health Status
During Mobilization, but Data Could Be Further Improved

track members with temporary medical conditions that render them
nondeployable. However, the Army National Guard is in the process of
implementing a system, called the Medical Non-Deployable Tracking Module
(MND-TM), that will track its members who have a temporary or permanent
medical condition that renders them nondeployable. Army National Guard
officials expect all states to use this system for its members by July
2007. Until all six reserve components are able to systematically identify
and track members' medical deployability status, DOD will not have the
most accurate information to centrally manage estimating the remaining
available pool of guard and reserve members for future deployments.

DOD has some visibility over reserve component members' medical status
during mobilization through the centralized DOD-wide database operated by
the Army Medical Surveillance Activity (AMSA). All active and reserve
component members are required to complete a medical predeployment form to
document the member's medical deployability status, which is then
forwarded to AMSA for entry into the database. Thus, information can be
obtained from the centralized database on reserve and active component
members who were determined nondeployable during mobilization due to
medical reasons. The member also completes a health assessment form after
deployment. However, we have noted in previous reports that the
centralized database has missing and incomplete forms. In our last report
issued in September 2004,48 we found that for the required forms from
reserve component members (1) not all of the forms had reached AMSA, (2)
only some of the forms that had reached AMSA had been entered into the
database, and (3) not all of the forms contained complete information,
thus limiting analysis.

We also noted that while the components were not in complete compliance
with the requirement to submit pre- and postdeployment assessments, the
number of assessments had grown significantly. During this review, we
found that DOD has continued to make progress toward collecting the
pre-and postdeployment forms. According to AMSA officials, the database
contained about 140,000 assessments at the end of 1999, grew to about 1
million assessments by May 2003, almost doubled at 1,960,125 by June 2004,
and was at 2,241,177 by June 2005.

48 GAO-04-1031.

Further, DOD has established a centralized deployment health quality
assurance program to improve data collection and accuracy.49 Each service
has also developed a deployment health quality assurance program. The
department's first annual report, documenting, among other things, issues
relating to predeployment health assessments, was issued in May 2005. The
DOD quality assurance program includes (1) periodic site visits jointly
conducted with staff from the Office of the Assistant Secretary for Health
Affairs and staff from the military services to assess compliance with the
deployment health requirements, (2) periodic reports from the services on
their quality assurance programs, and (3) periodic reports from AMSA on
health assessment data maintained in the centralized database. The report
noted that centralized management of quality assurance had improved
accountability of the preassessment forms on the part of the services.

For this review, we obtained predeployment information from AMSA officials
based on over 1 million active and reserve component predeployment health
assessment forms collected between November 2001 and June 2005. More than
5 percent of the reserve component and more than 6 percent of the active
component predeployment health assessment forms did not record the
servicemember's deployability status. Of the approximately 94 percent of
forms that were complete, nearly the same percent of reserve component and
active component members were found medically deployable, 94 percent of
the reserve component members compared to 96 percent of the active
component members. Unfortunately, the forms do not always capture
information regarding the reasons why members were found medically
nondeployable or do not capture that information in a systematic way. For
example, although the form has an entry for a narrative explanation to
explain why a member is medically nondeployable, an AMSA official informed
us that these explanations are often incomplete or not decipherable, and
can not be easily categorized. Furthermore, although the forms do provide
space for the member's deployment destination, this information is not
always filled in because, according to AMSA officials, deployment
destination is often not known by the member or is classified. Therefore,
the data presented here are for all worldwide deployments, including the
United States, and

49 This program was established following our 2003 review, GAO, Defense
Health Care: Quality Assurance Process Needed to Improve Force Health
Protection and Surveillance, GAO-03-1041 (Washington, D.C.: Sept. 19,
2003).

could change after the initial deployment, thus preventing an analysis by
operation.

As seen in table 1, the total nondeployable rate for all six reserve
components was more than 5 percent, while table 2 shows the total
nondeployable rate for the active component was almost 4 percent. While
the Army Reserve had the highest percentage of nondeployable
servicemembers among the reserve components, at about 9 percent, the
active Army had the highest percentage of nondeployable servicemembers
among the active components, at almost 6 percent. According to medical
officials, some of these nondeployable personnel, such as those who had
suffered multiple heart attacks, should have been discharged prior to the
time that they received their mobilization orders. Others had temporary
conditions, such as broken bones and pregnancies, that did not warrant
medical discharges but made the servicemember nondeployable at the time of
the assessment.

    Table 1: Service Decisions Concerning Reserve Components' Deployability,
                        November 2001 through June 2005

                          Deployable or             Total number 
                                                              of 
                          nondeployable            predeployment 
  Reserve                 answer        Percentage health           Percentage 
                          missing       with       assessments   
 Components Nondeployable       on form missing        completed nondeployable 
 Deployable                             answer                   
    Army                                                         
  Reserve           9,842         5,578       4.82       115,707 
  100,286                                                        
    Army                                                         
  National                                    3.31               
  181,160          10,959         6,584                  198,703 
Guard                                                         
    Navy                                                         
  Reserve              99         1,445      14.25        10,141 
8,597                                                         
 Air Force                                                       
  Reserve             156         2,341      14.95        15,661 
13,164                                                        
    Air                                                          
  National            243         3,335       8.64        38,603 
Guard                                                         
35,025                                                        
Marine                                                        
Corps               31           763      16.30               
3,886                                                   4,684 
  Reserve                                                        
Total                                                         
  342,118          21,330        20,046       5.23       383,499 

                       Source: GAO analysis of AMSA data.

Table 2: Service Decisions Concerning Active Components' Deployability, November
                             2001 through June 2005

                                    Deployable or             Total number 
                                                                        of 
                                    nondeployable            predeployment 
  Active                            answer        Percentage health           Percentage 
                                    missing       with       assessments   
Components Deployable Nondeployable       on form missing        completed nondeployable 
                                                  answer                   
Army       347,057        21,018        19,451       5.02       387,528 
Navy        20,190           109         1,627       7.42        21,928 
Air Force     150,045         1,477        14,544       8.76       166,066 
  Marine       47,318           166         4,191       8.11        51,678 
  Corps                                                                    
  Total       564,610        22,770        39,813       6.35       627,200 

Medical Referral Data Provide Insight on Care Provided during Mobilization

Source: GAO analysis of AMSA data.

The predeployment health assessment forms capture information on specific
medical referrals given to members by the reviewing health care official
during mobilization, which is useful in gaining some insight into the care
that members may have required during mobilization. These data are not as
helpful in determining why a member was not medically deployable since
they are not always related to why a member was determined to be
nondeployable. According to a senior OSD official, although any indicated
referral may be related to a disposition of nondeployable, this is not
always the case. Three common scenarios illustrate this relationship: (1)
a member is found to be clearly nondeployable from a medical standpoint,
and no referral is made; (2) a member is referred for further evaluation
for a condition for which deployability is questionable, in which case
there is a direct relation between the referral and the determination of
deployable or nondeployable; or (3) a member is found to be deployable,
but has a minor medical issue for which the health provider provides a
referral for treatment. According to a senior OSD official, the last
scenario is a fairly uncommon reason for a referral. Examples might
include a referral for a routine preventive test, such as a Pap test in a
gynecological clinic. The Pap test is a desired preventive medical test,
but depending on the date and result of the last Pap exam and the
individual's personal history and risk factors, it is not always necessary
to perform one prior to deployment.

