Defense Health Care: Medical Surveillance Improved Since Gulf War, But
Mixed Results in Bosnia (Letter Report, 05/13/97, GAO/NSIAD-97-136).

Pursuant to a legislative requirement, GAO determined what action, if
any, the Department of Defense (DOD) has taken to improve medical
surveillance before, during, and after deployments, focusing on
Operation Joint Endeavor.

GAO noted that: (1) DOD has initiated actions to improve its medical
surveillance for deployments since the Gulf War; (2) a joint medical
surveillance policy, currently under development since late 1994, calls
for a comprehensive DOD-wide medical surveillance capability to monitor
and assess the effects of deployments on servicemembers' health; (3)
provisions of the draft policy address the medical surveillance problems
experienced during the Gulf War; however, its success in resolving the
problems cannot be assessed until the directive and implementing
instruction are finalized and applied to a deployment; (4) DOD officials
expect the policy to be finalized by September 1997; (5) after the
policy is issued, the services and responsible offices are to develop
detailed implementing instructions; (6) DOD has also implemented two
comprehensive medical surveillance plans--one for Operation Joint
Endeavor in Bosnia-Herzegovina, Croatia, and Hungary, and the other for
the current deployment in Southwest Asia; (7) these plans address the
medical surveillance problems experienced during the Gulf War and
specifically call for identifying servicemember deployment information,
monitoring environmental health and disease threats, doing personnel
medical assessments, maintaining a centralized collection of medical
assessment data, and employing certain medical record-keeping
requirements; (8) recognizing that this is DOD's first attempt, its
success in implementing the medical surveillance plan for Operation
Joint Endeavor has been mixed; and (9) although the plan provided for
enhanced medical surveillance compared to the Gulf War, GAO's review
disclosed the following problems, all of which offer DOD and the
services lessons to be learned as they continue to develop their medical
surveillance capabilities: (a) the personnel database used for tracking
which Air Force and Navy personnel were deployed is considered
inaccurate by DOD personnel; (b) many Army personnel who should have
received postdeployment medical assessments did not receive them; (c)
when postdeployment medical assessments are done, they are frequently
done late; (d) the centralized database for collecting both in-theater
and home unit postdeployment medical assessments is incomplete for many
Army personnel; and (e) many servicemembers' medical records GAO
reviewed, maintained by medical units in Germany, were incomplete regar*

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  NSIAD-97-136
     TITLE:  Defense Health Care: Medical Surveillance Improved Since 
             Gulf War, But Mixed Results in Bosnia
      DATE:  05/13/97
   SUBJECT:  Medical information systems
             Medical records
             Medical examinations
             Health care services
             Military personnel
             Military operations
             Data bases
             Data integrity
             Health hazards
IDENTIFIER:  DOD Operation Joint Endeavor
             Bosnia
             Herzegovina
             Croatia
             Hungary
             Persian Gulf War
             Desert Storm
             Army Center for Health Promotion and Preventive Medicine 
             Geographical Information System
             Asia
             
******************************************************************
** This file contains an ASCII representation of the text of a  **
** GAO report.  Delineations within the text indicating chapter **
** titles, headings, and bullets are preserved.  Major          **
** divisions and subdivisions of the text, such as Chapters,    **
** Sections, and Appendixes, are identified by double and       **
** single lines.  The numbers on the right end of these lines   **
** indicate the position of each of the subsections in the      **
** document outline.  These numbers do NOT correspond with the  **
** page numbers of the printed product.                         **
**                                                              **
** No attempt has been made to display graphic images, although **
** figure captions are reproduced.  Tables are included, but    **
** may not resemble those in the printed version.               **
**                                                              **
** Please see the PDF (Portable Document Format) file, when     **
** available, for a complete electronic file of the printed     **
** document's contents.                                         **
**                                                              **
** A printed copy of this report may be obtained from the GAO   **
** Document Distribution Center.  For further details, please   **
** send an e-mail message to:                                   **
**                                                              **
**                                            **
**                                                              **
** with the message 'info' in the body.                         **
******************************************************************


