Chemical and Biological Defense: DOD and VA Need to Improve	 
Efforts to Identify and Notify Individuals Potentially Exposed	 
during Chemical and Biological Tests (28-FEB-08, GAO-08-366).	 
                                                                 
Tens of thousands of military personnel and civilians were	 
potentially exposed to chemical or biological substances through 
Department of Defense (DOD) tests since World War II. DOD	 
conducted some of these tests as part of its Project 112 test	 
program, while others were conducted as separate efforts. GAO was
asked to (1) assess DOD's efforts to identify individuals who	 
were potentially exposed during Project 112 tests, (2) evaluate  
DOD's current effort to identify individuals who were potentially
exposed during tests conducted outside of Project 112, and (3)	 
determine the extent to which DOD and the Department of Veterans 
Affairs (VA) have taken action to notify individuals who might	 
have been exposed during chemical and biological tests. GAO	 
analyzed documents and interviewed officials from DOD, VA, the	 
Department of Labor, and a veterans service organization.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-366 					        
    ACCNO:   A81149						        
  TITLE:     Chemical and Biological Defense: DOD and VA Need to      
Improve Efforts to Identify and Notify Individuals Potentially	 
Exposed during Chemical and Biological Tests			 
     DATE:   02/28/2008 
  SUBJECT:   Biological research				 
	     Biological warfare 				 
	     Chemical research					 
	     Chemical warfare					 
	     Defense capabilities				 
	     Evaluation criteria				 
	     Health hazards					 
	     Military forces					 
	     Military personnel 				 
	     Military research and development			 
	     Program evaluation 				 
	     Requirements definition				 
	     Veterans						 
	     Radiation exposure hazards 			 
	     Chemical exposure					 
	     Program goals or objectives			 
	     Transparency					 

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GAO-08-366

   

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Report to Congressional Requesters: 

United States Government Accountability Office: 

GAO: 

February 2008: 

Chemical And Biological Defense: 

DOD and VA Need to Improve Efforts to Identify and Notify Individuals 
Potentially Exposed during Chemical and Biological Tests: 

Chemical and Biological Defense: 

GAO-08-366: 

GAO Highlights: 

Highlights of GAO-08-366, a report to congressional requesters. 

Why GAO Did This Study: 

Tens of thousands of military personnel and civilians were potentially 
exposed to chemical or biological substances through Department of 
Defense (DOD) tests since World War II. DOD conducted some of these 
tests as part of its Project 112 test program, while others were 
conducted as separate efforts. GAO was asked to (1) assess DODï¿½s 
efforts to identify individuals who were potentially exposed during 
Project 112 tests, (2) evaluate DODï¿½s current effort to identify 
individuals who were potentially exposed during tests conducted outside 
of Project 112, and (3) determine the extent to which DOD and the 
Department of Veterans Affairs (VA) have taken action to notify 
individuals who might have been exposed during chemical and biological 
tests. GAO analyzed documents and interviewed officials from DOD, VA, 
the Department of Labor, and a veterans service organization 

What GAO Found: 

Since 2003, DOD has stopped actively searching for individuals who were 
potentially exposed to chemical or biological substances during Project 
112 tests, but did not provide a sound and documented basis for that 
decision. In 2003, DOD reported it had identified 5,842 servicemembers 
and estimated 350 civilians as having been potentially exposed during 
Project 112, and indicated that DOD would cease actively searching for 
additional individuals. However, in 2004, GAO reported that DOD did not 
exhaust all possible sources of information and recommended that DOD 
determine the feasibility of identifying additional individuals. In 
response to GAOï¿½s recommendation, DOD determined continuing an active 
search for individuals had reached the point of diminishing returns, 
and reaffirmed its decision to cease active searches. This decision was 
not supported by an objective analysis of the potential costs and 
benefits of continuing the effort, nor could DOD provide any documented 
criteria from which it made its determination. Since June 2003, 
however, non-DOD sourcesï¿½including the Institute of Medicineï¿½have 
identified approximately 600 additional names of individuals who were 
potentially exposed during Project 112. Until DOD provides a more 
objective analysis of the costs and benefits of actively searching for 
Project 112 participants, DODï¿½s efforts may continue to be questioned. 

DOD has taken action to identify individuals who were potentially 
exposed during tests outside of Project 112, but GAO identified four 
shortcomings in DODï¿½s current effort. First, DODï¿½s effort lacks clear 
and consistent objectives, scope of work, and information needs that 
would set the parameters for its effort. Second, DOD has not provided 
adequate oversight to guide this effort. Third, DOD has not fully 
leveraged information obtained from previous research efforts that 
identified exposed individuals. Fourth, DODï¿½s effort lacks transparency 
since it has not kept Congress and veterans service organizations fully 
informed of the progress and results of its effort. Until DOD addresses 
these limitations, Congress, veterans, and the American public cannot 
be assured that DODï¿½s current effort is reasonable and effective. 

DOD and VA have had limited success in notifying individuals 
potentially exposed during tests both within and outside Project 112. 
DOD has a process to share the names of identified servicemembers with 
VA; however, DOD has delayed regular updates to VA because of a number 
of factors, such as competing priorities. Furthermore, although VA has 
a process for notifying potentially exposed veterans, it was not using 
certain available resources to obtain contact information to notify 
veterans or to help determine whether they were deceased. Moreover, DOD 
had not taken any action to notify identified civilians, focusing 
instead on veterans since the primary impetus for the research has been 
requests from VA. DOD has refrained from taking action on notifying 
civilians in part because it lacks specific guidance that defines the 
requirements to notify civilians. Until these issues are addressed, 
some identified veterans and civilians will remain unaware of their 
potential exposure. 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-366]. For more information, contact Davi 
M. D'Agostino at (202) 512-5431 or [email protected]. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

DOD's Decision to Stop Actively Searching for Project 112 Individuals 
Was Not Based on a Sound and Documented Cost-Benefit Analysis: 

DOD's Effort to Identify Individuals Potentially Exposed during Non- 
Project 112 Tests Has Several Shortcomings: 

DOD and VA Have Had Limited Success in Notifying Potentially Exposed 
Individuals: 

Conclusions: 

Matters for Congressional Consideration: 

Recommendations for Executive Action: 

Agencies' Comments and Our Evaluation: 

Appendix I: Scope and Methodology: 

Appendix II: Comments from the Department of Defense: 

Appendix III: Comments from the Department of Veterans Affairs: 

Appendix IV: GAO Contact and Staff Acknowledgments: 

Related GAO Products: 

Tables: 

Table 1: Number of Servicemembers Identified as Having Been Potentially 
Exposed during Project 112: 

Table 2: Number of Non-Project 112 Servicemembers Identified by DOD as 
of December 2007: 

Table 3: Veterans Who VA Has Notified of Their Potential Exposure as of 
December 2007: 

Table 4: Number of Civilians Potentially Exposed as of December 2007: 

Abbreviations: 

DOD: Department of Defense: 

VA: Department of Veterans Affairs: 

OUSD (AT&L): Office of the Undersecretary of Defense for Acquisition, 
Technology, and Logistics: 

OUSD (P&R): Office of the Under Secretary of Defense for Personnel and 
Readiness: 

OASD (HA): Office of the Assistant Secretary of Defense for Health 
Affairs: 

United States Government Accountability Office: 

Washington, DC 20548: 

February 28, 2008: 

The Honorable Ike Skelton: 
Chairman: 
Committee on Armed Services: 
House of Representatives: 

The Honorable Vic Snyder: 
Chairman: 
Subcommittee on Oversight and Investigations: 
Committee on Armed Services: 
House of Representatives: 

The Honorable Mike Thompson: 
House of Representatives: 

As we have previously reported, since World War II, tens of thousands 
of military personnel and civilians have been involved in classified 
human experimentation and were potentially exposed to chemical and 
biological substances[Footnote 1] through tests conducted or sponsored 
by the Department of Defense (DOD).[Footnote 2] Some of these tests and 
experiments involved the intentional exposure of people to hazardous 
substances such as blister and nerve agents, biological agents, 
lysergic acid diethylamide (LSD), and phencyclidine (PCP). In some 
cases, healthy adults, psychiatric patients, and prison inmates were 
used in these tests and experiments. According to a 1994 staff report 
to the Senate Committee on Veterans Affairs, in some instances, 
servicemembers who consented to serve as human subjects found 
themselves participating in experiments quite different from those 
described at the time they volunteered.[Footnote 3] These tests and 
experiments were conducted to support weapon development programs, 
identify methods to protect the health of military personnel against a 
variety of diseases and combat conditions, and analyze U.S. defense 
vulnerabilities. From 1962 through 1974, DOD conducted a series of 
classified ship-based and land-based chemical and biological warfare 
tests involving military and civilian personnel as well as, in some 
cases, foreign personnel observers--both military and civilian. These 
tests were called Project 112 because in 1962 it was the 112th project 
of 150 delineated by the Secretary of Defense involving the classified 
testing of chemical and biological agents. 

Precise information on the number of tests, experiments, and 
participants is not available, and the exact numbers will never be 
known. However, as a result of questions raised by members of Congress 
and veterans since 1993, DOD has undertaken three major initiatives to 
identify individuals potentially exposed to chemical or biological 
substances during tests it has sponsored or conducted. First, from 1993 
to 1997, the former Office of the Assistant Secretary of Defense for 
Force Manpower and Personnel within the Office of the Under Secretary 
of Defense (OUSD) for Personnel and Readiness (P&R) participated in a 
working group with the military services and the Department of Veterans 
Affairs (VA) in response to a January 1993 Institute of Medicine 
report[Footnote 4] on the exposure of individuals to mustard agents and 
lewisite.[Footnote 5] The working group identified approximately 6,400 
servicemembers and civilians who were exposed to mustard agents and 
other chemical substances. 

Second, in August 2000, the acting Secretary of Veterans Affairs wrote 
a letter to the Secretary of Defense requesting assistance in obtaining 
information about a series of then-classified chemical and biological 
tests under DOD's Project 112 program. In response to this request and 
subsequent congressional direction in the Bob Stump National Defense 
Authorization Act for Fiscal Year 2003,[Footnote 6] the Office of the 
Assistant Secretary of Defense (OASD) for Health Affairs (HA) within 
OUSD (P&R) conducted an internal DOD investigation into Project 
112.[Footnote 7] In a resulting report issued in 2003, DOD identified 
5,842 servicemembers and estimated that 350 civilians had been 
potentially exposed during Project 112 tests.[Footnote 8] We 
subsequently evaluated DOD's efforts, and in May 2004, we reported that 
DOD appeared to have accurately identified all major chemical and 
biological tests associated with Project 112, but that there likely 
were servicemembers and civilian personnel potentially exposed to 
substances who had not been identified for various reasons.[Footnote 9] 

Third, and in further response to congressional direction in the 
Defense Authorization Act for FY 2003, the Office of the Special 
Assistant for Chemical and Biological Defense and Chemical 
Demilitarization Programs (hereafter referred to as the chemical and 
biological defense office) within the OUSD for Acquisition, Technology, 
and Logistics (AT&L) issued a task order to a contractor in September 
2004 to identify servicemembers and civilian personnel who might have 
been exposed to chemical and biological substances outside of Project 
112 tests.[Footnote 10] The research being done as a result of this 
task order is ongoing as of December 2007. 

For this review, you asked us to examine DOD's current effort to 
identify and notify individuals who were potentially exposed during 
chemical and biological tests conducted or sponsored by DOD, including 
tests conducted as a part of DOD's Project 112 program and tests 
conducted outside of Project 112. Accordingly, this report (1) assesses 
DOD's efforts since 2003 to identify individuals who were potentially 
exposed during chemical or biological tests conducted during Project 
112, (2) evaluates DOD's current effort to identify individuals who 
were potentially exposed during chemical or biological tests conducted 
outside of Project 112, and (3) determines the extent to which DOD and 
VA have taken action to notify individuals who might have been exposed 
during chemical and biological tests. 