More than 50,000 referrals were made on the predeployment health
assessments from November 2001 through June 2005 for both the active and
reserve components. As shown in table 3, of the 21,000 forms with
referrals for reserve component members, the referral rate averaged more
than 5 percent. As shown in table 4, of the 24,633 forms with referrals
for their active duty counterparts, the referral rate was about 4 percent.

Within the reserve components, the Army Reserve had the highest referral
rate at nearly 8 percent, while the Air National Guard and Air Force
Reserve had the lowest rates, both at less than 1 percent.

Table 3: Total Predeployment Referral Rate by Reserve Component, November
2001 through June 2005

                                        Total number of 
                                   predeployment events   Total predeployment 
               Reserve component         with referrals         referral rate 
             Army National Guard                 11,609                  5.84 
                    Army Reserve                  8,750                  7.56 
              Air National Guard                    201                  0.52 
               Air Force Reserve                    145                  0.93 
                    Navy Reserve                    211                  2.08 
            Marine Corps Reserve                     84                  1.79 
                           Total                 21,000                  5.48 

                       Source: GAO analysis of AMSA data.

Table 4: Total Predeployment Referral Rate by Active Component, November
2001 through June 2005

                                       Total number of 
                                predeployment events      Total predeployment 
             Active component           with referrals          referral rate 
                         Army                   20,312                   5.24 
                    Air Force                    3,047                   1.83 
                         Navy                      572                   2.61 
                 Marine Corps                      702                   1.36 
                        Total                   24,633                   3.93 

Source: GAO analysis of AMSA data.

Note: Predeployment Health Assessment forms may contain no referrals, one
referral, or multiple referrals per completed form.

There are 18 categories of referrals that can be checked on the
predeployment form, of which 1 is "other" and does not provide any further
detail. As seen in figure 1, the top 3 medical referrals for the reserve
components were "other," "dental," and "eye," whereas the top 3 referrals
for active components were "other," "dental," and "orthopedics." The rate
of medical referrals for the reserve components was almost 40 percent and
for the active components was almost 50 percent.

 Figure 1: Rate of Medical Referrals by Type for Active and Reserve Components
                      from November 2001 through June 2005

Rates of referrals Other

                                     Dental

eEy

thoOr

                                   GYN Mental

diacCar

                                      ENT

y

                                  PulmonarDerm

oNeur

                                     GI GU

y

                                    Pregnanc

yil

iguetFa

batCom

iologydAu

mFaTypes of referrals

Army Medical Holdover Database Provides Data on Activated Members Who Were
Not Deployed Due to Medical Problems

Reserve component

Active component

Source: GAO analysis of AMSA data.

Although the AMSA referral data do provide some insight into the medical
care required during mobilization, the referral data are not detailed
enough to determine the type of medical referral or determine the reason
for nondeployment.

The Army's medical holdover database, a module within the Medical
Operational Data System (MODS), does provide DOD with a snapshot of data
about the number of Army National Guard and Reserve members who were not
deployed after being called to active duty because of medical problems and
the medical reasons why they were not deployed after being activated.
Although all of the services may keep reserve component members on active
duty if they incur an injury in the line of duty following deployment,
only the Army has held reserve component members in need of medical care
at military treatment facilities prior to deployment. These

servicemembers are referred to as the medical holdover population. Because
of the large numbers of activated Army National Guard and Army Reserve
members placed in medical holdover by the Army in the early part of
Operation Iraqi Freedom, the Army Office of the Surgeon General created a
module in an existing database to track them. We examined the Army medical
holdover data to obtain information about the possible reasons why
servicemembers were found to be medically nondeployable. However, the data
cannot provide complete visibility over members' health status because the
population receiving medical care from the Army prior to deployment is
diminishing due to changes in Army's medical holdover policy. Further,
until January 2005, MODS was not used consistently by all case managers50
responsible for servicemembers in medical holdover.

Between December 2002 and October 2003, 4,850 activated Army reserve
component members were found medically nondeployable and kept on active
duty until their medical problems had been resolved and they were returned
to full duty or until they had been referred to a medical board and
discharged from the Army. In October 2003, the Army changed its policy to
allow the demobilization of personnel who were found to be nondeployable
within the first 25 days of activation. In accordance with this policy,
reserve component servicemembers identified in the first 25 days as having
a medical condition that renders the individual nondeployable may be
released from active duty immediately. As a result of this policy change,
the Army was able to demobilize reserve component members who were found
to be nondeployable within the first 25 days of their mobilization. The
change also reduced the inflow of reserve component members on active duty
with medical problems who were identified during the predeployment health
assessment process. As of August 11, 2005,51 only 860 reserve component
members52 were in a medical holdover status as a result of a medical
condition found prior to deployment.

50Draft regulation for the Medical Holdover Case Management Program states
that a case manager is normally a registered nurse who is assigned to
manage the medical care provided each medical holdover soldier. The case
manager implements the case management process with a focus on clinical
evaluation and outcomes.

51 As of August 11, 2005, the total number in medical holdover was
4,866-860 of whom were placed there prior to deployment, and the remainder
of whom were placed there due to a medical condition developed during
deployment.

52 According to an Army official, 87 of these 860 have been in a medical
holdover status for over a year due to complex medical conditions, such as
cancer.

As shown in figure 2, the most common medical condition that has prevented
a reserve component member from deployment53 is orthopedic in
nature-accounting for 56 percent of the 860 Army National Guard and Army
Reserve members who were found medically nondeployable and placed in a
medical holdover status-followed by internal medicine at 16 percent, and
neurological problems at 8 percent.

Figure 2: Medical Conditions of Army National Guard and Army Reserve
Members in a Medical Holdover Status as of August 11, 2005

2%

Dental

2%

Diabetes

2%

Ear, nose and throat

4%

General surgery

Cardiovascular

Mental health

Neurological

Internal medicine

Orthopedic

Source: GAO analysis of Army data.

53 Conditions that could disqualify a reserve component servicemember from
deployment and would cause the member to be released if identified
medically nondeployable during the first 25 days of activation include
temporary and permanent conditions that do not meet medical deployment
standards as outlined in AR 40-501, Chapter 3.

Lack of Visibility over Reserve Component Members' Health Status Could
Affect Planning for Future Deployments

Despite the more specific information about medical status that can be
obtained by reviewing these medical holdover data, the data are fairly new
and limited to those held at medical treatment centers.