Cover
================================================================ COVER


Report to Congressional Requesters

May 1997

DEFENSE HEALTH CARE - MEDICAL
SURVEILLANCE IMPROVED SINCE GULF
WAR, BUT MIXED RESULTS IN BOSNIA

GAO/NSIAD-97-136

Defense Health Care

(703176)


Abbreviations
=============================================================== ABBREV

  CINC - Commander in Chief
  DMDC - Defense Manpower Data Center
  DOD - Department of Defense
  HIV - Human Immuno-deficiency Virus
  JTF - Joint Task Force
  USACHPPM - U.S.  Army Center for Health Promotion and Preventive
     Medicine
  USAMRIID - U.S.  Army Medical Research Institute of Infectious
     Diseases
  USAREUR - U.S.  Army Europe

Letter
=============================================================== LETTER


B-275801

May 13, 1997

The Honorable Strom Thurmond
Chairman
The Honorable Carl Levin
Ranking Minority Member
Committee on Armed Services
United States Senate

The Honorable Floyd Spence
Chairman
The Honorable Ronald Dellums
Ranking Minority Member
Committee on National Security
House of Representatives

Approximately 697,000 military personnel served in the Persian Gulf
from August 1990 to June 1991.  Soon after redeploying from the
Persian Gulf, many experienced health problems such as fatigue,
muscle and joint pain, memory loss, and severe headaches.  After over
30 studies, 18 public hearings conducted by the Presidential Advisory
Committee on Gulf War Veterans' Illnesses, and significant Department
of Defense (DOD) efforts, the nature and causes of these illnesses
remain unclear.  The Presidential Advisory Committee's final report
concluded that many of the health concerns of Gulf War veterans may
never be fully resolved because of a lack of data. 

Concerned about the health data problem, Congress directed us to
determine the extent to which the medical records for personnel who
deployed to the Persian Gulf War are complete.\1

We found that, according to the DOD officials we interviewed, the
Persian Gulf War medical records are widely recognized as incomplete
and inaccurate in documenting all medical events for servicemembers
while deployed to the Persian Gulf.  Accordingly, as agreed with your
Committees, we sought to determine what action, if any, DOD has taken
to improve medical surveillance before, during, and after
deployments, focusing especially on Operation Joint Endeavor, which
was conducted in the countries of Bosnia-Herzegovina, Croatia, and
Hungary. 

To accomplish this objective, we interviewed officials and obtained
pertinent documentary evidence from officials at the Office of the
Assistant Secretary of Defense for Health Affairs; the Joint Staff;
the Offices of the Surgeons General at Army, Navy, and Air Force
Headquarters in Washington, D.C.; and other responsible offices.  We
also (1) obtained information from the DOD Deployment Surveillance
Team's database in Falls Church, Virginia, and (2) reviewed the
medical records for active duty servicemembers in selected Army units
in Germany who deployed to Operation Joint Endeavor.  Appendix II
describes, in more detail, the scope and methodology for this report. 


--------------------
\1 National Defense Authorization Act for Fiscal Year 1997 (sec. 
744). 


   BACKGROUND
------------------------------------------------------------ Letter :1

A military medical surveillance system that collects, analyzes, and
disseminates health information facilitates DOD's ability to
intervene in a timely manner to address health care problems
experienced by military personnel.  DOD believes such a system is one
of the principal means to ensure a fit and healthy force and to
prevent disease and injuries from degrading warfighting capabilities. 
Based on our review of the Presidential Advisory Committee and the
Institute of Medicine reports\2 and discussions with DOD officials,
for the purposes of this report we identified four major elements of
a military medical surveillance system, as shown in table 1. 