To evaluate DOD's efforts to identify all individuals who were 
potentially exposed to chemical or biological substances during Project 
112 tests and tests outside of Project 112, we interviewed and obtained 
documentation from cognizant DOD, Institute of Medicine, and contractor 
officials. To determine how potentially exposed individuals were 
identified, we visited record repository sites where contractors were 
conducting research and observed their research and documentation 
process. To determine the extent to which DOD and VA have taken action 
to notify servicemembers who might have been exposed during chemical 
and biological tests, we met with DOD officials to discuss their 
efforts to provide names of identified servicemembers to VA and with VA 
officials to describe VA's notification process. We evaluated the 
reliability of DOD's and VA's databases containing the names of 
individuals potentially exposed during chemical and biological tests 
and found that there were potential problems with the quality and 
reliability of the information. Although we determined that the 
information was sufficiently reliable for the purposes of our review, 
this report discusses weaknesses with DOD's information, and our 
recommendation to address them. Consequently, the number of individuals 
whom we report as having been identified and notified is based on 
information from DOD's and VA's databases and is approximate. We also 
met with representatives from a veterans service organization to gain 
their perspectives on DOD and VA efforts to identify and notify 
veterans potentially exposed to chemical and biological substances 
during DOD tests. Because DOD identified civilians who might have been 
exposed to chemical or biological substances, we also met with DOD and 
Department of Labor officials to ascertain their roles and 
responsibilities in notifying such civilians. Additional information on 
our scope and methodology appears in appendix I. We conducted this 
performance audit from June 2007 to February 2008 in accordance with 
generally accepted government auditing standards. Those standards 
require that we plan and perform the audit to obtain sufficient, 
appropriate evidence to provide a reasonable basis for our findings and 
conclusions based on our audit objectives. We believe that the evidence 
obtained provides a reasonable basis for our findings and conclusions 
based on our audit objectives. 

Results in Brief: 

DOD stopped actively searching for individuals who were potentially 
exposed to chemical or biological substances during Project 112 tests 
in 2003, but has yet to provide a sound and documented basis for its 
decision. In 2003, DOD reported it had identified 5,842 servicemembers 
and estimated 350 civilians as having been potentially exposed during 
Project 112, and indicated that DOD would cease actively searching for 
additional individuals, but that it would investigate any new 
information that might be presented and share any additional or changed 
information with VA and the public. In 2004, after reviewing DOD's 
efforts, we reported that DOD did not exhaust all possible sources of 
information during its investigation of Project 112, and we recommended 
that DOD determine the feasibility of identifying additional 
individuals.[Footnote 11] Sound management principles require that such 
a determination be based on an objective analysis of the related costs 
and benefits. However, in response to our recommendation, DOD 
determined continuing an active search for individuals had reached the 
point of diminishing returns, and reaffirmed its decision to cease 
active searches. DOD officials could not provide us with a supporting 
analysis based on objective data. Nor could they provide any documented 
criteria which they used to make their determination, since OASD (HA) 
was not required to provide any support or basis for the decision. 
However, since June 2003, non-DOD sources have identified approximately 
600 additional names of servicemembers and civilians who were 
potentially exposed as a result of Project 112. For example, in 2007, 
the Institute of Medicine identified 394 individuals not previously 
identified by DOD while researching the long-term health effects of 
participants in the shipboard hazard and defense tests, which were a 
subset of Project 112 tests. In light of the increasing number of 
individuals who have been identified since DOD ceased actively 
searching, until DOD makes a sound and documented decision about the 
costs and benefits of actively searching for Project 112 participants, 
DOD's efforts may continue to be questioned. We are recommending that 
DOD perform and document a sound, methodologically defensible analysis 
of the costs and benefits of searching for individuals who may have 
been exposed to chemical or biological substances during Project 112 
tests and share this analysis with Congress. 

DOD has taken actions to identify individuals who were potentially 
exposed during chemical or biological tests outside of Project 112, but 
we identified four shortcomings in DOD's current effort. First, DOD's 
effort lacks clear and consistent objectives, scope of work, and 
information needs that would set the parameters for this effort. For 
example, DOD believes it should focus its efforts on individuals who 
were potentially exposed during chemical or biological tests as 
directed by the Defense Authorization Act for FY 2003, but the VA would 
like to have information on individuals who have been potentially 
exposed to chemical or biological substances during testing, 
transportation, and storage since VA is responsible for adjudicating 
all claims by servicemembers, regardless of how they were exposed. We 
found inconsistent objectives provided by DOD to the contractor and 
determined they were the result of various executive, congressional, 
and DOD directions establishing different expectations. Second, until 
June 2007, OUSD (AT&L)'s chemical and biological defense office had not 
assigned an official to oversee the contractor's effort, nor had the 
officials from that office visited any repositories where the 
contractor had proposed or completed work, resulting in little 
substantive oversight of the contractor. Numerous factors affect the 
office's ability to provide oversight, including a lack of consistent 
leadership, a shortage of personnel, and a lack of defined roles and 
responsibilities. Third, OUSD (AT&L)'s chemical and biological defense 
office did not fully leverage all available prior knowledge and 
research of DOD and non-DOD entities to identify and use information 
they developed on individuals potentially exposed during DOD's chemical 
and biological tests. For example, in the current effort, OUSD (AT&L)'s 
chemical and biological defense office had not contacted or coordinated 
with former members of the OUSD (P&R) task force, or the non-DOD 
scientists who developed data from another study on servicemembers who 
were potentially exposed. Such coordination could have helped DOD 
identify and prioritize site visits and ensure that the contractor was 
not duplicating efforts. Fourth, DOD had not worked with veterans and 
veterans service organizations to identify DOD projects or tests 
outside Project 112 that may have exposed members of the armed forces 
to chemical or biological substances, as required by the Defense 
Authorization Act for FY 2003, and has not kept Congress and veterans 
service organizations fully informed about its efforts. Until DOD 
addresses these shortcomings, DOD leadership and Congress have little 
assurance of the reasonableness and effectiveness of DOD's current 
effort. We are recommending that DOD take a number of specific steps to 
enhance these efforts. 

DOD and VA have had limited success in notifying individuals 
potentially exposed during chemical or biological tests, both within 
and outside of Project 112. While DOD has a process and has shared the 
names of identified servicemembers with VA, we identified three 
shortcomings. First, the transmission of information between DOD and VA 
has been inconsistent because, according to DOD officials, the exchange 
of information does not follow a specific schedule, there are competing 
priorities for resources, and DOD has experienced database management 
issues. Second, although VA has a process for sending notification 
letters to veterans who have been identified as having been potentially 
exposed, VA has not used certain available resources to obtain contact 
information. To date, VA has sent notification letters to 48 percent of 
the names that DOD has provided to them and that they may be able to 
contact. VA officials noted that while the total number of notification 
letters sent is 48 percent of the number of names that DOD has provided 
to them and that they may be able to contact, it represents all of the 
individuals for whom they were able to obtain contact information. A 
number of factors VA cannot control have impeded its ability to notify 
veterans, such as missing social security numbers. However, we found 
that VA was not using certain available resources to obtain contact 
information to notify servicemembers who could be identified and 
notified, or to help determine whether they were deceased. For example, 
VA officials told us that they were using credit bureau databases as a 
source for contact information, and they had not regularly coordinated 
with the Internal Revenue Service to use their databases and had not 
coordinated directly with the Social Security Administration to obtain 
contact information from veterans receiving social security benefits or 
to identify deceased veterans using the agency's death index. Third, 
while we previously recommended that DOD address the appropriateness of 
and responsibility for reporting new information related to civilians 
who were identified and DOD concurred with our recommendation,[Footnote 
12] DOD has not taken any action to notify approximately 1,900 
civilians who were potentially exposed during chemical or biological 
tests. DOD officials told us they have primarily focused on 
servicemembers since the primary impetus for the research has been 
requests for information from VA. In addition, DOD has not notified 
these civilians in part because it lacks specific guidance that defines 
the requirements, roles, responsibilities, and mechanisms to notify 
civilians or transmit civilian exposure information to the appropriate 
agency for notification. Specifically, while the Defense Authorization 
Act for FY 2003 required DOD to identify its tests or projects that may 
have exposed members of the armed forces to chemical or biological 
substances, it did not specifically address civilian personnel who may 
have been affected by these tests. Furthermore, there does not appear 
to be a requirement for DOD or other federal agencies, such as the 
Department of Labor, to notify civilians of their potential exposure. 
Until DOD and VA address these shortcomings, some veterans and 
civilians will remain unaware of their potential exposure. To ensure 
that civilians who were potentially exposed to chemical or biological 
substances as a result of tests conducted or sponsored by DOD are aware 
of their circumstances, we are suggesting that Congress consider 
requiring the Secretary of Defense, in consultation with the Secretary 
of Labor, to develop specific guidance that ensures that civilians who 
were potentially exposed to chemical or biological substances as a 
result of tests conducted or sponsored by DOD are aware of their 
circumstances. We are also recommending that DOD and VA take steps to 
improve their efforts to share, obtain, and use available information 
and to more effectively notify servicemembers who may have been exposed 
to chemical or biological substances during DOD tests. 

We provided DOD, VA, and the Department of Labor with a draft copy of 
this report for comment. DOD generally agreed with five 
recommendations, but disagreed with the recommendation to conduct and 
document a cost-benefit analysis associated with continuing the search 
for additional Project 112 participants, and to provide Congress with 
the results of this analysis. The department noted that it has made a 
full accounting of its Project 112 efforts to date and has no credible 
leads to continue this research. However, because the department has 
not adequately addressed our May 2004 recommendation to determine the 
feasibility of addressing unresolved issues associated with Project 112 
and a number of non-DOD sources have identified additional names of 
individuals potentially exposed during Project 112 since DOD's 2003 
report to Congress, we are suggesting Congress consider requiring the 
Secretary of Defense to conduct and document an analysis that includes 
a full accounting of information known, and the related costs, 
benefits, and challenges associated with continuing the search for 
additional Project 112 participants; and to provide Congress with the 
results of this analysis. VA agreed with one recommendation and 
partially agreed with another recommendation that pertained to their 
activities, and the Department of Labor did not provide us with any 
comments. The departments' comments and our evaluation of them are 
discussed on pages 30-32. DOD and VA also provided technical comments, 
which we incorporated as appropriate. DOD's and VA's comments are 
reprinted in appendices II and III, respectively. 