Although senior military officials at various levels of command told us
that the health status of reserve component members did not affect
deployment schedules, the extent to which unit commanders have had to find
replacement members to fill in for members who were medically unqualified
upon alert, the reasons why, and how, or if, this impacted planning of
operations in Iraq and Afghanistan are unknown. However, DOD's lack of
visibility over reserve component members' health status when they are
called to active duty could affect planning for future deployments as the
demand for troops for the Global War on Terrorism continues.

The Army has had to transfer reserve component personnel from nonmobilized
units to mobilized units to meet mission requirements. For example, the
Army Inspector General reported in February 2005 that with increasing
frequency, Army units identified for alert and mobilization had previously
provided members to other units. The report noted that frequently more
than half of a deploying unit's personnel had been transferred into the
unit to meet personnel requirements. This "ripple effect" is occurring
across the Army reserve force, and each subsequent mobilization requires
more and more personnel transfers to meet personnel requirements. The need
for these personnel transfers is largely due to an outdated Cold War
strategy that planned to use the reserve forces as a later deploying force
and therefore did not give them full resources. As more units are used for
this "cross-leveling", it becomes even more important that the Army have
good visibility over the health status of the remaining reserve component
members.

In addition, as shown in table 5, the health status has declined for
active and reserve components after returning from deployment as shown by
data from the pre-and postdeployment health assessments. The Army National
Guard and Army Reserve had the highest percentage of servicemembers
indicating their health as fair to poor on the postdeployment health
assessment.

Table 5: Rate of Servicemembers' Health Status as Recorded on Pre-and
Postdeployment Forms for Active and Reserve Components from November 2001
through June 2005

Predeployment: Postdeployment: Predeployment: Postdeployment: Military
component good to excellent good to excellent

fair to poor fair to poor

                      Reserve component: Active component:

          Army Reserve            95.77       87.05       2.70          12.30 
       Army National Guard        96.57       89.07       2.27          10.31 
      Marine Corps Reserve        98.36       89.90       0.99    
       Air National Guard         99.13       97.43       0.42    
        Air Force Reserve         99.00       96.49       0.40    
          Navy Reserve            98.60       93.67       0.64    

             Army                95.00            90.53            3.44       
         Marine Corps            97.51            93.49            1.74       
          Air Force              98.82            97.73            0.86       
             Navy                96.88            94.27            2.55       

Source: GAO analysis of AMSA data.

As the pace of operations for the reserve forces continues to be high and
the health status of returning members is diminished, it becomes even more
important that DOD has good visibility over the availability of remaining
units. Improved visibility and tracking of the health status and medical
deployability of these members is a key component in the calculation of
the members available for planning future deployments.

    Extent to which Members with Preexisting Medical Conditions Required
    Treatment during Deployment Cannot Be Determined

While Specific Deployment Criteria for Operations Enduring Freedom and
Iraqi Freedom Continue to Evolve, Tracking of Known Preexisting Conditions
Has Not Begun

DOD cannot determine the extent to which reserve component members
received care for preexisting medical conditions while deployed in
theater54 because DOD has not determined what preexisting medical
conditions may be allowed into specific theaters of operations. The
purpose of examining members and properly screening them at the
mobilization stations is to help ensure that members are medically and
physically fit to deploy and do not have any condition that would
adversely affect the mission. As noted in DOD guidance,55 fitness
specifically includes the ability to accomplish the task and duties unique
to a particular operation, and the ability to tolerate the environmental
and operational conditions of the deployed location. Specific medical
deployment criteria for proper screening are essential for determining
preexisting medical conditions that can not be adequately addressed in
theater and could stress in theater medical capabilities. While evidence
suggests that members did deploy with preexisting conditions, the total
impact of this is unknown.

Developing and updating medical criteria for a specific theater of
operations are the responsibilities of the combatant commands-for
Operation Enduring Freedom and Operation Iraqi Freedom this is U.S.
Central Command (CENTCOM). The CENTCOM medical deployment criteria have
been evolving over the course of these operations. CENTCOM has updated
this guidance six times throughout these operations to include more
specific guidance to the theater of operations; the last update was issued
in January 2005. During the initial mobilizations for these operations,
the services were dependent on CENTCOM general deployment criteria issued
in May 2001, which did not identify medical conditions that would render a
member medically unfit for these operations. In the absence of specific
guidance early on during the operations, the services relied upon their
own medical deployment criteria. For the Army, specific criteria did not
exist until February 2005.56

54 For the purposes of this report, preexisting medical conditions refer
to those medical conditions that were not identified during mobilization
that may limit a member's ability to perform his or her mission and cannot
be adequately addressed in theater.

55 Minimal Standards of Fitness for Deployment to the CENTCOM Area of
Responsibility, January 2005.

56 Army Regulation 40-501 was updated to include standards for deployment
in February 2005.

The original CENTCOM deployment criteria made a general statement that all
personnel must be assessed and determined to be medically and
psychologically fit for worldwide deployment to a combat theater and that
the in-theater health infrastructure provides only limited medical care.
Not until May 2004 did CENTCOM update its deployment criteria to include
more specific guidance. This updated guidance stated that servicemembers
who have existing medical conditions may deploy if all of the following
conditions were met: (1) an unexpected worsening of the condition is not
likely to have a medically grave outcome; (2) the condition is stable; and
(3) any required ongoing health care or medications must be immediately
available in theater in the military health system, and have no special
handling, storage, or other requirements, such as electrical power. The
criteria provided a list of conditions that may preclude medical clearance
for DOD civilians and contractors (including current heart failure,
history of heat stroke, and uncontrolled hypertension); however, according
to CENTCOM officials, this list of conditions did not apply to
servicemembers because they were already covered by service-specific
guidelines. The most recent CENTCOM deployment criteria applicable to all
servicemembers and DOD civilians and contractors were issued in January
2005, and update theater-specific immunization requirements and provide
more detailed guidance on contact lens wear, among other things. As these
policies are developed, the combatant command is to provide them to the
services, which are then responsible for determining how they implement
the screening requirements in terms of screening their deploying forces,
including activated reservists.

Because DOD has not determined what preexisting conditions may be allowed
into a specific theater of operations, it has not known what preexisting
conditions to track. As noted, the medical deployment criteria for the
current theater of operations have been evolving, but specific medical
deployment criteria have not been developed for other potential theaters
of operation. However, some preexisting medical conditions may be common
to all theaters of operation. DOD has not determined this. Further,
although DOD has a number of systems for tracking medical conditions in
theater, the current databases have not been modified to capture data on
known preexisting conditions for this specific operation. For example, the
Joint Medical Workstation (JMeWS) provides medical treatment status and
medical surveillance information, as well as tracks and reports patient
location within a theater of operations and during evacuation from
frontline medical units to stateside medical treatment facilities. The
U.S. Transportation Command (TRANSCOM) utilizes the TRANSCOM Regulating
Command and Control Evacuation System (TRAC2ES) to document patient
movements, such as medical evacuations.