                                Table 1
                
                  Major Elements of a Military Medical
                          Surveillance System

                           Environmental
                           health threat
                           assessment
                           and disease    Medical
Deployment information     monitoring     assessments    Recordkeeping
-------------------------  -------------  -------------  -------------
Who deployed               Predeployment  Predeployment  All
                           health threat  medical        servicemember
Location in theater        assessment     assessments    health events
                                                         in-theater
When they were there       Continuous     Postdeploymen  and at home
                           in-theater     t medical      unit
                           monitoring of  assessments
                           health                        Predeployment
                           threats        Centralized    and
                                          collection of  postdeploymen
                           Monitoring of  medical        t medical
                           disease and    assessment     assessments
                           nonbattle      data
                           injuries                      Use of
                                                         investigation
                                                         al drugs
----------------------------------------------------------------------
The Presidential Advisory Committee and the Institute of Medicine
investigations into the causes of illnesses experienced by Gulf War
veterans confirmed the need for effective medical surveillance
capabilities.  Research efforts to determine the causes of what has
become known as veterans' Gulf War illnesses have been hampered due
to incomplete medical surveillance data on (1) the names and
locations of personnel deployed to the Persian Gulf, (2) exposure of
personnel to environmental health hazards, (3) changes in the health
status of personnel deployed in the theater, and (4) records of
immunizations and other health services provided to the individuals
while deployed.  In essence, the data available were poorly suited to
support epidemiological\3 and health outcome studies related to
veterans' Gulf War illnesses. 


--------------------
\2 Health Consequences of Service During the Persian Gulf War: 
Recommendations for Research and Information Systems, Institute of
Medicine, Medical Follow-up Agency (Washington, D.C.:  National
Academy Press, 1996); Presidential Advisory Committee on Gulf War
Veterans' Illnesses:  Interim Report (Washington, D.C.:  U.S. 
Government Printing Office, Feb.  1996); Presidential Advisory
Committee on Gulf War Veterans' Illnesses:  Final Report (Washington,
D.C.:  U.S.  Government Printing Office, Dec.  1996). 

\3 Epidemiology is the scientific study of the incidence,
distribution, and control of disease in a population. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :2

DOD has initiated actions to improve its medical surveillance for
deployments since the Gulf War.  A joint medical surveillance policy,
currently under development since late 1994, calls for a
comprehensive DOD-wide medical surveillance capability to monitor and
assess the effects of deployments on servicemembers' health. 
Provisions of the draft policy address the medical surveillance
problems experienced during the Gulf War; however, its success in
resolving the problems cannot be assessed until the directive and
implementing instruction are finalized and applied to a deployment. 
DOD officials expect the policy to be finalized by September 1997. 
After the policy is issued, the services and responsible offices are
to develop detailed implementing instructions. 

DOD has also implemented two comprehensive medical surveillance
plans--one for Operation Joint Endeavor in Bosnia-Herzegovina,
Croatia, and Hungary and the other for the current deployment in
Southwest Asia.  These plans address the medical surveillance
problems experienced during the Gulf War and specifically call for
identifying servicemember deployment information, monitoring
environmental health and disease threats, doing personnel medical
assessments, maintaining a centralized collection of medical
assessment data, and employing certain medical record-keeping
requirements. 

Recognizing that this is DOD's first attempt, its success in
implementing the medical surveillance plan for Operation Joint
Endeavor has been mixed.  Although the plan provided for enhanced
medical surveillance compared to the Gulf War, our review disclosed
the following problems, all of which offer DOD and the services
lessons to be learned as they continue to develop their medical
surveillance capabilities: 

  -- Deployment information.  The personnel database used for
     tracking which Air Force and Navy personnel were deployed is
     considered inaccurate by DOD personnel. 

  -- Medical assessments.  Many Army personnel who should have
     received postdeployment medical assessments did not receive
     them.  Of
     618 personnel in 12 selected Army units whose medical records we
     reviewed, 24 percent did not receive in-theater postdeployment
     medical assessments, 21 percent did not receive home station
     postdeployment medical assessments, and 32 percent did not
     receive a tuberculin test. 

When postdeployment medical assessments are done, they are frequently
done late.  Personnel in the 12 selected Army units who received home
station postdeployment medical assessments received them on average
nearly 100 days after they left theater instead of within 30 days as
required by the plan.  Similarly, personnel receiving the tuberculin
tests received them on average 142 days after they left theater.  The
tuberculin test was required to be done soon after 90 days of the
servicemember's departure from the theater. 

The centralized database for collecting both in-theater and home unit
postdeployment medical assessments is incomplete for many Army
personnel.  The database omitted 12 percent of the in-theater medical
assessments done and 52 percent of the home unit medical assessments
done for the 618 servicemembers whose records we reviewed. 