Background: 

On January 6, 1993, the Institute of Medicine published a report that 
discussed secret U.S. chemical weapons programs during World War 
II.[Footnote 13] The report found that an estimated 60,000 military 
personnel participated as human experimental subjects in tests of 
exposure to mustard agents and lewisite and unknown numbers of 
additional servicemembers may have been exposed to these substances 
through their participation in the production, transportation, and/or 
storage of these chemical substances. On February 18, 1993, we issued a 
report that found VA lacked information about individuals who were 
exposed during secret DOD chemical tests.[Footnote 14] After Members of 
Congress, the President of the United States, and the Secretary of 
Defense exchanged a series of letters about this issue in 1993, the 
Deputy Secretary of Defense issued an agencywide memo that released all 
individuals from any nondisclosure restrictions that might have been 
placed on them, tasked the secretaries of the military departments to 
undertake efforts to declassify and provide to VA as soon as possible 
information about individuals who were potentially exposed, and 
directed OUSD (P&R) to establish a task force to monitor the status of 
DOD's efforts. As a result, OUSD (P&R), the military services, and VA 
developed the Chemical Weapons Exposure Study Task Force to identify 
DOD personnel exposed to chemical substances during testing, training, 
transport, production, and storage. By conducting site visits and other 
research efforts, the task force identified approximately 6,400 
servicemembers and civilians who were potentially exposed to mustard, 
lewisite, and other chemical substances. The office created a database 
with information about these individuals (hereafter referred to as OUSD 
(P&R) database) and, according to OUSD (P&R), sent certificates of 
commendation to more than 700 individuals for whom it could find 
contact information. In addition to its own research, OUSD (P&R), on 
behalf of the task force, issued a task order for a contractor to 
analyze, extract, and develop a database of information on all 
volunteers and/or other subjects potentially exposed to live chemical 
or biological substances. The contractor developed a database and 
issued a series of reports that identified the locations of human 
exposures to chemical substances, including those resulting from tests 
and a variety of other activities such as transportation, production, 
storage, and disposal.[Footnote 15] Congress continued to look into 
this issue during 1994 through a series of hearings and a staff report 
that was prepared for the U.S. Senate's Committee on Veteran 
Affairs.[Footnote 16] 

The issue of servicemembers being used as human subjects during DOD's 
chemical and biological tests received high-level attention again in 
2000, when the acting Secretary of Veterans Affairs wrote a letter to 
the Secretary of Defense requesting assistance in obtaining information 
about a series of then-classified chemical and biological tests under 
DOD's Project 112 program. OASD (HA) officials consequently initiated 
some actions to identify potentially exposed individuals. Subsequently, 
DOD, VA, and Congress exchanged a series of correspondence about the 
need to identify individuals who were potentially exposed during these 
tests. Eventually, the Defense Authorization Act for FY 2003 required 
DOD to submit to Congress and the Secretary of Veterans Affairs a 
comprehensive plan for the review, declassification, and submittal to 
VA of all DOD records and information on Project 112 that are relevant 
to the provision of benefits by the Secretary of Veterans Affairs to 
members of the armed forces who participated in that project. During 
this effort, DOD identified 5,842 servicemembers and estimated that 350 
civilians had been potentially exposed during Project 112 tests, and 
this information was entered into a Project 112 database. The act 
further required the Comptroller General to evaluate the plan and its 
implementation. 

The Defense Authorization Act for FY 2003 also required DOD to work 
with veterans and veterans service organizations to identify DOD 
projects or tests outside of Project 112 that may have exposed members 
of the armed forces to chemical or biological substances. In June 2004, 
we reported that DOD had not yet begun its investigation to identify 
such projects or tests and recommended that the Secretary of Defense 
direct the appropriate office(s) to finalize and implement a plan for 
identifying DOD projects and tests conducted outside of Project 112 
that might have exposed servicemembers to chemical or biological 
substances and ensure that the plan addresses the scope, reporting 
requirements, milestones, and responsibilities for those involved in 
completing this effort.[Footnote 17] According to an OASD (HA) 
official, OASD (HA) made an informal agreement with OUSD (AT&L) to 
undertake this effort since OASD (HA) did not have the resources to 
conduct an investigation itself or to fund a contractor to do the 
research. In September 2004, OUSD (AT&L)'s chemical and biological 
defense office issued a task order to fulfill this provision of the 
legislation. The research being done as a result of this task order is 
ongoing as of December 2007. 

DOD's Decision to Stop Actively Searching for Project 112 Individuals 
Was Not Based on a Sound and Documented Cost-Benefit Analysis: 

In June 2003, after having identified several thousand servicemembers 
and hundreds of civilians as having been potentially exposed to 
chemical or biological substances during Project 112, DOD stopped 
actively searching for additional individuals. According to a 
knowledgeable DOD official, this decision was made without a sound and 
documented cost-benefit analysis. The Defense Authorization Act for FY 
2003 required DOD to review records and information necessary to 
identify members of the armed forces who were or may have been exposed 
to chemical or biological substances as a result of Project 112. 
Subsequently, in June 2003, DOD issued a report to Congress that stated 
that 5,842 servicemembers and an estimated 350 civilians might have 
been exposed during Project 112 tests. The report also indicated that 
DOD had ceased its active search for individuals potentially exposed 
during Project 112 tests and that it would investigate any new 
information that may be presented as well as share any additional or 
changed information with VA and the public. 

In 2004, we reported that DOD performed a reasonable investigation of 
servicemembers who were potentially exposed to the substances used 
during Project 112 tests. However, we found that DOD had not exhausted 
all possibilities for identifying additional servicemembers and 
civilian personnel who had been potentially exposed. Therefore, we 
recommended that DOD determine the feasibility of addressing these 
unresolved issues. In response to our recommendation, DOD determined 
continuing an active search for individuals had reached the point of 
diminishing returns, and reaffirmed its decision to cease active 
searches. This decision was not supported by any objective analysis of 
the potential costs and benefits of continuing the effort. Instead, 
this decision was made by officials in OASD (HA) who had a working 
knowledge of Project 112 tests and the contents of chemical and 
biological test record repositories. These officials concluded that the 
record repositories that had been searched contained the majority of 
Project 112 documents; therefore, they believed that the bulk of 
exposures related to Project 112 tests had already been identified. 
Furthermore, the officials decided that the application of resources 
necessary to continue searching for Project 112 exposures would result 
in a diminishing return on their investment. The Office of Management 
and Budget has stated that a good cost-benefit analysis should include 
a statement of the assumptions, the rationale behind them, and a review 
of their strengths and weaknesses.[Footnote 18] This could include a 
full accounting of information known, related costs, benefits, and 
challenges of continuing to search for additional Project 112 
participants. Moreover, our prior work has shown that there are 
elements integral to a sound cost-benefit analysis.[Footnote 19] For 
example, the analysis should include a thorough evaluation of the 
social benefits and costs of investments, identify objectives to ensure 
a clear understanding of the desired outcome, and include a list of the 
relevant impacts to ensure that all aspects are considered. DOD could 
not provide us with a quantitative analysis based on objective data or 
any documented criteria because OASD (HA) was not required to provide 
any support or basis for the decision. 

Since DOD's June 2003 report to Congress and its decision to cease 
actively searching for additional exposures, additional individuals who 
may have been exposed as a result of Project 112 tests have been 
identified through various non-DOD sources, as shown in table 1. For 
example, the Institute of Medicine conducted a study on the long-term 
health effects of participation in the shipboard hazard and defense 
tests that were conducted as a subset of Project 112.[Footnote 20] This 
study identified 394 individuals who had been potentially exposed and 
who were previously unknown to DOD. According to DOD and Institute of 
Medicine officials, the additional names were discovered when the 
Institute of Medicine applied a more inclusive methodology in its 
research. In addition, our previous work in 2004 reported that DOD did 
not exhaust all possible sources of information during its 
investigation of Project 112 and our own research for that report 
resulted in the identification of 39 additional potentially exposed 
servicemembers.[Footnote 21] For example, DOD had limited success in 
identifying exposures during land-based tests because it was unable to 
find documentation, and it did not specifically search for individual 
civilian personnel in its investigation because it considered them to 
be outside of its scope. Furthermore, DOD officials have told us that 
veterans who participated in Project 112 tests have contacted DOD on 
their own initiative in search of information and documentation related 
to their exposures, which has resulted in 165 additional veterans being 
identified as having been potentially exposed during these tests. 

Table 1: Number of Servicemembers Identified as Having Been Potentially 
Exposed during Project 112: 

Total number of Project 112 names identified as of December 2007: 
6,440. 

DOD's 2003 Report to Congress: 5,842. 

Number of names identified since DOD's 2003 report: 598. 

Number of names identified since DOD's 2003 report: Institute of 
Medicine research (394 names): [Empty]. 

Number of names identified since DOD's 2003 report: Veterans' inquiries 
(165 names); [Empty]. 

Number of names identified since DOD's 2003 report: GAO research (39 
names); [Empty]. 

Source: GAO analysis of DOD data. 

Note: The number of individuals that we report as identified is based 
on information from DOD's and VA's databases and is approximate. Cases 
reported in this table may reflect duplicates. Naming nomenclature 
(suffixes, nicknames, abbreviations, etc.) makes it difficult to 
eliminate all potential duplicate names. When in doubt, DOD treats 
cases as separate individuals. 

[End of table] 

DOD's current effort to identify individuals who may have been exposed 
to chemical or biological substances during activities outside of 
Project 112, discussed in the following section of this report, has 
also resulted in the discovery of information related to Project 112 
tests. Specifically, the DOD contractor has found evidence that 
individuals who DOD already knew were potentially exposed to substances 
during at least one known Project 112 test were also potentially 
exposed during other Project 112 tests. 

In light of the increasing number of individuals who have been 
identified since DOD ceased actively searching, until DOD makes a sound 
and documented decision regarding the cost and benefits of actively 
searching for individuals potentially exposed during Project 112 tests, 
Congress and veterans may continue to question the completeness and 
accuracy of DOD's effort. 

DOD's Effort to Identify Individuals Potentially Exposed during Non- 
Project 112 Tests Has Several Shortcomings: 

Although DOD has taken action to identify individuals who were 
potentially exposed during chemical or biological tests outside of 
Project 112, we identified several shortcomings in the current effort. 
Specifically, we found that DOD's approach was hampered by (1) a lack 
of clear and consistent objectives, scope of work, and information 
needs; (2) management and oversight weaknesses; (3) a limited use of 
the work of other entities that previously identified exposed 
individuals; and (4) a lack of transparency in DOD's efforts. 

DOD Issued a Task Order to Identify Individuals Potentially Exposed 
during Tests Conducted Outside of Project 112: 

In response to the Defense Authorization Act for FY 2003 and our May 
2004 recommendation that DOD finalize and implement a plan to identify 
individuals who were potentially exposed during tests conducted outside 
of Project 112, DOD issued a task order in September 2004. The task 
order identified four sets of tasks that the contractor was to 
undertake to accomplish the task order's objectives within 3 years-- 
perform literature searches, conduct and review on-site data 
collections, data mine existing databases, and augment a database 
maintained by the contractor. The contractor has issued monthly reports 
on its work to OUSD (AT&L)'s chemical and biological defense office, 
which indicate that the contractor has taken action on each of these 
tasks. OUSD (AT&L)'s chemical and biological defense office and the 
contractor have agreed that the on-site reviews will be conducted at a 
total of 18 sites that were identified and prioritized based on 
established criteria, such as relevance and number of documents 
expected to be present. As of October 2007, the contractor has 
completed on-site data collection at 5 of these 18 sites, and as of 
December 2007 was collecting data at 3 additional sites. 

During its site visits, the contractor's staff searches a variety of 
documents for information that pertains to human exposure to chemical 
or biological substances.[Footnote 22] The documents that are 
identified as having relevant information are then scanned into an 
electronic file and the information from those documents--such as the 
individual's name, the substance to which the subject was exposed, and 
the activity that resulted in the exposure--is entered into a database. 
The contractor conducts a quality assurance review before this 
information is delivered to OASD (HA) officials. OASD (HA) officials 
told us that they perform a detailed review of this information, query 
the contractor to resolve errors or inconsistencies, and make 
modifications to the information provided by the contractor if they 
have received or read other information that they believe could add 
contextual sophistication. Once OASD (HA) officials complete their 
review of the information, it is added to the DOD chemical and 
biological test database that they maintain (hereafter referred to as 
the OUSD (AT&L) task order database). While the database information is 
not provided to OUSD (AT&L)'s chemical and biological defense office, 
the contractor's monthly report to this office includes the number of 
identified individuals that the contractor has provided to OASD (HA). 