Evidence Suggests that Reserve Component Members Have Been Deployed into
Theater with Preexisting Medical Conditions

The Joint Patient Tracking Application (JPTA) was initially designed for
use within Landstuhl Regional Medical Center in Germany as a way to manage
Operations Enduring Freedom and Iraqi Freedom patients. In 2004, the
services were directed by the Assistant Secretary of Defense for Health
Affairs to implement JPTA at military treatment facilities in theater and
the continental United States to improve patient tracking and management.
The Disease Nonbattle Injury (DNBI) rates for the services in Operations
Enduring Freedom and Iraqi Freedom are tracked in the DNBI database by the
Air Force Institute for Operational Health. We did not evaluate these
systems since they do not distinguish care provided for preexisting
medical conditions.

Although DOD does not systematically develop or report information about
the extent of care that was provided in theater to reserve component
members for preexisting medical conditions,57 senior military medical
officials who served in theater have provided examples of reserve
component members who were deployed with preexisting medical conditions
that could not be adequately addressed in theater. Some officials told us
that such treatments strained in theater medical capabilities and
infrastructure.

According to a senior military official in the surgeon's office of the
commander in chief of the U.S. Central Command (CENTCOM), there were many
instances of individuals, from all services, who deployed into the Iraq
and Afghanistan theater of operations with conditions for which they
should have been considered nondeployable. Also, medical officials from
both the Army and Navy cited examples of conditions seen in theater that
should have rendered members nondeployable. Among the examples cited were
members with a history of heart attack, severe asthmatics (the desert
conditions were not suitable for these members), severe hypertension, a
woman 4 months into chemotherapy for breast cancer, and a man who had
received a kidney transplant 2 weeks prior to deploying. Other examples
included cases involving members deployed with sleep apnea requiring
machines that are run by electricity, even though electricity was either
unavailable or unpredictable. Another soldier, we were told, who arrived
in theater was diabetic and required an insulin pump for treatment. We
were also told of a number of psychiatric

57 Although some systems exist to track various aspects of medical care
provided in theater, we did not identify any system that tracks care
provided to reserve component members for preexisting conditions.

patients who were suffering from conditions such as bipolar disorder who
should not have been in the desert because the medications that they were
taking caused them to sweat profusely. One Air Force Reserve medical
official who served in theater preparing members to be medically evacuated
estimated that of the approximate 2,000 reservists she helped to evacuate,
10 percent being evacuated were due to preexisting conditions such as
diabetes and heart problems, with the most common condition being
diabetes. The commander of an Army Guard unit deployed to Iraq told us
about a member who had deployed with a preexisting knee problem for which
he had to be returned to the United States to correct. The issue was
eventually resolved and the member was allowed to redeploy with his unit.

According to a September 2004 Air National Guard Surgeon General
memorandum,58 unacceptable dental health should preclude a member from
deploying under any circumstances because dental resources do not exist in
theater. However, the Air National Guard's Surgeon General has noted that
dental emergencies are historically and currently the most common
preventable reason for loss of manpower in the wartime theater.59 In
addition, the Air Force's Air Surgeon Chief of Medical Services
Directorate commented on January 17, 2003, in response to a case involving
an Air National Guard member who had been sent into theater with an
obvious major preexisting dental condition, that it is unreasonable to
expect deployed doctors and dentists to perform remedial procedures and
provide care that should have been accomplished at home because it takes
too much time away from treating injured and ill in theater, and it
results in lost man hours for the gaining unit that it needs to accomplish
its war-fighting requirements. In our small group discussions with Army
National Guard, one servicemember said that he was told that he would
receive dental care in theater, although this care was never provided. At
one Air National Guard unit command we visited, officials informed us of a
member who was mobilized and subsequently deployed with preexisting dental
problems in late 2003, because (1) the dental condition was not disclosed
by the member and (2) the unit command did not have a current dental exam
in his medical records to prove otherwise. The member would not have been
deployed had his true dental condition been initially

58 This is based on Dental Class III or IV classification standards. This
is a servicewide standard.

59 The Air National Guard issued the memorandum, via SG Log Letter 04-026,
on September 27, 2004.

Other Reasons Members May Have Arrived in Theater with Preexisting
Conditions

Conclusions

identified, but he received substantial dental work while deployed.60
According to a unit command official, the member was subsequently returned
to his unit command because his dental costs and related work downtime
were excessive.

In addition to a lack of specific guidance from CENTCOM to the services
early in the operations, military medical officials told us other reasons
why members may have arrived in theater with preexisting medical
conditions. First, military officials stated that in some cases members
did not disclose their preexisting medical conditions because they wanted
to serve their country. A Navy official, for example, stated that a Navy
officer with hypertension did not disclose his medical condition in order
to deploy to Iraq to support Operation Iraqi Freedom. Because the
officer's medical condition worsened in Iraq, the Navy had to return him
to his home unit and find a replacement to fill his position. We were also
told of members who arrived in theater with preexisting conditions with
the expectation that they would be taken care of while they were there.
For example, a senior medical official stated that one servicemember
arrived in theater with one kidney and in need of dialysis, which was not
available in theater. Early in operations several servicemembers with
hernias were deployed with the expectation that the surgery would be
conducted in theater.

It is important to have up-to-date medical criteria specific to a theater
of operations to alert members to changing condition in theater or new
information on vaccinations, for example. Developing and updating medical
criteria for a specific theater of operations is the responsibility of the
commander in chief of the combatant command-in this case, CENTCOM. As
these polices are completed and updated, the combatant command is to
provide them to the services, who are then responsible for determining how
they implement the requirements in terms of screening their deploying
forces including activated reservists.

The findings we present in this report are not new. In the aftermath of
the first Persian Gulf War, a number of DOD and GAO studies were issued
that identified problems with guard and reserve personnel being medically
and physically fit for duty. DOD agreed with many of the studies' findings
and

60 From November 2003 through January 2004, the reservist incurred a total
of 20 dental office and clinic visits and received two fillings, two
extractions, four root canals, and three crowns, at a cost of about $5,200
to the military.

recommendations but never developed a plan with goals, time frames, and
measurable results to improve visibility over reserve component members'
health status. At times, Congress has stepped in and directed DOD to make
a number of improvements, especially for quality assurance and tracking of
health assessment data collected before and after a member's deployment.
Congress recently directed OSD to develop and implement a comprehensive
plan to improve management of the health status of the reserve component.
The importance of such a plan has become even more important in the
current environment, where the pool of guard and reserve members with the
right skills from which to fill requirements for DOD's overseas and
domestic commitments is dwindling.

Further, many of DOD's personnel policies, including its medical policies,
are outdated, as they are based on Cold War strategy that allowed the
reserve force more time to mobilize before deployment. Now the reserve
force deploys with the active force and is expected to be medically and
physically fit when called to duty. The lack of oversight of reserve
members' health status, however, does not appear to be unique to the
reserve component. Oversight, as seen in the area of enforcing DOD's
reporting requirement on the status of physical fitness for both the
active and reserve components, has not taken place. No repercussions exist
if a service does not provide this report on time, nor are there any
deadlines for the annual report to be submitted to OSD.