  -- Medical record-keeping.  Many servicemembers' medical records we
     reviewed, maintained by medical units in Germany, were
     incomplete regarding in-theater postdeployment medical
     assessments done, medical servicemembers' visits during
     deployment, and documentation of personnel receiving the
     tick-borne encephalitis vaccine. 


   DOD'S DRAFT JOINT MEDICAL
   SURVEILLANCE POLICY
------------------------------------------------------------ Letter :3

For over 2 years, DOD officials have been working to develop a
DOD-wide joint medical surveillance directive and instruction that
establish policy and assign responsibility for improving DOD's
medical surveillance for deployments.  The intent of the policy is to
expand the concept of medical surveillance during deployments to a
more comprehensive approach for monitoring and assessing the health
consequences related to servicemembers' participation in deployments. 

We reviewed this draft policy and found that it addresses the types
of medical surveillance problems experienced during the Gulf War--the
lack of personnel deployment information and medical assessments, the
failure to monitor environmental and disease health threats, and the
failure to meet record-keeping requirements.  Specifically, the draft
policy instruction assigns responsibilities as follows: 

  -- Assigns to the Defense Manpower Data Center (DMDC) the
     responsibility for collecting and maintaining information,
     available for dissemination on a daily basis, on each
     servicemember deployed to a theater, the length of time the
     servicemember was deployed, and the exact location within the
     theater of that member's unit. 

  -- Specifies that the Commander in Chief (CINC) and the Joint Task
     Force (JTF) Surgeon deploy technically specialized units with
     the capability and expertise required to identify infectious and
     environmental diseases, make health hazard assessments, and do
     advanced diagnostic testing. 

  -- Requires the military services and the CINCs to conduct
     predeployment medical assessments, to include assessing mental
     health and drawing blood samples. 

  -- Requires the CINC Surgeon and the JTF Surgeon to conduct
     postdeployment medical assessments at the time of redeployment
     or within 30 days of final departure, to include assessing
     mental health and drawing blood samples.  For both the
     predeployment and the postdeployment medical assessments, the
     policy calls for the assessment forms to be forwarded to a
     single office within DOD for centralized collection purposes and
     to allow future analyses. 

  -- Directs the CINC Surgeon and the JTF Surgeon to ensure that
     medical records are accurately kept and health-related events
     are documented during deployment.  Specifically suggested are
     records of predeployment and postdeployment assessments and all
     health interventions (which would include all immunizations). 

The draft directive and implementing instruction are currently under
review by various offices within DOD.  DOD officials expect the
directive and instruction to be issued by September 1997.  The
responsible offices are required to develop the necessary
implementing documents within
180 days of the directive's effective date. 


   DOD'S IMPLEMENTATION OF A
   MEDICAL SURVEILLANCE PLAN IN
   OPERATION JOINT ENDEAVOR
------------------------------------------------------------ Letter :4

While DOD was still developing its joint medical surveillance policy
for deployments, the Assistant Secretary of Defense for Health
Affairs issued, in January 1996, a medical surveillance plan for U.S. 
forces deploying to Bosnia-Herzegovina, Croatia, and Hungary under
Operation Joint Endeavor.  This medical surveillance plan encompassed
the concepts under consideration in the draft joint policy, was
developed by a triservice working group, and was coordinated by the
Joint Staff with the services.  It was designed to reflect the
lessons learned from the Gulf War and to address the potential health
risks in the Bosnian theater.  According to DOD officials, this
DOD-wide, centrally managed medical surveillance plan was the first
DOD had developed for a deployment of U.S.  forces.  The strategy for
implementing the plan was determined by the service Surgeons General,
the Joint Staff, and the European Command Surgeon. 

Using the four major elements of a military medical surveillance
system described earlier, we examined DOD's and the services'
implementation of the Operation Joint Endeavor medical surveillance
plan. 


      IDENTIFYING DEPLOYED
      SERVICEMEMBERS AND TRACKING
      THEIR MOVEMENTS IN THEATER
---------------------------------------------------------- Letter :4.1

The ability to identify the population at risk is an essential part
of an effective military medical surveillance system.  It is
important to know which servicemembers deployed to the theater and
where they were located within the theater during the deployment. 
This information is needed to facilitate monitoring and analysis of
how changes in the servicemembers' health status is related to
various environmental, biological, chemical, or other health threats. 
Our review indicated that DOD continues to experience problems with
its capability to track the population at risk during deployments. 