The task order identified specific locations for the contractor to 
review and was supposed to be completed in September 2007; however, the 
contractor was unable to complete its work within the 3-year schedule 
and has subsequently received a 3-year extension. This task order is 
valued at almost $4.5 million, and the estimated value of the extension 
is between $2.5 million and $3.7 million. Based on the project's June 
2007 concept of operations plan, which DOD developed as a result of 
this review, the contractor is expected to meet the project's 
objectives and complete collection and analysis of information obtained 
from 18 data collection sites by September 2010. Since the remaining 
sites have been prioritized based on expected level of information and 
other criteria, DOD officials believe that the remaining data 
collection efforts could be completed more quickly. 

DOD's Current Effort Lacks Clear and Consistent Objectives, Scope of 
Work, and Information Needs: 

DOD's current effort to identify individuals potentially exposed to 
chemical or biological substances lacks clear and consistent 
objectives, scope of work, and information needs, which affects DOD's 
ability to know whether it has accomplished the project's goals. First, 
the objectives of DOD's current effort are inconsistent. The Defense 
Authorization Act for FY 2003, which was the genesis for DOD's current 
effort, directed the Secretary of Defense to identify DOD projects or 
tests outside of Project 112 that may have exposed members of the armed 
forces to chemical or biological substances. However, the focus of the 
current effort has expanded to include other exposures, including those 
resulting from immunizations, transportation, storage, and occupational 
accidents. This occurred because the documents that are guiding this 
effort, including the project's September 2004 statement of work and 
its June 2007 concept of operations plan, have been used 
interchangeably to define the scope of the work. 

We identified a difference of opinion between DOD and VA regarding the 
overall focus of the contractor's research efforts. Officials in OUSD 
(AT&L)'s chemical and biological defense office stated that they 
believe the contractor should focus only on identifying participants in 
DOD tests since the Defense Authorization Act for FY 2003 was the 
genesis of this task order, and they believe that the primary interest 
is in individuals who were not aware of their exposures or are unable 
to report their exposures due to the classified nature of the tests. 
They also believe that individuals accidentally exposed at a work 
location might be protected under occupational health regulations and 
statutes. However, VA officials stated that they would prefer that DOD 
provide information on all exposures, including those not associated 
with DOD tests, since VA is responsible for adjudicating all claims by 
servicemembers, regardless of how they were exposed. The contractor 
conducting the search has included all types of exposures in its 
research, which according to DOD and contractor officials is based on 
VA's stated preferences. 

Second, the scope of DOD's current effort is unclear. Specifically, 
while the Defense Authorization Act for FY 2003 directed DOD to 
identify only members of the armed forces, the task order's 2004 
statement of work and the June 2007 concept of operations plan state 
that the objective of the project is to collect information on all 
servicemembers and civilian personnel who might have been exposed from 
1946 to present. However, DOD's current effort has not included an 
active search of civilian personnel. Instead, at the direction of DOD, 
the contractor is collecting information on civilians who may have been 
exposed to chemical or biological substances when it comes across those 
names while searching for servicemembers. DOD officials stated that 
they focused their efforts on servicemembers because VA has actively 
requested information about servicemembers from DOD for years and the 
department has not received any inquiries about the civilians. At the 
time of our review, the contractor had collected information on 
approximately 700 civilian personnel who were potentially exposed to 
chemical or biological substances. 

Third, the amount and type of information that the contractor needs to 
collect for this effort has been expanded from the original task order 
requirement. The task order specifies that the information to be 
collected should identify potential human exposure events, the names of 
test programs, chemical and biological substances involved, and the 
names of volunteers or participants. However, DOD has expanded the 
information that the contractor should collect, which may be 
lengthening the time for the contractor to complete its work. For 
example, in February 2007, officials from one of the repository sites 
provided the contractor a CD with names and exposure information for 
2,300 individuals who were exposed to a series of biological tests at 
Fort Detrick, Maryland, known as Operation Whitecoat. However, as of 
October 2007, the contractor had not provided DOD with these names 
because it was adding information, such as the test objective and 
summary, and exposure and treatment information. Since most of these 
2,300 individuals had been previously aware of their exposures due to 
Fort Detrick's independent outreach efforts, a DOD official who has 
worked with these individuals has stated that it is unclear how much 
additional information the contractor needs to collect about this 
group. While OASD (HA) officials have said that the additional 
information has been helpful for their needs, they and VA officials 
have also acknowledged that the identity of the chemical or biological 
substance to which an individual was potentially exposed is the most 
pertinent information.[Footnote 23] 

Without consistent guidance about the objectives, scope of work, and 
information necessary to meet DOD's goals and objectives, DOD's current 
effort might not produce the desired results. After discussing this 
issue with DOD officials, in December 2007 officials in OUSD (AT&L)'s 
chemical and biological defense office stated that they plan to revise 
the task order's statement of work, concept of operations plan, and a 
DOD implementation plan to clarify the scope of work and the focus of 
the research to servicemembers--the original focus as identified in the 
Defense Authorization Act for FY 2003. 

DOD's Current Effort Has Lacked Adequate Oversight: 

Until recently, DOD's current effort has lacked adequate oversight of 
the contractor activities and results. We have previously reported that 
providing effective oversight is essential and, at times, DOD's 
oversight was wanting, as it did not always task personnel with 
oversight duties or establish clear lines of accountability.[Footnote 
24] While OUSD (AT&L)'s chemical and biological defense office 
established three different points of contact throughout the life of 
the task order who participated in meetings when the work started in 
2004 and assisted the contractor undertaking the effort in accessing 
repository sites when requested, these points of contact were not 
performing active oversight activities nor were they designated as the 
project manager for this effort. During our review, officials in OUSD 
(AT&L)'s chemical and biological defense office realized that their 
predecessors had not selected a project manager and selected one of the 
office's civilian employees to oversee the effort. 

We also found that DOD had not visited any of the repository sites 
where the contractor had proposed or completed its research to ensure 
that the work was effectively and efficiently meeting the task order's 
objectives. We visited the three repository sites where the contractor 
was conducting its work during our review. At one location, a 
knowledgeable DOD official expressed concerns to us that the 
contractor's presence and research in one of the site's libraries might 
not be needed. However, since officials in OUSD (AT&L)'s chemical and 
biological defense office had not visited the site or met with site 
officials, they were unaware of these concerns and therefore were 
unable to decide whether the contractor should be conducting work at 
that particular site or whether the research funds and time should be 
spent at a site that they believe might provide more relevant 
information. 

In addition, until June 2007, OUSD (AT&L)'s chemical and biological 
defense office had not regularly evaluated the effectiveness or 
efficiency of the contractor's work. For example, at the time of our 
review, officials in OUSD (AT&L)'s chemical and biological office told 
us that they did not know the extent to which each of the task order's 
four tasks was meeting its objective to identify servicemembers and 
civilians who were potentially exposed to chemical or biological 
substances during testing and other activities. Therefore, DOD was not 
in a position to determine whether the task order needed to be modified 
to focus DOD's resources and the contractor's research efforts to those 
tasks that will best meet its objectives. 

Further, while the contractor had implemented its own quality 
assurance/quality control process that was approved by OUSD (AT&L)'s 
chemical and biological defense office, the office had not taken any 
action to independently assess the accuracy and characterization of the 
information that the contractor was providing to the OASD (HA), which 
maintains DOD's databases of potentially exposed individuals. As a 
result, officials in OUSD (AT&L)'s chemical and biological defense 
office, who are responsible for overseeing the contractor's efforts, 
have limited knowledge about the accuracy and characterization of the 
information that was being collected. 

Review and assessment of the contractor-provided data by the project 
manager are important because we identified potential problems with the 
accuracy of that information. For example, our work indicated that 
there are discrepancies between the number of individuals reported by 
the contractor in its monthly reports to OUSD (AT&L)'s chemical and 
biological office and the number of individuals that exist in OASD 
(HA)'s database that could not be adequately explained. In addition, at 
the time of our review, the characterization in the contractor's 
monthly reports provided to OUSD (AT&L)'s chemical and biological 
defense office that all of these individuals were potentially exposed 
during chemical or biological tests gave the wrong impression to the 
project manager. For example, while the contractor has characterized 
the individuals it has identified as having been involved in DOD's 
chemical and biological "tests", an unknown number of these exposures 
resulted from immunizations, transportation, occupational, and storage 
accidents. This number also includes individuals who might have been 
associated with the tests but who were not exposed to any substances, 
such as those who participated in physical exercises to test the 
durability of chemical and biological suits or who could have been part 
of a test control group. OASD (HA) officials were able to identify at 
least 1,800 names in the database that were not exposed to any 
substances, which leaves about 7,100 names in the database that have 
been potentially exposed to chemical or biological substances, as shown 
in table 2.[Footnote 25] DOD and contractor officials stated that they 
have included these names in the database so that they could 
appropriately respond to these individuals' concerns if they contact 
DOD or VA. Specifically, according to DOD, including these names in the 
database enables the department to refute any claims by individuals who 
participated in tests where they were not exposed to any chemical or 
biological substances. 

Table 2: Number of Non-Project 112 Servicemembers Identified by DOD as 
of December 2007: 

Number of names in OUSD (AT&L) task order database: 8,979; 

Number of names in OUSD (AT&L) task order database: Number of names in 
OUSD (AT&L) task order database that have been identified as having 
been potentially exposed to a chemical or biological substance: 7,120;  

Number of names in OUSD (AT&L) task order database: Number of names in 
OUSD (AT&L) task order database that have not been exposed to any 
chemical or biological substances; 1,859; 

Number of names awaiting entry into database: 844; 

Total: 9,823. 

Source: GAO analysis of DOD data. 

Note: The number of individuals that we report as identified is based 
on information from DOD's and VA's databases and is approximate. Cases 
reported in this table may reflect duplicates. Naming nomenclature 
(suffixes, nicknames, abbreviations, etc.) makes it difficult to 
eliminate all potential duplicate names. When in doubt, DOD treats 
cases as separate individuals. 

[End of table] 

We identified a variety of factors affecting the ability of OUSD 
(AT&L)'s chemical and biological defense office to provide oversight, 
including a lack of consistent leadership, inadequate internal 
controls, a shortage of personnel, and a lack of defined roles and 
responsibilities. For example, the position that was identified as the 
office's point of contact for the task order is a 1-year position. 
Consequently, the contractor has had to work with three different 
individuals during the first 3 years of the task order. The official 
holding this position during our review requested and was granted a 2- 
year extension in this position, and thus he has been able to implement 
a number of internal controls to improve the oversight and 
accountability of this project. In addition, until September 2007, the 
respective roles and responsibilities of OUSD (AT&L)'s chemical and 
biological defense office and OASD (HA) had not been clearly 
identified. In September 2007, in response to our review, OUSD (AT&L)'s 
chemical and biological defense office and OASD (HA) signed an 
implementation plan that identified their respective roles and 
responsibilities. 