OUSD/P&R has the authority to set medical and physical fitness policy and
processes to oversee this area; however, OUSD/P&R has not taken action to
exercise its authority to address these long-standing problems.

Recommendations for As DOD proceeds to develop a comprehensive plan for
improving management over the health status of the reserve components in
response Executive Action to the Ronald W. Reagan National Defense
Authorization Act for Fiscal Year 2005, we recommend six actions.

To have visibility over reserve components' compliance with routine
medical and physical fitness examinations, we recommend that the Secretary
of Defense

o  	direct the Under Secretary for Personnel and Readiness, in concert
with the Assistant Secretary for Health Affairs and the Principal Deputy
to the Under Secretary, to establish a management control framework and
execute a plan for issuing guidance, establishing quality assurance for
data

reliability, and tracking compliance with routine medical and physical
fitness examinations; and

o  	direct the Under Secretary for Personnel and Readiness, in concert
with the Principle Deputy who oversees the Office of Morale, Welfare, and
Recreation, to take steps to enforce the service reporting requirement on
the status of members' physical fitness in conjunction with the actions
taken in the first recommendation.

To improve DOD's visibility over reserve components' health status after
they are called to duty, we recommend that the Secretary of Defense

o  	direct the Under Secretary of Defense for Personnel and Readiness, in
concert with the Assistant Secretary of Health Affairs, to also oversee
the development of the reserve components' tracking systems to identify
and track members' temporary and permanent medical conditions that limit
deployability; and

o  	direct the Under Secretary of Defense for Personnel and Readiness, in
concert with the Assistant Secretary of Health Affairs, to modify the
medical predeployment forms to better capture reasons for nondeployment
and medical referrals.

To help prevent the deployment of reserve component members with
preexisting medical conditions that could adversely affect the mission and
strain resources in theater, and to provide visibility over those members
deployed with preexisting conditions for which treatment can be provided
in theater, we recommend that the Secretary of Defense:

o  	direct the Chairman of the Joint Chief of Staff to determine what
preexisting medical conditions should not be allowed into specific
theaters of operations, especially during the initial stages of the
operation, and to take steps to ensure that each service component
consistently utilizes these as criteria for determining the medical
deployability of its reserve component members during mobilization; and

o  direct the Chairman of the Joint Chief of Staff, in concert with the
service

  Agency Comments
  and Our Evaluation

secretaries, to explore using existing tracking systems to track those who
have treatable preexisting medical conditions in theater.

In written comments on a draft of this report, DOD did not concur with our
first and fourth recommendations, partially concurred with our fifth
recommendation, and concurred with our second, third, and sixth
recommendations. DOD did not concur with our recommendation that it
establish a management control framework and execute a plan for issuing
guidance, establishing quality assurance for data reliability, and
tracking

compliance with routine medical examinations. DOD did not state that it
disagreed with our findings; however, DOD stated that it had initiatives
underway that addressed our recommendation. DOD further noted that because
policies, programs, and instructions are already in place or in process,
it did not see the need for any additional action. We disagree with DOD's
conclusion because, based on our review, we do not believe that DOD's
initiatives are far enough along to dismiss further action, and we
continue to believe that our recommendation has merit. We agree that the
initiatives DOD cited in its written comments are positive steps toward
correcting the identified problems, but management and planning remain a
concern. We have not seen enough evidence to agree that DOD has put in
place a management control framework that will enforce holding all
responsible levels accountable, ensuring that all routine medical
requirements are being met, and that complete and reliable data are being
entered into the appropriate tracking systems. As noted in our report, the
problems with determining the health status of the reserve force were
revealed during Operations Desert Shield and Desert Storm, and in the
decade that has passed since then DOD has made little progress to correct
the identified problems. As a result, in 2004, Congress directed DOD to
establish a Joint Medical Readiness Oversight Committee to oversee the
development and implementation of a comprehensive medical readiness plan.
As also noted in our report, the committee held its first meeting in
February 2005, and a plan to improve medical readiness was being developed
during this review. We do not believe that a committee can be held
accountable for ensuring that such actions take place. Ultimately, the
Under Secretary of Defense for Personnel and Readiness, in concert with
the Assistant Secretary for Health Affairs, are accountable for enforcing
the requirements for routine medical examinations.

Moreover, DOD stated that it has established a new quality assurance
program that monitors electronic data with validation through medical
record reviews of a wide range of force health protection measures. We did
not find this to be true during our review. With the exception of the Navy
Reserve, the reserve components do not monitor electronic data of routine
medical examinations with validation through medical record reviews.
Further, we found the data in the reserve components' tracking systems to
be unreliable for purposes of determining compliance with routine medical
examinations. As noted in our report, compliance with these routine
medical examinations is the first step toward determining who is medically
fit or ready for duty. DOD stated that its compliancemonitoring Individual
Medical Readiness program regularly reports the overall medical readiness
status for each servicemember. However, we found that the Individual
Medical Readiness program's outcomes are

derived from data in the reserve components' tracking systems, which we
have found to be unreliable, with the exception of the Navy Reserve, for
the purposes of determining compliance with routine medical examinations.
DOD stated that its Individual Medical Readiness program's data are being
incorporated into overall unit readiness status reports, providing
visibility of reserve component medical readiness throughout the line
command structure. We believe that until top management at DOD ensures
that complete and reliable data on routine medical examinations are being
entered into its tracking systems, DOD and Congress will continue to have
a false picture of medical readiness for the reserve components. We
believe that our first recommendation still has merit.

DOD concurred with our recommendation that DOD take steps to enforce the
services' reporting requirement on the status of their members' physical
fitness. DOD stated that DOD instruction 1308.3, dated November 5, 2002,
among other things, requires the active and reserve components to provide
an annual report to the Principal Deputy of the OUSD/P&R not later than
March 31. DOD stated that the Air Force, the Navy, and the Marine Corps
have submitted their reports. DOD noted that exceptions to the reporting
requirement for the Air Force and the Army had been approved. However,
during our review we were told that none of the reports had been submitted
to the Principal Deputy as required. We raised concerns in this report
about the data reliability of the tracking systems for physical fitness.
We found that the reserve components are unable to report complete and
reliable data on compliance with routine physical fitness examinations on
a componentwide basis due to incomplete and unreliable data. Just as we
found with routine medical examinations, we also found that DOD lacked
quality assurance of the data on compliance with physical fitness
examinations in its tracking systems. We do not know what data reliability
issues DOD will cite in its annual reports on physical fitness. We note
that the responsible office for physical fitness oversight, the Office of
Morale, Welfare, and Recreation, does not participate in the Joint Medical
Readiness Oversight Committee that is directed to oversee improvements in
medical readiness, nor are we aware of any DOD plans to include
improvements in the oversight of physical fitness in its comprehensive
medical readiness plan. Therefore, we have expanded our first
recommendation to include routine physical fitness examinations in the
actions to be addressed.