In researching the Persian Gulf War illnesses, the Institute of
Medicine and the Presidential Advisory Committee reported that
inaccurate information on the location of servicemembers in the
theater presented problems in identifying exposures to various health
threats.  Both recommended that DOD improve its ability to track the
location of units in the theater.  DOD established systems to
identify the location of units during the Gulf War; however, the
research groups reported that their use for epidemiological studies
was limited because the systems did not provide information at the
individual servicemember level.  During the Gulf War, servicemembers
frequently did not remain with their units. 

DOD established a system, used in Operation Joint Endeavor, to
identify which servicemembers deployed to the theater.  The services
are required to supply deployment data to the DMDC in Monterey,
California, which is responsible for maintaining a database on those
servicemembers who are deployed. 

In determining the extent to which the services had done the required
postdeployment medical assessments, we used the Army's deployment
data and did not find any errors about which servicemembers had
deployed.\4 However, DOD officials expressed their concerns about the
accuracy of the deployment database for Air Force and Navy personnel. 
Air Force officials told us that the Air Force had supplied
information to DMDC on servicemembers it planned to deploy.  These
servicemembers were added to the DMDC database, but many never
actually deployed.  We were also told that the Navy's personnel
deployment data were inaccurate because elements of two construction
battalions (at least 200 servicemembers) that deployed to Operation
Joint Endeavor do not appear in the DMDC database.  DOD officials
told us that they have also frequently heard concerns about the
accuracy of the deployment database and met in mid-March 1997 with
representatives from the services, DMDC, and other offices to discuss
ways to correct the problems. 

While the DMDC database provides information on which units and which
personnel within those units deploy to a theater, DOD has not yet
developed a system for accurately tracking the movement of individual
servicemembers in units within the theater.  This capability is
important for accurately identifying exposures of servicemembers to
health hazards in the theater. 


--------------------
\4 While we did not find any instances where Army servicemembers
shown in the deployment database as deploying under Operation Joint
Endeavor did not, in fact, deploy, we did not examine whether
additional servicemembers may have deployed who were not included in
the deployment database. 


      CAPABILITY TO ASSESS AND
      TEST FOR HEALTH HAZARDS AND
      MONITOR THEIR OCCURRENCE
      DURING DEPLOYMENTS
---------------------------------------------------------- Letter :4.2

A military medical surveillance program should contain mechanisms for
identifying the potential health and environmental hazards that
deploying troops will encounter in the theater.  Such information can
then be used to develop effective preventive countermeasures and
identify those exposed to these threats.  During the Gulf War, DOD
did little prospective monitoring of environmental health threats in
the theater and had no systematic means of tracking and centrally
reporting the occurrence of diseases and nonbattle injuries during
the war. 


         ENVIRONMENTAL HEALTH
         THREAT ASSESSMENTS
-------------------------------------------------------- Letter :4.2.1

In its 1996 report, the Institute of Medicine recommended that, in
preparing for deployments, DOD should monitor the environment for
possible health threats and prepare for rapid response and
investigation and collect accurate data on exposures to those threats
in the theater of operations. 

Prior to deployments, DOD identifies diseases/illnesses common to the
environment in the theater and informs medical personnel and
deploying troops on ways to avoid or protect themselves from these
diseases/illnesses.  According to DOD officials, a predeployment
assessment of potential health hazards in the Operation Joint
Endeavor theater indicated that diseases such as tick-borne
encephalitis, hemorrhagic fever, typhus, and lyme disease could be
problems.  A tick-borne encephalitis vaccine was offered to those
military personnel who might be in danger of contracting the disease
because of their proximity to ticks.  In addition, troops were
advised on ways to best protect themselves from the other diseases,
and medical personnel were instructed to be particularly alert for
symptoms that might indicate that a servicemember had one of the
diseases/conditions.  Of the potential diseases/illnesses identified,
only one case of hemorrhagic fever was diagnosed, and the patient was
successfully treated. 