DOD Did Not Fully Leverage the Work of Other Entities that Identified 
Exposed Individuals: 

In planning, executing, and evaluating DOD's current effort, OUSD 
(AT&L)'s chemical and biological defense office did not fully leverage 
the work of other entities that had previously identified exposed 
individuals. Multiple DOD and non-DOD organizations have conducted a 
variety of independent efforts since the early 1990s, through which 
they have identified thousands of individuals who were potentially 
exposed during chemical or biological tests. These entities possess 
specific information about the tests--to include the location of test 
records--and the personnel conducting the work developed institutional 
knowledge. While OUSD (AT&L)'s chemical and biological defense office 
leveraged Project 112 information from the OASD (HA), it did not 
leverage information available from other DOD and non-DOD sources. For 
example, between 1993 and 1997, the joint DOD-VA task force identified 
approximately 6,400 individuals who were potentially exposed to sulfur 
mustard, lewisite, and other chemical substances. OUSD (P&R) led the 
effort by using some of its own personnel to conduct the research and 
visit several repository sites in addition to issuing a task order for 
a contractor--the same contractor DOD is currently using to research 
and identify tests and exposures--to develop a database containing 
information on the location, chemicals tested, and dates of the 
chemical weapons research program. During this period, OUSD (P&R) 
personnel involved with the research became very knowledgeable about 
the issues, collected boxes of information, and issued various reports. 
OUSD (P&R) officials transferred the names of the individuals who were 
identified to OASD (HA) officials in April 2005. According to OUSD 
(P&R) officials, however, officials in OUSD (AT&L)'s chemical and 
biological defense office had not met with any of the personnel with 
institutional knowledge or examined any of the documents that OUSD 
(P&R) still maintained. Since OUSD (P&R)'s reports identified locations 
of exposures, officials in OUSD (AT&L)'s chemical and biological 
defense office could have used this information as another source to 
help validate and prioritize the repository sites proposed by the 
contractor for its current effort, and to eliminate potential 
redundancy. 

Furthermore, as a result of independent research efforts by the 
Institute of Medicine about the health effects of DOD chemical tests 
using human subjects, the organization developed a database that 
contained the names and addresses of more than 4,000 servicemembers who 
were potentially exposed to chemical substances during a series of 
tests at Edgewood, Maryland. However, OUSD (AT&L)'s chemical and 
biological defense office was not aware of this database since the 
office had not coordinated with the organization. Institute of Medicine 
officials told us that they believe the names and contact information 
in this database could help DOD with its efforts since the names were 
collected from the same locations where the contractor for DOD's 
current effort is doing its research. Subsequent to our September 2007 
meeting with the Institute of Medicine, its officials contacted OASD 
(HA) to establish the protocols to transfer the names of identified 
individuals to DOD so that it can determine whether these individuals 
are already included in any of DOD's databases. Without communicating 
and coordinating with DOD and non-DOD organizations that have 
previously conducted similar efforts, DOD's current effort will not be 
able to take advantage of existing information so that it can focus its 
resources on the areas where information is missing. 

DOD's Current Effort Lacks Transparency: 

DOD's current effort lacks transparency since it has not worked with 
veterans, and it has not kept Congress and veterans service 
organizations fully informed about the status of its efforts. Although 
DOD officials conducted outreach to veterans during its Project 112 
research effort and the Defense Authorization Act for FY 2003 required 
DOD to work with veterans and veterans service organizations to 
identify projects and tests outside of Project 112 that may have 
exposed members of the armed forces to chemical and biological 
substances, DOD has not included veterans and veterans service 
organizations during its current effort. DOD also has not kept 
Congress, veterans, and the public informed on the status of its 
current effort as it did during its Project 112 investigation. 
Specifically, in 2002, DOD established a public internet site to 
provide interested persons with information on what happened during 
those tests that might have affected the health of those who served. 
The internet site included a status report on DOD's efforts so that 
veterans and others could monitor the progress, and it also contained 
reports, documents, and links to related internet sites. The internet 
site, which was operated by OASD (HA), has not been updated with 
information about DOD's current effort to identify individuals outside 
of Project 112. Representatives from a veterans service organization 
that has pursued information regarding DOD's use of servicemembers as 
human subjects told us they were not aware of DOD's current effort and 
they believe DOD has not been transparent and forthcoming with the 
information that it has obtained. These officials stated that the 
continuous lack of collaboration and transparency has negatively 
affected the level of trust veterans and the veterans service 
organization have in DOD regarding its commitment to fully identify and 
disclose information regarding these tests. The representatives stated 
that it is imperative for DOD to be as transparent as possible so that 
Congress, veterans, and the public have reason to believe the cloak of 
secrecy regarding these tests has been lifted and individuals who were 
potentially exposed could receive appropriate medical care and 
benefits. DOD officials acknowledged the importance of keeping veterans 
informed so that they know that these tests are no longer classified, 
they are entitled to a medical screening for long-term health effects, 
and they can assist in DOD's efforts to identify other individuals who 
might have been exposed. Until DOD is more transparent about its 
efforts to identify individuals who were potentially exposed during 
these previously classified tests, Congress, veterans, and the public 
could have reason to believe that the cloak of secrecy has not been 
lifted and not realize the reasonableness, effectiveness, success, and 
challenges of DOD's current effort. 

DOD and VA Have Had Limited Success in Notifying Potentially Exposed 
Individuals: 

DOD and VA have had limited success in notifying individuals who were 
potentially exposed to chemical and biological substances during 
Project 112 tests or testing that occurred outside of Project 112 due 
to several factors. First, DOD has inconsistently transmitted 
information about identified servicemembers to VA. Second, VA has not 
used all available resources to obtain contact information for 
servicemembers who were identified as having been potentially exposed. 
Finally, DOD has not taken any actions to notify civilians who have 
been identified. 

DOD Has Inconsistently Transmitted Information to VA: 

While DOD and VA have a process in place to share the names of 
servicemembers who are identified as having been potentially exposed to 
chemical and biological substances, the transmission of information 
between the two agencies has been inconsistent. To date, DOD has 
provided information to VA as agreed upon through an informal 
arrangement. Under the arrangement, DOD generally provides VA with the 
servicemember's name, as well as any information related to the 
potential exposure that DOD uncovered during its investigation, such as 
the chemical or biological substance that was used, the dosage of the 
chemical or biological substance, and the date of the exposure. As of 
October 2007, DOD had used this process to transmit to VA approximately 
20,700 names of servicemembers who had been potentially exposed to 
chemical or biological substances.[Footnote 26] The informal 
arrangement between DOD and VA did not establish a schedule for the 
exchange of information, so DOD provides newly acquired exposure 
information to VA in batches of varying size and at inconsistent 
intervals. When we began our work we found that DOD had not provided VA 
with any updates after September 2006 even though, as of June 2007, DOD 
had added approximately 1,800 additional servicemember names to its 
chemical and biological exposure database. Subsequent to our inquiries, 
however, DOD provided VA with an update in September 2007. According to 
DOD officials, regular updates to VA have been delayed because of a 
number of factors, including competing priorities such as current 
military operations, lack of personnel, database management issues, and 
lack of an impetus to take a proactive approach. Although limited 
personnel and competing priorities might be valid issues, until DOD 
provides regular updates of identified servicemembers to VA in a timely 
manner, VA will be unable to notify identified veterans about their 
potential exposure to chemical or biological substances. 

VA Has Not Used Certain Available Resources to Notify Veterans: 

VA has not used certain available resources to obtain contact 
information for and to notify veterans who were identified as having 
been potentially exposed to chemical or biological substances. To 
notify veterans who were potentially exposed to chemical or biological 
substances during DOD tests, VA matches the list of potentially exposed 
veterans it obtains from DOD against its own database of veterans to 
find either contact information or a Social Security number. If no 
Social Security number is located, VA matches the available veterans' 
information to information contained in the National Personnel Records 
Center. Once a Social Security number is obtained, VA usually uses a 
private credit bureau and on occasion has used the Internal Revenue 
Service database to obtain contact information for the veteran. In 
responding to a draft of this report, VA notes that it uses the credit 
bureau for a variety of reasons, including its up-to-date data 
transmissions from the Social Security Administration, expedience in 
responding, and general accuracy of information. As shown in table 3, 
as of December 2007, VA had obtained contact information for and sent 
notification letters to 48 percent of the names that DOD provided to 
them and that they may be able to contact.[Footnote 27] VA officials 
noted that while the total number of notification letters sent is 48 
percent of the number of names that DOD has provided to them and that 
they may be able to contact, it represents all of the individuals for 
whom they were able to obtain contact information. 

Table 3: Veterans Who VA Has Notified of Their Potential Exposure as of 
December 2007: 

Number of names DOD has provided to VA; 
OUSD (P&R): 6,739; 
Project 112: 6,440; 
OUSD (AT&L) task order: 7,531; 
Total: 20,710. 

Names with no numeric identifier (e.g., social security number or 
service number); 
OUSD (P&R): 666; 
Project 112: 385; 
OUSD (AT&L) task order: none; 
Total: 1,051. 

Names of veterans known to be deceased; 
OUSD (P&R): 2,157; 
Project 112: 733; 
OUSD (AT&L) task order: 500; 
Total: 3,390. 

Possible number of veterans to be notified (i.e., veterans who have an 
identifier and are not documented as deceased); 
OUSD (P&R): 3,916; 
Project 112: 5,322; 
OUSD (AT&L) task order: 7,031; 
Total: 16,269. 

Number of notification letters mailed by VA; 
OUSD (P&R): 319[A]; 
Project 112: 4,438; 
OUSD (AT&L) task order: 2,987; 
Total: 7,744. 

Percentage of veterans sent notification letters for those known not to 
be deceased and for which VA has a numeric identifier; 
OUSD (P&R): 8%; 
Project 112: 83%; 
OUSD (AT&L) task order: 42%; 
Total: 48%. 

Source: GAO analysis of VA data. 

Note: The number of individuals that we report as notified is based on 
information from DOD's and VA's databases and is approximate. Cases 
reported in this table may reflect duplicates. 

[A] OUSD (P&R) officials told us that they also sent 722 "Certificates 
of Commendation" to veterans who had been identified and for whom 
contact information could be obtained. It is unknown whether these 
certificates were sent to veterans who also received notification 
letters from VA. 

[End of table] 

A number of factors beyond VA's control have impeded its ability to 
notify veterans of their potential exposure to chemical or biological 
substances. For example, some records have been lost or destroyed, and 
existing documentation contains limited information and often does not 
identify names of participants, while others were not turned in by the 
scientists who were conducting the research. When the records can be 
found, they do not necessarily identify the participants, but may 
instead refer to control numbers that were issued to the participants, 
which cannot be cross-referenced to other documents for identification. 
For those records that do include identification of participants, the 
information may contain only the participants' initials, nicknames, or 
only first or last names. Also, since a number of these records do not 
include the participant's military service number or social security 
number, it is difficult to determine the exact identity of these 
individuals. Further, the contact information that VA is able to obtain 
may not be accurate. For example, more than 860 notification letters 
have been returned as undeliverable to VA. 

However, VA is not using other available resources to obtain contact 
information to notify veterans. For example, while VA told us that it 
was using a company that is able to provide current contact information 
as a source, it had not coordinated with the Social Security 
Administration to obtain contact information for veterans receiving 
social security benefits or to identify deceased veterans using the 
agency's death index and had not regularly used the Internal Revenue 
Service's information. VA officials acknowledged that they had not 
directly used the death index and that a memorandum of understanding 
with the Social Security Administration might facilitate a new way to 
accomplish this. However, they noted the credit bureau receives weekly 
updates from the Social Security Administration's death index. VA 
officials also acknowledged that it planned to make more frequent use 
of IRS databases. Until VA implements a more effective process to 
obtain contact information for veterans, some veterans will remain 
unaware of their potential exposure or the availability of health exams 
and the potential for benefits directly related to an exposure. 