DOD concurred with our recommendation that DOD oversee the development of
the reserve components' tracking systems to identify and track members'
temporary and permanent medical conditions that limit deployability. DOD
stated that it is already actively adapting existing

systems, and in some cases creating new ones, that can be used to track
the medical status of active and reserve members, to include those known
conditions that could limit an individual's deployability. DOD noted that
it continues to pursue better integration between medical and personnel
data systems to improve visibility regarding deployment-limiting medical
conditions, whether temporary or permanent, but the overall effectiveness
will continue to be limited by lack of access to civilian medical records
of reserve component members.

DOD did not concur with our recommendation that DOD modify the medical
predeployment form to better capture reasons for nondeployment and medical
referrals. DOD stated that the best sources of accurate information about
what medical reasons kept service members from deploying are the permanent
medical records. This may be the case, but we continue to believe our
recommendation has merit because DOD has no way to systematically analyze
the information to determine why servicemembers are medically
nondeployable. Because the predeployment form is used to document whether
a servicemember is deployable, this existing form could be modified to
better capture the reasons for determining why a servicemember is
determined nondeployable. Although the form has an entry for a narrative
explanation to state why a member is medically nondeployable, AMSA
officials informed us that these explanations are often not decipherable,
incomplete, and can not be easily categorized. DOD also stated that the
existing predeployment form already includes a list of the most common
referral categories to simplify the documentation process for the health
care provider. In addition, DOD also noted that data from the forms are
captured electronically and are readily available to monitor for trends in
referral patterns, among other things. We do not believe that any
meaningful analysis for referrals can be determined from these forms
because we found that the top medical referral category for the reserve
and active components was "other". This heavy use of the category "other"
does not provide any insight as to what medical care a member is receiving
after being called to duty. Given that the rate of medical referrals for
the reserve components was almost 40 percent and for the active components
was almost 50 percent, we continue to believe that DOD should modify the
predeployment form to better capture reasons for nondeployment and medical
referrals.

DOD partially concurred with our recommendation that DOD determine what
preexisting medical conditions should be allowed into a specific theater
of operations, especially during the initial stages of operations, and
take steps to consistently utilize these criteria for determining medical
deployability. DOD stated that certain conditions clearly should render a

member nondeployable, and the services have made strides in defining these
conditions and incorporating them into their applicable policies and
procedures. But DOD also noted that due to the ever-changing nature of a
theater of operations and the inexact nature of medicine, a list of
nondeployable preexisting conditions will never be fully comprehensive or
fully enforceable. We agree that a list of nondeployable preexisting
medical conditions can never be fully comprehensive; however, we still
believe DOD could establish a list of what preexisting medical conditions
should be allowed into specific theaters of operations, especially during
the initial stages of operations, so that in future deployments DOD would
not experience situations such as those that occurred with members being
deployed into Iraq who clearly had preexisting conditions that should have
prevented their deployment.

DOD concurred with our recommendation that DOD explore using existing
tracking systems to track those who have treatable preexisting medical
conditions in theater. DOD noted that refinements to medical tracking
system are ongoing. We wish to note that before DOD's tracking systems can
be used to track those who have treatable preexisting medical conditions
in theater, DOD must determine what preexisting medical conditions should
be allowed into a specific theater of operations as called for in our
fifth recommendation.

DOD noted in its overall comments that the reserve and active forces use
many of the same reporting tools within each service and face the same
basic challenges in ensuring data quality. DOD stated that where tracking
systems are shared, the reserve components depend on the active components
to develop and fund those systems, and that priority for deployment of
large systems has historically been given to the active component. DOD
also pointed out that our report indicates that the health status of
members deteriorates with multiple deployments and that the data we used
are self-reported and should be taken with great caution and in the proper
context. We used the self-reported data from postdeployment health
assessments to help demonstrate the importance of good visibility over the
reserve forces. We noted that the demand for reserve personnel, especially
within the Army components, continues, and the pool of reserve members
used to fill requirements is dwindling. Further, the health status of
returning reserve and guard members is not as good as it was before
deployment as our analysis of the pre-and postdeployment health
assessments showed. Therefore, it becomes even more important that DOD
have good visibility over the health status of remaining reserve force to
help determine what is left for future deployments.

DOD's comments are reprinted in their entirety in appendix II.

We are sending copies of this report to the Secretary of Defense; the
Secretaries of the Army, the Navy, and the Air Force; the Commandant of
the Marine Corps; the Chairman of the Joint Chiefs of Staff; and the
Director, Office of Management and Budget. We will also make copies
available to others upon request. In addition, the report will be
available at
no charge on the GAO Web site at http://www.gao.gov.

If you or your staff has any questions concerning this report, please
contact me at (202) 512-5559 or [email protected]. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on the
last page of this report. GAO staff who made major contributions to this
report are listed in appendix III.

Derek B. Stewart
Director, Defense Capabilities and Management

                       Appendix I: Scope and Methodology

To assess the Department of Defense's (DOD) ability to determine the
reserve components' compliance with routine medical and physical fitness
examinations, we reviewed federal statutes and Office of the Secretary of
Defense (OSD) applicable directives and instructions to identify and
understand the roles and responsibilities of the offices within DOD for
management of the health status of the reserve components. We discussed
these statutes and guidance with senior officials in the Office of the
Under Secretary of Defense for Personnel and Readiness. We reviewed and
discussed service policies and regulations for medical and physical
fitness with military officials within the service surgeons' general
offices and other service headquarters' officials responsible for physical
fitness in the service personnel and operations functions. We also
reviewed and discussed reserve component policies and guidance for medical
and physical fitness examinations with officials within the reserve
component surgeons' general offices and other reserve component officials
responsible for physical fitness in the respective reserve component
personnel and operations functions. We interviewed cognizant officials
involved with policy development, administration, tracking, and reporting
on compliance with medical and physical fitness examinations from the
following offices or commands:1

Office of the Secretary of Defense

o  	Assistant Secretary of Defense for Health Affairs, Deployment Health
Support Directorate;

o  Assistant Secretary of Defense for Reserve Affairs; and

o  	Principal Deputy Under Secretary of Defense for Personnel and
Readiness, the Office of Morale, Welfare, and Recreation.

Army

o  Assistant Secretary of the Army, Manpower and Reserve Affairs;

o  	U.S. Army Office of the Surgeon General and Commanding General, Army
Medical Command;

o  U.S. Army Reserve Command, Fort McPherson, Georgia;

o  National Guard Bureau;

o  Army National Guard;

o  First U.S. Army, Fort Gillem, Georgia;

o  U.S. Army Forces Command, Fort McPherson, Georgia;

1 Unless otherwise noted, the officials listed in this appendix have their
offices in the Pentagon or at locations in the Washington, D.C.,
metropolitan area.