The establishment in 1994 of the U.S.  Army Center for Health
Promotion and Preventive Medicine (USACHPPM) has been a major
enhancement to DOD's ability to perform environmental monitoring and
tracking since the Gulf War.  This capability was augmented in
October 1995 with the establishment of the 520th Theater Army Medical
Laboratory.  This laboratory is a deployable public health laboratory
that can provide environmental sampling and analysis in theater.  The
sampling results can then be used to determine what specific
preventive measures and safeguards should be taken to protect troops
from harmful exposures and to develop procedures to treat anyone
exposed to health hazards. 

Early in the planning for Operation Joint Endeavor, the Armed Forces
Medical Intelligence Center identified potential environmental health
threats in Bosnia-Herzegovina as coming primarily from exposures to
air, water, and soils contaminated by hazardous industrial waste.  In
recognition of these potential threats, the Army laboratory was sent
to Bosnia-Herzegovina to assist deployed preventive medicine units
and to monitor environmental health hazards.  While the laboratory
was preparing for the mission, USACHPPM deployed an advance
monitoring team to the theater in January 1996 to begin sampling the
soil and water in the Tuzla area, where most of the U.S.  forces were
to be located.  The laboratory arrived on-site in February 1996 and
began conducting more extensive air, water, soil, and other
environmental monitoring.  In June 1996, USACHPPM augmented the
laboratory's efforts with additional air monitoring stations at nine
regional locations in the theater where troops were concentrated. 
Through January 14, 1997, 2,564 air, water, and soil samples were
taken, from which more than 112,000 reportable analyses were done. 
The results of the sampling indicated that no significant health
risks were posed from the water, air, or soil in the theater but that
prudent field sanitation measures should be taken. 

The information USACHPPM obtains through its air, soil, and water
sampling is entered into a database, which is then linked with DMDC's
information on the units deployed to the theater.  Using mapping data
obtained from the National Imaging and Mapping Agency, USACHPPM
analysts can then identify which units, if any, are in the most
danger of exposure to environmental contaminants.  Using this method,
which was developed in response to the Gulf War oil fires, and which
USACHPPM refers to as its Geographical Information System, DOD can
calculate the degree of risk to specific units at specific theater
locations and recommend preventive actions, as necessary.  Also, on a
retrospective basis, USACHPPM can also identify which units in the
theater might have been exposed to other types of health threats,
such as chemical, biological, or contagious disease threats. 
However, the troop location information is available only down to the
unit level; information on specific locations of individuals within
given units is still not available. 


         MONITORING OF DISEASES
         AND NONBATTLE INJURIES
-------------------------------------------------------- Letter :4.2.2

During the Gulf War, DOD did not systematically track, monitor, and
report the types and numbers of diseases and nonbattle injuries
experienced by servicemembers.  Recognizing that such information
would be useful, DOD's Joint Staff mandated in January 1993 that
weekly reports on the rates of diseases and nonbattle injuries be
provided to appropriate commanders during all deployments.  This is
being done during Operation Joint Endeavor.  A major purpose of the
program is to detect diseases and nonbattle injuries before they
become major outbreaks and thereby limit the services' capabilities
to carry out their missions. 

The weekly reports are categorized into 15 different areas such as
respiratory problems, orthopedic injuries, and unexplained fevers. 
Miscellaneous/administrative visits can also be reported to track
immunizations, prescription refills, physical examinations,
laboratory tests, and follow-up visits.  The data are summarized into
theater-wide illness and injury trends so that preventive measures
can be identified and forwarded to appropriate theater/field
commanders to alert them to any abnormal trends or to actions that
should be taken. 

DOD officials believe the predeployment assessment of environmental
health hazards, the environmental sampling, and the medical
surveillance monitoring done during Operation Joint Endeavor have
enabled better tracking and medical troop surveillance than that
available during the Gulf War.  In addition, they believe the
capabilities now available through USACHPPM and the Army laboratory,
capabilities that were not available during the Gulf War, have
greatly improved DOD's ability to monitor and track environmental
threats and exposures. 