DOD Has Not Notified Civilians Due in Part to a Lack of Specific 
Guidance: 

DOD has not taken any actions to notify civilians who have been 
identified as having been potentially exposed during Project 112 tests 
and other chemical and biological tests, due in part to a lack of 
specific guidance defining the requirements to notify civilians. The 
Defense Authorization Act for FY 2003 required DOD to identify its 
tests or projects that may have exposed members of the armed forces to 
chemical or biological substances, but did not specifically address 
civilian personnel who may have been affected by these tests. However, 
in our 2004 report we recommended that DOD address the appropriateness 
of and responsibility for reporting new information, such as the 
identification of additional potentially exposed servicemembers, 
civilian employees, contractors, and foreign nationals who participated 
in the tests. In its response to our report, DOD concurred with our 
recommendation and stated that it would determine the appropriate 
reporting channels for civilian employees, contractors, and foreign 
national participants who were identified as being potentially 
exposed.[Footnote 28] However, DOD has not taken any action with the 
approximately 1,900 civilian names that it maintains, as shown in table 
4. Instead, DOD has focused its efforts on the identification and 
notification of servicemembers who were potentially exposed. DOD 
officials stated that they have focused on identifying and notifying 
servicemembers since the primary impetus for their efforts to identify 
and notify individuals who may have been exposed has been requests for 
information from veterans and VA. 

Table 4: Number of Civilians Potentially Exposed as of December 2007: 

Civilians identified during OASD (HA) investigation of Project 112: 
882. 

Civilians identified during OASD (HA) investigation of Project 112: 
327. 

Civilians identified during OUSD (AT&L)'s chemical and biological 
office task order: 715. 

Total number of civilians identified as being potentially exposed: 
1,924. 

Source: GAO analysis of DOD data. 

Note: The number of individuals that we report as identified and 
notified is based on information from DOD's and VA's databases and is 
approximate. Cases reported in this table may reflect duplicates. 
Naming nomenclature (suffixes, nicknames, abbreviations, etc.) makes it 
difficult to eliminate all potential duplicate names. When in doubt, 
DOD treats cases as separate individuals. 

[End of table] 

OASD (HA) has not acted in part because it is unclear whether it is 
required to notify civilians or transmit civilian exposure information 
to another agency for notification. During our review, DOD and 
Department of Labor officials stated that they were unaware of a 
requirement for them to notify civilians of their potential exposure. 
However, our April 2005 report about civilian and contractor exposures 
to chemical substances in Vietnam identified compensation programs that 
might be available for civilians who were exposed during these chemical 
and biological tests if they come forward and present evidence that 
they were potentially exposed.[Footnote 29] Specifically, federal 
employees can file claims for workers compensation with their employing 
agency, which refers the claims to the Department of Labor under the 
Federal Employees Compensation Act. Employees who work under contract 
to the U.S. government can file workers compensation claims through 
their employers with the employers' insurance carrier. Without an 
effort to develop and provide guidance for notifying civilians, those 
civilians who have been identified may not be aware of their potential 
exposure. 

Conclusions: 

Since World War II, potentially tens of thousands of military personnel 
and civilians have been exposed to chemical or biological substances 
during previously classified DOD tests. As this population becomes 
older, it will become more imperative for DOD and VA to identify and 
notify these individuals in a timely manner because they might be 
eligible for health care or other benefits. While DOD has concluded 
that continuing an active search for individuals potentially exposed 
during Project 112 has reached a point of diminishing returns, it has 
not conducted an informed cost-benefit analysis, which could guide DOD 
in identifying the extent to which it might need to take additional 
actions. Without conducting a sound and documented cost-benefit 
analysis that includes a full accounting of information known and the 
challenges associated with continuing to search for Project 112 
participants, DOD will not be in a position to make an informed and 
transparent decision about whether any of the remaining investigative 
leads could result in meaningful opportunities to identify additional 
potentially exposed individuals. Furthermore, until DOD conducts such 
an analysis, Congress, veterans, and the public may continue to 
question the completeness and accuracy of DOD's efforts. Moreover, 
while DOD has undertaken efforts to identify and notify individuals who 
were potentially exposed during tests outside of Project 112, the 
department has not worked with veterans and veterans service 
organizations during its current effort as required by the Defense 
Authorization Act for FY 2003, and it has not coordinated its efforts 
with other DOD and non-DOD organizations. Until DOD and VA undertake 
more effective and efficient efforts to identify and notify potentially 
exposed individuals--including consistent guidance about the scope of 
work, such as clearly defined goals and objectives and agreement on the 
type and amount of information that is necessary to collect; effective 
internal controls and oversight practices; coordination with other 
entities to leverage existing information; regular updates to VA; and 
utilization of all available resources--Congress, veterans, and the 
public may continue to question DOD and VA's commitment to this effort. 
Furthermore, in the absence of transparency about these previously 
classified tests and DOD's efforts to identify individuals who were 
potentially exposed, Congress, veterans, and the public could have 
reason to believe that the cloak of secrecy has not been lifted and may 
not understand the success and challenges of DOD's current effort. 
While DOD and VA have developed a process for notifying servicemembers 
who were potentially exposed, it is unclear whether DOD or any other 
agency, such as the Department of Labor, is required to notify 
potentially exposed civilians who are identified. Therefore, without 
specific guidance that defines the requirements, roles and 
responsibilities, and mechanisms to notify civilians who have been 
potentially exposed to chemical or biological substances, these 
individuals might continue to be unaware of their circumstances. 

Matters for Congressional Consideration: 

We are suggesting the Congress consider the following two matters: 

* To provide greater transparency and resolve outstanding questions 
related to DOD's decision to cease actively searching for the 
identification of individuals associated with Project 112, Congress 
should consider requiring the Secretary of Defense to consult with and 
address the concerns of VA, veterans, and veterans service 
organizations; to conduct and document an analysis that includes a full 
accounting of information known, and the related costs, benefits, and 
challenges associated with continuing the search for additional Project 
112 participants; and to provide Congress with the results of this 
analysis. Our draft report addressed this recommendation to the 
Secretary of Defense; however, because DOD disagreed, we elevated this 
to a matter for congressional consideration. 

* To ensure that civilians who were potentially exposed to chemical or 
biological substances as a result of tests conducted or sponsored by 
DOD are aware of their circumstances, Congress should consider 
requiring the Secretary of Defense, in consultation with the Secretary 
of Labor, to develop specific guidance that defines the requirements, 
roles and responsibilities, and mechanisms to notify civilians who have 
been potentially exposed to chemical or biological substances. 

Recommendations for Executive Action: 

To ensure a sound and documented process for DOD's decision regarding 
the identification of individuals associated with Project 112, we 
recommend that the Secretary of Defense direct the Office of the Under 
Secretary of Defense for Personnel and Readiness to conduct and 
document an analysis that includes a full accounting of information 
known, and the related costs, benefits, and challenges associated with 
continuing the search for additional Project 112 participants, and to 
provide Congress with the results of this analysis. In developing the 
analysis, DOD should consult with and address the identified concerns 
of VA, veterans, and veterans service organizations. 

To ensure that DOD's current effort to identify individuals who were 
potentially exposed during chemical and biological tests outside of 
Project 112 are more efficient, effective, and transparent, and to 
ensure that its databases contain accurate information, we recommend 
that the Secretary of Defense direct the Office of Under Secretary of 
Defense for Acquisition, Technology, and Logistics to take the 
following four actions: 

* in coordination with the Office of the Under Secretary of Defense for 
Personnel and Readiness and the Secretary of Veterans Affairs, modify 
the guidance about the scope of work for its current effort, such as 
the statement of work and concept of operations plan, to clearly define 
consistent, reasonable, and acceptable goals and objectives, and the 
type and amount of information that will need to be collected to meet 
these goals and objectives; 

* implement effective internal controls and oversight practices, such 
as periodic site visits, regular assessments of the contactor's 
efforts, and quality assurance reviews of the information provided by 
the contractor; 

* coordinate and communicate with other entities that previously 
identified exposed individuals to leverage existing information, 
including institutional knowledge and documents; and: 

* make its efforts transparent with regular updates to Congress, the 
public, and veterans service organizations. 

To ensure that DOD has taken appropriate action in its efforts to 
notify servicemembers who were potentially exposed, we recommend that 
the Secretary of Defense direct the Office of the Under Secretary of 
Defense for Personnel and Readiness to take appropriate action to 
address the factors--such as competing priorities and database 
management weaknesses--affecting DOD's ability to forward the names of 
potentially exposed individuals to VA in a timely and effective manner. 

To ensure that all veterans who have been identified as having been 
potentially exposed to chemical or biological substances have been 
notified, we recommend that the Secretary of Veterans Affairs take 
steps to increase its use of available resources, such as the Internal 
Revenue Service, to implement a more efficient and effective process 
for obtaining contact information for living veterans. 

Agencies' Comments and Our Evaluation: 

We requested comments from DOD, VA, and the Department of Labor on a 
draft copy of this report. DOD generally agreed with five 
recommendations, but disagreed with the first recommendation to conduct 
and document a cost-benefit analysis associated with continuing the 
search for additional Project 112 participants, and to provide Congress 
with the results of this analysis. VA agreed with one recommendation 
and partially agreed with another recommendation that pertained to its 
activities. The Department of Labor did not provide us any comments. 
Because DOD disagreed with the recommendation to conduct and document a 
cost-benefit analysis associated with continuing the search for 
additional Project 112 participants and has not adequately addressed 
our May 2004 recommendation to determine the feasibility of addressing 
unresolved issues associated with Project 112, we added a Matter for 
Congress to consider directing the Secretary of Defense to conduct such 
an analysis. DOD and VA also provided technical comments, which we 
incorporated as appropriate. DOD's and VA's comments are reprinted in 
appendices II and III, respectively. 

DOD agreed to and has in some cases begun taking action to respond to 
five of the recommendations. Specifically, DOD stated that it has 
already coordinated on updating program goals and objectives for the 
identification of individuals who were potentially exposed during 
chemical and biological tests outside of Project 112 and is revising 
the statement of work, implementation plan, and concept of operations 
to ensure consistent guidance and deliverables. DOD also stated that it 
has taken steps to increase oversight of the project and has 
established an implementation plan with OASD (HA) delineating oversight 
responsibilities. In addition, DOD stated that it will take steps to 
determine if other organizations are conducting similar work to 
identify potentially exposed individuals and will coordinate and 
leverage all available information. The department also stated that it 
will expand its current efforts to update the public and make efforts 
more transparent. Finally, DOD and VA are in the process of discussing 
short-term and long-term improvements necessary for improving the 
transfer of information to VA in a timely and effective manner. We 
believe these are positive steps that, when completed, will address the 
intent of our recommendations. 

DOD did not agree with the first recommendation to conduct and document 
an analysis that includes a full accounting of information known, and 
the related costs, benefits, and challenges associated with continuing 
the search for additional Project 112 participants, and to provide 
Congress with the results of this analysis. DOD stated that it believes 
it made a full accounting of its efforts available to Congress in 2003, 
that it has not received any credible leads that would allow DOD to 
continue its research, and that it currently knows of no other 
investigative leads that would meaningfully supplement what it believes 
to be a total picture of Project 112. However, as discussed in our May 
2004 report, we identified a number of credible leads that could 
possibly result in additional Project 112 information. In addition, as 
discussed in this report, almost 600 additional individuals who were 
potentially exposed during Project 112 (more than a 10 percent 
increase) have been identified by non-DOD sources since DOD's 2003 
report to Congress and its decision to cease actively searching for 
additional exposures. In light of the increasing number of individuals 
who have been identified since DOD provided its report to Congress in 
2003 and ceased its active search for additional individuals, until the 
department provides a more substantive analysis that supports its 
decision to cease active searches for additional individuals 
potentially exposed during Project 112 tests, Congress and veterans may 
continue to question the completeness and level of commitment to this 
effort. Because DOD has disagreed with our recommendation and has not 
adequately addressed our May 2004 recommendation to determine the 
feasibility of addressing unresolved issues associated with Project 
112, we have added a Matter for Congress to consider directing the 
Secretary of Defense to conduct such an analysis. 