Appendix I: Scope and Methodology

o  Army Fitness School, Ft. Benning, Georgia;

o  Fifth U.S. Army, Fort Sam Houston, Texas;

o  U.S. Army Medical Command, Fort Sam Houston, Texas;

o  U.S. Army Dental Command, Fort Sam Houston, Texas;

o  Army Audit Agency; and

o  MEDPROS Program Office.

Navy

o  Assistant Secretary of the Navy, Manpower and Reserve Affairs;

o  Office of the Chief of Navy Operations;

o  Office of the Chief of Navy Reserve;

o  Bureau of Medicine and Surgery;

o  Commander Navy Reserve Forces Command, New Orleans, Louisiana; and

o  Navy Personnel Command, Millington, Tennessee.

Marine Corps

o  U.S. Marine Corps Health Services, Headquarters;

o  	U.S. Marine Corps Manpower and Reserve Affairs, Headquarters,
Quantico, Virginia; and

o  Marine Forces Reserve, Headquarters, New Orleans, Louisiana.

Air Force

o  Department of the Air Force, Headquarters;

o  Assistant Secretary of the Air Force for Manpower and Reserve Affairs;

o  Office of Air Force Reserve, Headquarters;

o  Air Force Reserve Command, Robins Air Force Base, Georgia;

o  National Guard Bureau;

o  Air National Guard, Headquarters;

o  Air National Guard Readiness Center; and

o  Air Reserve Personnel Center, Denver, Colorado.

We also conducted medical and physical fitness file reviews with an Army
National Guard unit from the Mid-Atlantic region and an Army Reserve unit
from the Mid-west region. We chose units that had deployed for Operations
Enduring Freedom or Iraqi Freedom. During these visits we

Appendix I: Scope and Methodology

collected and analyzed information from available2 medical and personnel
files to assess the reserve component members' compliance with routine
medical and physical fitness examinations. We also documented difficulties
the units had in ensuring that all members complied with medical and
physical fitness examinations. Finally, during the site visits, we
conducted group discussions with unit members regarding their experience
with routine examination requirements.

To gain a better understanding of how the components collect data about
their members' compliance with routine medical and dental examinations and
physical fitness assessments, we assessed the reliability of data produced
by several services' databases. Assessing the reliability of the services'
data included consideration of issues such as the completeness and
currency of the data from the respective database system's program
managers, administrators, and contractors; assurances that all members are
included and the information is up to date; and examination of who is
using the data and for what purposes, and the users' assessment of
reliability. We also examined whether the data tracked through the
services' systems was subjected to quality control measures, such as
conducting periodic testing of the data against medical records, to ensure
the accuracy and reliability of the data. In addition, we reviewed
existing documentation related to the data sources and interviewed
knowledgeable agency officials about the data. Overall, the reserve
components' data we assessed regarding compliance with routine medical and
dental examinations and fitness assessments did not accurately reflect the
total population of service members, had limited data quality assurance,
and were unreliable for the purposes of this report; however, we
determined that the Navy Reserve's medical data were sufficiently reliable
for our purposes. Data from the Navy Reserve's Medical Readiness Reporting
System were found reliable because Readiness Commands conduct inspections
that include examining the data for accuracy, Medical Department
Representatives verify 10 percent of the updated medical records after
each weekend drill, and the data are reported to the Commander, Navy
Reserve Forces Command biweekly. Further, we did not assess the
reliability of the Marine Corps Reserve's medical data because the Marine
Corps was in the process of changing from the Shipboard Automated Medical
System, a stand-alone non-Web-based

2 We reviewed all available medical and physical fitness files during our
visits to the units. Some files were not available because (1) members who
had deployed with the unit had transferred to another unit or were no
longer serving, (2) some files had been misplaced, and (3) some members
were having a routine exam and their file was with them.

Appendix I: Scope and Methodology

system, to the Navy Reserve's system. All reserve components' physical
fitness data that we reviewed had missing or incomplete information, had
limited data quality controls, or did not accurately reflect the total
population of service members due to limited access to the database.
Therefore, we determined the data to be unreliable for the purposes of
assisting us in determining reserve component members' compliance with
physical fitness examinations.

To assess DOD's visibility over reserve components' health status after
they are called to duty and the care, if any, provided to those deployed
with preexisting conditions, we collected and analyzed information from a
variety of sources throughout DOD. We interviewed officials at the six
reserve component headquarters and officials responsible for mobilizing
the reserve components. We also observed the mobilization of Army National
Guard and Army Reserve members at Fort Bliss, Texas, to obtain information
on their health status during this process. We obtained and analyzed data
provided on medical deployability from the DOD-wide centralized database
on pre-and postdeployment health assessments, maintained at the Army
Medical Surveillance Activity, and discussed available data with these
officials. We also obtained and analyzed data on Army servicemembers who
were held at mobilization stations for medical reasons from the Army's
medical holdover database (Medical Operational Data System). Based on our
review of databases we used, we determined that the DOD-provided data were
reliable for the purposes of this report. To address the extent of medical
care provided in theater for preexisting medical conditions, we reviewed
the Joint Chiefs of Staff procedures for Deployment Health Surveillance
and Readiness and information provided by the U.S. Central Command
Surgeon's General office regarding medical deployment criteria for
Operations Enduring Freedom and Iraqi Freedom. We also collected and
reviewed the services' medical instructions, memoranda, policies, and
medical data. We reviewed several databases for relevance regarding
collecting in theater medical data on preexisting conditions.
Specifically, we obtained information and discussed the following
databases: Joint Medical Workstation, the U.S. Transportation Command
Regulating Command and Control Evacuation System, the Joint Patient
Tracking Application, and the Air Force Institute for Operational Health
Disease Nonbattle Injury database.

However, we did not identify any databases used to collect information on
members that may have had preexisting conditions when deployed. We also
interviewed military medical officials who had served in theater to obtain
information on preexisting conditions of reserve component members while
deployed. In addition to those offices and commands

Appendix I: Scope and Methodology

previously listed, we discussed reserve component medical deployment
policies, medical and physical fitness policies and instructions, and data
regarding medical and physical fitness issues with responsible officials
from:

Department of Defense

o  Joint Chiefs of Staff, J-4 (Logistics), Medical Readiness Division;

o  U.S. Transportation Command, Scott AFB, Illinois;

o  U.S. Central Command, MacDill, AFB, Florida; and

o  Army Medical Surveillance Activity.

Army

o  	U.S. Army Office of the Surgeon General and Commanding General, Army
Medical Command;

o  U.S. Army Center for Health Promotion and Preventive Medicine-Europe;

o  Army Reserve Unit, Mid-west region;

o  Walter Reed Army Medical Center; and

o  Soldier Readiness Processing, Medical Operations, Fort Bliss, Texas.

Navy

o  Navy Reserve Readiness Command Southwest, California;

o  Navy and Marine Corps Reserve Center, California; and

o  Navy Branch Medical Clinic, Virginia.

Marine Corps

o  Marine Corps Mobilization Command, Kansas City, Missouri; and

o  4th Combat Engineer Battalion, Maryland.

Air Force

o  Air Force Institute for Operational Health;

o  	142nd Fighter Wing Air National Guard, Portland International Airport,
Oregon;

o  	163rd Air Refueling Wing Air National Guard, March Air Reserve Base,
California;

o  	349th Air Mobility Wing U.S. Air Force Reserve, Travis Air Force Base,
California; and

o  	452nd Air Mobility Wing U.S. Air Force Reserve, March Air Reserve
Base, California.

Appendix I: Scope and Methodology

We reviewed Air Force audit and inspection reports. We interviewed
officials with the Air Force Audit Agency regarding its report on the Air
Force's Individual Deployment Process3 to obtain a better understanding of
the report's scope and methodology to assess reserve components'
compliance with medical and dental requirements. We assessed the
reliability of the Air Force Audit Agency's analyses by (1) reviewing
relevant documentation of their analyses, and (2) interviewing
knowledgeable officials about the audit work and analyses. We determined
the analyses were sufficiently reliable to use as one of the sources of
evidence describing the extent of discrepancies in Air Force medical and
dental records. We also reviewed the Air Force Inspection Agency's Health
Services reports and its annual analysis reports for calendar year 2004.4

We also found DOD's Army Medical Surveillance Activity (AMSA) database and
the Army's Medical Operational Data System (MODS) to be sufficiently
reliable for the purposes of our report due to their data quality controls
and currency. In addition, through our review of existing information
about the systems and the resulting data and through discussions with
cognizant agency officials, we found the data sufficiently reliable for
the purposes of this report.

We interviewed the Chief of AMSA. We discussed the information in the
DOD-wide centralized health assessment database and obtained selected data
from all the reserve and active component members' pre-and postdeployment
health assessments that were completed from November 2001 through June
2005. Assessments became mandatory for all mobilized reserve component
members on October 25, 2001. The data we obtained contained predeployment
health assessment records for 383,449 reserve component members and
627,200 for active members. We analyzed the data that we obtained to
determine the categories of medical referrals and deployability status.5
We also analyzed data on the self-reported general

3 Air Force Audit Agency, Individual Deployment Process, Audit Report
F2005-0005-FD3000 (June 13, 2005).

4 Air Force Inspection Agency, Health Services Inspection, ARC Inspection
Results, ARC Element Results, Annual Analysis Calendar Year 2004 (as of
June 20, 2005).

5The data represent deployment events. A deployment event is defined as a
servicemember completing a pre-or postdeployment health assessment form
with no recent history (within 6 months) of completing a separate pre-or
postdeployment health assessment form.

Appendix I: Scope and Methodology

health of the reserve component members and compared the data from
predeployment assessments with the data from postdeployment assessments.
All of our analyses compared data across the reserve components to look
for differences or trends.

Further, we reviewed the Army's medical holdover data in MODS and found
them reliable for our reporting purposes. The Office of the Army Surgeon
General uses MODS to monitor and track the medical holdover population.
The intended use of this system is for the MEDCOM and other command
elements to track active and reserve component servicemembers in
outpatient medical treatment, while still on active duty status.

We conducted our review from October 2004 through September 2005 in
accordance with generally accepted government auditing standards.

Appendix II: Comments From the Department of Defense

Appendix II: Comments From the Department of Defense

Appendix II: Comments From the Department of Defense

Appendix II: Comments From the Department of Defense

Appendix II: Comments From the Department of Defense

Appendix II: Comments From the Department of Defense

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact Derek B. Stewart (202) 512-5559 or [email protected]

Acknowledgments 	In addition to the contact named above, Brenda S.
Farrell, Assistant Director; James Bancroft, Larry Bridges, Renee S.
Brown, Sara Hackley, Kenya Jones, Ron La Due Lake, Karen Kemper, Julia
Matta, Jen Popovic, and Nicole Volchko.

Related GAO Products

Defense Health Care: Improvements Needed in Occupational and Environmental
Health Surveillance during Deployment to Address Immediate and
Longstanding Health Issues. GAO-05-632. Washington, D.C.: July 19, 2005.

Reserve Forces: An Integrated Plan is Needed to Address Army Reserve
Personnel and Equipment Shortages. GAO-05-660. Washington, D.C.: July 12,
2005.

Defense Health Care: Force Health Protection and Surveillance Policy
Compliance Was Mixed, but Appears Better for Recent Deployments.

GAO-05-120. Washington, D.C.: November 12, 2004.

Military Personnel: DOD Needs to Address Long-term Reserve Force
Availability and Related Mobilization and Demobilization Issues.
GAO04-1031. Washington, D.C.: September 15, 2004.

Defense Health Care: DOD Needs to Improve Force Health Protection and
Surveillance Processes. GAO-04-158T. Washington, D.C.: October 16, 2003.

Defense Health Care: Quality Assurance Process Needed to Improve Force
Health Protection and Surveillance. GAO-03-1041. Washington, D.C.:
September 19, 2003.

Military Personnel: DOD Needs More Data to Address Financial and Health
Care Issues Affecting Reservists. GAO-03-1004. Washington, D.C.: September
10, 2003.

Military Personnel: DOD Actions Needed to Improve the Efficiency of
Mobilizations for Reserve Forces. GAO-03-921. Washington, D.C.: August 21,
2003.

Defense Health Care: Army Has Not Consistently Assessed the Health Status
of Early-Deploying Reservists. GAO-03-997T. Washington, D.C.: July 9,
2003.

Defense Health Care: Army Needs to Assess the Health Status of All
Early-Deploying Reservists. GAO-03-437. Washington, D.C.: April 15, 2003.

Defense Health Care: Most Reservists Have Civilian Health Coverage but
More Assistance Is Needed When TRICARE is Used. GAO-02-829. Washington,
D.C.: September 6, 2002.

Related GAO Products

VA and Defense Health Care: Military Medical Surveillance Policies in
Place, but Implementation Challenges Remain. GAO-02-478T. Washington,
D.C.: February 27, 2002.

Gender Issues: Improved Guidance and Oversight Are Needed to Ensure
Validity and Equity of Fitness Standards. GAO/NSIAD-99-9. Washington,
D.C.: November 17, 1998.

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

Reserve Forces: DOD Policies Do Not Ensure That Personnel Meet Medical and
Physical Fitness Standards. GAO/NSIAD-94-36. Washington, D.C.: March 23,
1994.

Operation Desert Storm: War Highlights Need to Address Problem of
Nondeployable Personnel. GAO/NSIAD-92-208. Washington, D.C.: August 31,
1992.

Operation Desert Storm: Full Army Medical Capability Not Achieved.

GAO/NSIAD-92-175. Washington, D.C.: August 18, 1992.

National Guard: Peacetime Training Did Not Adequately Prepare Combat
Brigades for Gulf War. GAO/NSIAD-91-263. Washington, D.C.: September 24,
1991.

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