In response to our recommendations, VA agreed to work with DOD to 
modify the guidance about the scope of work for its current effort to 
clearly define consistent, reasonable, and acceptable goals and 
objectives; and the types and amount of information that will need to 
be collected to meet these goals and objectives. VA also agreed to 
contact the Internal Revenue Service to determine if a more timely 
response can be obtained from them to assist VA in notifying 
individuals potentially exposed to chemical or biological substances. 
We believe these steps are consistent with the intent of our 
recommendations. However, VA disagreed with a part of our 
recommendation that it needs to pursue information from the Social 
Security Administration since the credit bureau that VA uses to obtain 
contact information already receives the same information from the 
Social Security Administration. Accordingly, we adjusted our 
recommendation to the Secretary of Veterans Affairs so that it did not 
refer to the Social Security Administration as another source of 
information. 

We are sending copies of this report to other interested congressional 
committees, the Secretary of Defense, the Secretary of Veterans 
Affairs, and the Secretary of Labor. 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 [hyperlink, http://www.gao.gov]. 

If you have any questions about this report, please contact me at (202) 
512-5431 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 contributions to this report 
are listed in appendix IV. 

Signed by: 

Davi M. D'Agostino: 

Director, Defense Capabilities and Management: 

[End of section] 

Appendix I: Scope and Methodology: 

To assess the Department of Defense's (DOD) efforts since 2003 to 
identify servicemembers and civilians who may have been exposed to 
chemical or biological substances used during tests conducted under 
Project 112, we reviewed and analyzed documents pertaining to Project 
112, including DOD's 2003 Report to Congress: Disclosure of Information 
on Project 112 to the Department of Veterans Affairs. We interviewed 
officials at the Office of the Secretary of Defense, Washington, D.C., 
including the Under Secretary of Defense for Acquisition, Technology, 
and Logistics, and the Under Secretary for Personnel and Readiness. We 
also interviewed officials at the Office of the Assistant Secretary of 
Defense for Health Affairs who were responsible for conducting DOD's 
investigation of Project 112 tests and have been designated as the 
single point of contact for providing information related to tests and 
potential exposures during Project 112. We interviewed officials at the 
Institute of Medicine and reviewed their 2007 report on the long-term 
health effects of participation in the shipboard hazard and defense 
tests of Project 112.[Footnote 30] In addition, we reviewed and 
analyzed our prior reports as well as reports of other organizations to 
provide a historical and contextual framework for evaluating DOD's 
efforts. 

To evaluate DOD's current effort to identify servicemember and civilian 
exposures that occurred during activities outside of Project 112 tests, 
we reviewed and analyzed reports, briefings, and documents and 
interviewed officials at the Office of the Secretary of Defense, 
Washington, D.C., including the Under Secretary of Defense for 
Acquisition, Technology, and Logistics and the Under Secretary of 
Defense for Personnel and Readiness. We also interviewed officials at 
the Office of the Assistant Secretary of Defense for Health Affairs, 
who have been designated as the single point of contact for providing 
information related to tests and potential exposures outside of Project 
112. In addition, we interviewed officials at the U.S. Army Medical 
Research Institute of Infectious Diseases and the U.S. Army Medical 
Research and Materiel Command, Fort Dietrich, Maryland; the Department 
of Veterans Affairs, Washington, D.C; the Institute of Medicine, 
Washington, D.C; the Vietnam Veterans of America, Silver Spring, 
Maryland; and DOD's contractor currently conducting research to 
identify potential exposures that occurred outside of Project 112. We 
also evaluated DOD's methodology for identifying servicemembers and 
civilians who may have been exposed to chemical or biological 
substances by observing the process the contractor uses to conduct 
research at repositories containing documents related to chemical and 
biological exposures from tests and other activities, such as the 
transportation and storage of chemical and biological substances. We 
interviewed officials and observed storage facilities at the three 
chemical or biological substance exposure record repositories where the 
contractor was currently conducting its work: Edgewood Chemical and 
Biological Center Technical Library, Aberdeen Proving Grounds, 
Maryland; U.S. Army Research, Development, and Engineering Command 
Historical Office, Aberdeen Proving Grounds, Maryland; and U.S. Army 
Medical Research Institute of Infectious Diseases Technical Library, 
Fort Detrick, Maryland. In addition, we interviewed officials and 
observed the records storage area at the U.S. Army Medical Research 
Institute of Infectious Diseases Medical Records Office, Fort Detrick, 
Maryland, where information about Operation Whitecoat is maintained. We 
also reviewed DOD's outreach efforts and the extent to which DOD 
coordinated with other agencies that might have useful information, 
including the Department of Veterans Affairs (VA), the Department of 
Labor, the Institute of Medicine, and the Vietnam Veterans of America. 

To evaluate VA's process to notify servicemembers whom DOD has 
determined may have been exposed to a chemical or biological substance, 
we interviewed VA officials with the Veteran's Benefit Administration, 
Veteran's Health Administration, and Office of Planning and Policy, and 
gathered data concerning their success in making notifications. In 
particular, we documented the number of servicemembers whose names had 
been provided to VA by DOD, the extent to which notification letters 
were sent, the extent to which veterans were deceased, and the number 
of cases where sufficient documentation was not available to obtain 
contact information to make notifications. 

We assessed the reliability of DOD's and VA's data by interviewing 
agency officials knowledgeable about the data and by reviewing existing 
information about the data and the systems used to maintain and produce 
them. Although we found that there were potential problems with the 
quality and reliability of the information, we determined that the data 
were sufficient for the purposes of this report. 

We conducted this performance audit from June 2007 to February 2008 in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. 

[End of section] 

Appendix II: Comments from the Department of Defense: 

NUCLEAR AND CHEMICAL AND BIOLOGICAL DEFENSE PROGRAMS: 

Assistant To The Secretary Of Defense: 
3050 Defense Pentagon: 
Washington, DC 20301-3050: 

January 24, 2008: 

Ms. Davi M. D'Agostino: 

Director, Defense Capabilities and Management: 
U.S. Government Accountability Office: 
441 G Street, N.W.: 
Washington, DC 20548: 

Dear Ms. D'Agostino: 

This is the Department of Defense (DoD) response to the Government 
Accounting Office (GAO) draft report, "Chemical And Biological Defense: 
DoD and VA Need to Improve Efforts to Identify and Notify Individuals 
Potentially Exposed during Chemical and Biological Tests," dated 
December 21, 2007 (GAO Code 351052/ GAO-08-366). 

The DoD comments to GAO recommendations are contained in enclosure 1. 
The DoD concurred with four recommendations, concurred with comment on 
one recommendation, and non-concurred with recommendation 1 (pertaining 
to GAO's recommendation for full cost-benefit analysis associated with 
continuing the search for additional Project 112 participants). In 
support of our non-concurrence to recommendation 1, the Office of the 
Assistant Secretary of Defense for Health Affairs (OASD(HA)) made a 
full accounting of its efforts to Congress in August 2003 stating the 
DoD had ceased the active stage of its Project 112 investigation, but 
would pursue any new leads that became available as evidenced in the 
OASD(HA) information sheet, at enclosure 2. Finally, our technical 
comments to the draft report are provided at enclosure 3. 

Should you have any questions, please phone or email the point of 
contact, COL David Jarrett, 703-697-5116, [email protected]. 

Sincerely,

Signed by: 

Arthur T. Hopkins: 
Principal Deputy: 

Enclosures: 
As stated: 

GAO Draft Report ï¿½ Dated December 21, 2007 GAO CODE 351052/GAO-08-366: 

"Chemical And Biological Defense: DoD and VA Need to Improve Efforts to 
Identify and Notify Individuals Potentially Exposed during Chemical and 
Biological Test" dated December 21, 2007 (GAO Code 351052): 

Department Of Defense Comments To The Recommendations: 

Recommendation I: The GAO recommends that the Secretary of Defense 
direct the Office of the Under Secretary of Defense for Personnel and 
Readiness to conduct and document an analysis that includes a full 
accounting of information known, and the related costs, benefits, and 
challenges associated with continuing the search for additional Project 
112 participants, and to provide Congress with the results of this 
analysis. In developing the analysis, DoD should consult with and 
address the identified concerns of the Department of Veterans Affairs 
(VA), veterans, and veterans service organizations. 

DOD Response: Nonconcur. DoD believes it made a full accounting of its 
efforts available to Congress in 2003 (see enclosure 2 detailing DoD's 
Project 112 efforts). At that time, DoD informed Congress that it had 
ceased the active stage of the investigation, but would pursue any new 
leads that became available. DoD does not believe that the cessation of 
the effort lends itself to a cost benefit analysis. To date, DoD has 
received no credible leads that would allow DoD to continue its 
research. Thus, DoD sees no advantage to conducting a cost-benefits 
analysis four years after informing Congress of its plans. 

DoD does not believe that any degree of replicate searching of records 
archives for a program terminated long ago would result in a more 
complete documentation of all aspects of the program. DoD believes the 
evidence found to date produces an accurate, total picture of Project 
112/SHAD (Shipboard Hazard and Defense). DoD currently knows of no 
other investigative leads that would meaningfully supplement that 
picture. 

Most of the new names added to the Project 112 database came from 
reexamining existing data already in DoD possession, not from finding 
new documentation. Additionally, veterans continue to provide the 
Office of the Assistant Secretary of Defense (Health Affairs) 
(OASD(HA)) with temporary duty orders, letters of commendation, etc., 
(records that are not permanently archived by the military) that 
document their and fellow veterans participation in Project 112. In 
these cases, DoD uses this information to give these veterans credit 
for participating in Project 112. 

Recommendation 2: The GAO recommends that the Secretary of Defense 
direct the Office of the Under Secretary of Defense for Acquisition, 
Technology, and Logistics in coordination with the Office of the Under 
Secretary of Defense for Personnel and Readiness and the Secretary of 
Veterans Affairs, modify the guidance about the scope of work for its 
current effort, such as the statement of work and concept of operations 
plan, to clearly define consistent, reasonable, and acceptable goals 
and objectives, and the type and amount of information that will need 
to be collected to meet those goals and objectives. 

DOD Response: Concur. Office of the Assistant Secretary of Defense 
(Health Affairs) (OASD(HA)) and Office of the Under Secretary of 
Defense for Acquisition, Technology, and Logistics (OUSD(AT&L)) 
personnel have already coordinated on updating program goals and 
objectives for the identification of individuals who were potentially 
exposed during chemical and biological tests outside of Project 112. 
The statement of work, implementation plan, and concept of operations 
are under revision to ensure consistent guidance and deliverables. 

Recommendation 3: The GAO recommends that the Secretary of Defense 
direct the Office of the Under Secretary of Defense for Acquisition, 
Technology, and Logistics implement effective internal controls and 
oversight practices, such as periodic site visits, regular assessments 
of the contractor's efforts, and quality assurance reviews of the 
information provided by the contractor. 

DOD Response: Concur. The Office of the Under Secretary of Defense for 
Acquisition, Technology, and Logistics (OUSD(AT&L)) has increased its 
oversight of the program and has established an implementation plan 
with the Office of the Assistant Secretary of Defense (Health Affairs) 
(OASD(HA)) delineating program oversight responsibilities. The 
following controls have been ongoing: monthly reporting, quarterly 
program reviews, and data reviews with OASD(HA). Per the 
recommendation, OUSD(AT&L) will conduct site visits on a quarterly 
basis. 

Recommendation 4: The GAO recommends that the Secretary of Defense 
direct the Office of the Under Secretary of Defense for Acquisition, 
Technology, and Logistics to coordinate and communicate with other 
entities that previously identified exposed individuals to leverage 
existing information, including institutional knowledge and documents. 

DOD Response: Concur. As part of the revised statement of work, a 
quarterly analysis/search will be conducted to determine if other 
organizations are conducting similar work. The Office of the Under 
Secretary of Defense for Acquisition, Technology, and Logistics 
(OUSD(AT&L)) will coordinate and leverage all available information 
including institutional knowledge and documents. 

Recommendation 5: The GAO recommends that the Secretary of Defense 
direct the Office of the Under Secretary of Defense for Acquisition, 
Technology, and Logistics make its efforts transparent with regular 
updates to Congress, the public, and veterans' service organizations. 

DOD Response: Concur with comment. The draft report mentions using the 
existing DoD website to update veterans on the current search efforts 
for non-Project 112 exposed personnel. The Office of the Assistant 
Secretary of Defense (Health Affairs) (OASD(HA)) intends to add 
information on its current efforts to the Office of Force Health 
Protection & Readiness (FHP&R) website ([hyperlink, 
http://fhp:osd.mil/]) to update the public and make efforts more 
transparent. Similarly, OASD (HA) will update Veteran's Service 
Organizations (VSO) on these efforts during regularly scheduled 
meetings with VSO representatives. 

Recommendation 6: The GAO recommends that the Secretary of Defense 
direct the Office of the Under Secretary of Defense for Personnel and 
Readiness to take appropriate action to address the factors--such as 
competing priorities and database management weaknesses-affecting DOD's 
ability to forward the names of potentially exposed individuals to the 
Secretary of Veterans Affairs in a timely and effective manner. 

DOD Response: Concur. Office of the Assistant Secretary of Defense 
(Health Affairs) (OASD (HA)) personnel and the Department of Veterans 
Affairs (VA) have discussed short term and long term improvements 
necessary for improving the transfer of information to the VA in a 
timely and effective manner. OASD(HA) and VA are in the process of 
formalizing data transfer agreements. 

[End of section] 

Appendix III: Comments from the Department of Veterans Affairs: 

THE SECRETARY OF VETERANS AFFAIRS: 
WASHINGTON: 

January 29, 2008: 

Ms. Davi M. D'Agostino: 
Director, Defense Capabilities and Management: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. D'Agostino: 

The Department of Veterans Affairs (VA) has reviewed the Government 
Accountability Office's (GAO) draft report, Chemical And Biological 
Defense: DOD and VA Need to Improve Efforts to Identify and Notify 
Individuals Potentially Exposed during Chemical and Biological Tests 
(GAO-08-366). VA agrees with GAO's conclusions and concurs in part with 
GAO's recommendations that are addressed to VA. 

The Department of Defense and VA need to improve efforts to identify 
and notify individuals potentially exposed during chemical and 
biological tests. The enclosure specifically addresses GAO's 
recommendation and provides additional discussion and comments to the 
draft report. VA appreciates the opportunity to comment on your draft 
report. 

Sincerely, 

Signed by: 

James B. Peake, M.D.: 
Enclosure: 

Department of Veterans Affairs (VA) Comments to Government 
Accountability Office (GAO) Draft Report Chemical And Biological 
Defense: DOD and VA Need to Improve Efforts to Identify and Notify 
Individuals Potentially Exposed during Chemical and Biological Tests 
(GAO-08-366): 

To ensure that all veterans who have been identified as having been 
potentially exposed to chemical or biological substances have been 
notified, GAO recommends that the Secretary of Veterans Affairs take 
the following action: 

* Increase its use of available resources, such as the Social Security 
Administration (SSA) and Internal Revenue Service (IRS), to implement a 
more efficient and effective process for obtaining contact information 
for living veterans. 

Concur in part ï¿½ VA will contact IRS to determine if a more timely 
response can be obtained from them. We do not agree that additional 
inquiry capability with SSA will yield additional information since 
ChoicePoint already uses the same data from SSA that we would be 
requesting. 

In coordination with the Office of the Under Secretary of Defense for 
Personnel and Readiness and the Secretary of Veterans Affairs, modify 
the guidance about the scope of work for its current effort, such as 
the statement of work and concept of operations plan, to clearly define 
consistent, reasonable, and acceptable goals and objectives, and the 
type and amount of information that will need to be collected to meet 
these goals and objectives. 

Concur ï¿½ VA looks forward to working with DoD on this recommendation.

[End of section] 

Appendix IV: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Davi M. D'Agostino, (202) 512-5431 or [email protected]: 

Acknowledgments: 

In addition to the contact named above, Robert L. Repasky (Assistant 
Director), Tommy Baril, Renee S. Brown, Brian D. Pegram, Steven 
Putansu, Terry L. Richardson, and Karen Thornton made key contributions 
to this report. 

[End of section] 

Related GAO Products: 

Agent Orange: Limited Information Is Available on the Number of 
Civilians Exposed in Vietnam and Their Workers' Compensation Claims. 
GAO-05-371. Washington, D.C.: April 22, 2005. 

Chemical And Biological Defense: DOD Needs to Continue to Collect and 
Provide Information on Tests and Potentially Exposed Personnel. GAO-04- 
410. Washington, D.C.: May 14, 2004. 

Human Experimentation: An Overview on Cold War Era Programs. GAO/T- 
NSIAD-94-266. Washington, D.C.: September 28, 1994. 

Veterans Disability: Information From Military May Help VA Assess 
Claims Related to Secret Tests. GAO/NSIAD-93-89. Washington, D.C.: 
February 18, 1993. 

[End of section] 

Footnotes: 

[1] In this report the term "substance" is synonymous with the term 
"agent." Both terms are used to mean chemical and biological agents, 
simulants (a substitute for a more toxic agent), tracers, vaccines, and 
medical and "non-harmful" substances. 

[2] GAO, Chemical and Biological Defense: DOD Needs to Continue to 
Collect and Provide Information on Tests and Potentially Exposed 
Personnel, GAO-04-410 (Washington, D.C.: May 14, 2004); Human 
Experimentation: An Overview on Cold War Era Programs, GAO/ T-NSIAD-94-
266 (Washington, D.C.: Sept. 28, 1994); Veterans Disability: 
Information from Military May Help VA Assess Claims Related to Secret 
Tests, GAO/NSIAD-93-89 (Washington, D.C.: Feb. 18, 1993); Department of 
Veterans Affairs, Chemical Warfare Agent Experiments Among U.S. Service 
Members (Washington, D.C.: Updated August 2006); Institute of Medicine, 
Veterans at Risk: The Health Effects of Mustard Gas and Lewisite 
(Washington, D.C.: 2003). 

[3] Senate Committee on Veterans Affairs, Is Military Research 
Hazardous to Veterans' Health? Lessons Spanning Half a Century, 103rd 
Cong., 2d sess., 1994, Committee Print 103-97. 

[4] Institute of Medicine, Veterans at Risk: The Health Effects of 
Mustard Gas and Lewisite. 

[5] Mustard agents and lewisite are chemical warfare agents known as 
vesicants because of their ability to form vesicles, or blisters, on 
exposed skin. 

[6] Pub. L. No. 107-314, ï¿½ 709 (2002), hereafter referred to as the 
Defense Authorization Act for FY 2003. 

[7] A team from the Office of the Deputy Assistant Secretary of Defense 
for Force Health Protection & Readiness within OASD (HA) led the 
investigation. 

[8] DOD, 2003 Report to Congress Disclosure of Information on Project 
112 to the Department of Veterans Affairs (Washington D.C.: 2003). 

[9] GAO-04-410. 

[10] As defined in the Federal Acquisition Regulation, a "task order" 
is issued against an indefinite delivery services contract, also 
referred to as an umbrella contract, which does not procure or specify 
a firm quantity of services (other than a minimum or maximum quantity). 
In this case the umbrella contract is for operations of the DOD 
Chemical, Biological, Radiological and Nuclear Defense Information 
Analysis Center. This umbrella contract is being administered by a 
contracting officer's representative with the Air Combat Command. 

[11] GAO-04-410. 

[12] GAO-04-410. 

[13] Institute of Medicine, Veterans at Risk: The Health Effects of 
Mustard Gas and Lewisite. 

[14] GAO/NSIAD-93-89. 

[15] DOD, Phase II Final Report on Chemical Weapons Exposure Study Task 
Force (CWEST) Event Database (Arlington, Va.: August 1995) and DOD, 
Phase III Chemical Weapons Exposure Study Task Force (CWEST) Event 
Database (Arlington, Va.: June 1996). 

[16] Is Military Research Hazardous to Veterans' Health? Lessons 
Spanning Half a Century. 

[17] GAO-04-410. 

[18] Office of Management and Budget, Guidelines and Discount Rates for 
Benefit-Cost Analysis of Federal Programs, Circular A-94 (Washington, 
D.C.: Oct. 29, 1992). 

[19] GAO, Surface Transportation: Many Factors Affect Investment 
Decisions, GAO-04-744 (Washington, D.C.: June 30, 2004). 

[20] Institute of Medicine, Long-Term Health Effects of Participation 
in Project SHAD (Shipboard Hazard and Defense) (Washington, D.C.: 
2007). 

[21] GAO-04-410. Our research for the 2004 report resulted in the 
identification of 167 additional potentially exposed individuals, 
including 39 servicemembers and 128 civilians. 

[22] The current effort has identified an array of substances to which 
individuals have been potentially exposed, which include medicinal 
substances (e.g., Benadryl), chemical or biological agents (e.g., LSD), 
biological simulants (e.g., bacillus globigii), vaccines (e.g., rubella 
virus vaccine), and "non-harmful" substances (e.g., caffeine). 

[23] The identity of the substance to which an individual was 
potentially exposed is the most pertinent information because any 
potential benefits that the veteran could receive would be based on the 
veteran's ability to link a current ailment to that particular 
substance, regardless of the details about the amount of the 
individual's exposure. 

[24] GAO, A Call For Stewardship: Enhancing the Federal Government's 
Ability to Address Key Fiscal and Other 21st Century Challenges, GAO-08-
93SP (Washington, D.C.: December 2007); High-Risk Series: Department of 
Defense Contract Management, GAO-07-310 (Washington, D.C.: January 
2007); Contract Management: Opportunities to Improve Surveillance on 
Department of Defense Service Contracts, GAO-05-274 (Washington, D.C.: 
Mar. 17, 2005). 

[25] OASD (HA) officials told us that they were unable to precisely 
identify the number of individuals in the database who were either 
potentially exposed in a nontest event or not exposed to any chemical 
or biological substance for multiple reasons, such as the information 
that they collected did not clearly identify whether the individuals 
were exposed to any substances. Since DOD assigns an exposure to an 
individual when the information is not clear, it is possible that some 
of the people recorded as exposed in the database were in fact not 
exposed. 

[26] This number includes the total number of servicemembers who were 
identified as having been potentially exposed during chemical and 
biological tests conducted or sponsored by DOD, including tests 
conducted as part of DOD's Project 112 program and tests conducted 
outside of Project 112. 

[27] While DOD had provided 20,710 names to VA, the VA office that is 
responsible for notifying veterans has identified 3,390 of these 
veterans as deceased and consequently did not send notification letters 
to them. In addition, VA officials stated that they are unable to 
obtain contact information for the 1,051 veterans missing a numeric 
identifier. Of the remaining 16,269 names, some of these individuals 
could be deceased or impossible to locate due to various factors, such 
as missing social security numbers. 

[28] GAO-04-410. 

[29] GAO, Agent Orange: Limited Information Is Available on the Number 
of Civilians Exposed in Vietnam and Their Workers' Compensation Claims, 
GAO-05-371 (Washington, D.C.: Apr. 22, 2005). The report identified 
compensation programs that are available to restore lost wages and pay 
medical expenses of those who are disabled by an occupational-related 
illness. 

[30] Institute of Medicine, Long-Term Health Effects of Participation 
in Project SHAD (Shipboard Hazard and Defense) (Washington, D.C.: 
2007). 

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