      ABILITY TO IDENTIFY CHANGES
      IN SERVICEMEMBERS' HEALTH
      STATUS DURING DEPLOYMENT
---------------------------------------------------------- Letter :4.3

Military medical surveillance should include the identification of
changes in the health status of servicemembers during and after a
deployment.  Baseline information on the status of servicemembers'
health before they deploy is highly desirable in determining whether
their health status changed during a deployment.  Predeployment and
postdeployment medical assessments, including blood samples, provide
for a comparison from which postdeployment epidemiological analyses
can be done.  Collecting and maintaining a centralized database of
such medical assessment data also facilitate such analyses. 

During the Gulf War, the absence of data on servicemembers' health,
including both baseline health information and postdeployment health
status information, greatly complicated the epidemiological research
done by the Institute of Medicine and the Presidential Advisory
Committee following the war. 


         PREDEPLOYMENT MEDICAL
         ASSESSMENTS
-------------------------------------------------------- Letter :4.3.1

DOD's medical surveillance plan did not require the collection of
baseline health status information on servicemembers who deployed
during Operation Joint Endeavor.  Rather, the services were required
to follow their existing service requirements for ensuring that all
personnel were medically fit for deployment. 

Initially, in developing the medical surveillance plan, DOD officials
considered collecting a predeployment blood sample for all deploying
servicemembers.  However, this approach was not followed, according
to DOD officials, because (1) DOD already had blood samples that had
been drawn during the services' periodic testing for the Human
Immuno-deficiency Virus (HIV), (2) many servicemembers had already
deployed when the collection was being discussed, and (3) the
collection of blood samples would have been logistically difficult. 
DOD officials considered the blood samples drawn for the HIV testing
to be acceptable baseline samples. 

Our review, however, found that predeployment blood samples were not
available for many servicemembers who deployed under Operation Joint
Endeavor and that many of the blood samples, in the repository for
servicemembers who deployed, were quite old.  More specifically, data
from USACHPPM, which oversees the blood repository, show that
predeployment blood samples are not available for 2,476 (9.3 percent)
of the 26,621 servicemembers who had deployed to Bosnia-Herzegovina
as of March 12, 1996.  Also, the data show that the last blood
samples for 9,266 (38.4 percent) of the 24,145 predeployment blood
samples were more than 24 months old.  Moreover, the data show that
the last blood samples for 1,544 (6.4 percent) of the predeployment
blood samples were more than
5 years old.  DOD's draft medical surveillance policy requires a new
blood sample to be drawn prior to a servicemember's deployment when
the last blood sample is over a year old.  Therefore, the age of
these blood samples raises questions as to their reliability as
predeployment baseline samples. 


         POSTDEPLOYMENT MEDICAL
         ASSESSMENTS
-------------------------------------------------------- Letter :4.3.2

Postdeployment medical assessments were required for servicemembers
who deployed to Bosnia-Herzegovina, Croatia, and Hungary.  However,
based on our review of documentation in both the Deployment
Surveillance Team's database and the servicemembers' medical records
we reviewed, we concluded that the required assessments were not done
for many Army personnel.  Moreover, in those instances where
postdeployment medical assessments were done, they were done much
later than required. 

For those deployed under Operation Joint Endeavor, two postdeployment
medical assessments were to be done--one assessment was to be done in
theater shortly before the servicemembers redeployed to their home
station and the other at the home station within 30 days of leaving
the theater.  The assessments consist of the servicemember's
responses to a series of questions to be answered by the
servicemember covering the member's general health status.  After
completion by the servicemember, a health care provider was required
to review the responses to the questions and refer the servicemember
for further evaluation, if appropriate.  At the time of the
in-theater postdeployment medical assessment, medical personnel were
required to collect a blood sample and send it to the central blood
repository in the United States.  If this blood sample was not
collected during the in-theater postdeployment medical assessment
process, it was to be collected at the time of the home unit
postdeployment medical assessment.  Postdeployment requirements also
included administering a battery of mental health questionnaires
designed to identify servicemembers needing further psychological
evaluation.  Tuberculin skin tests were also required at the
servicemembers' home stations soon after 90 days of departure from
the theater.  Tuberculosis was considered a potential health threat
in the theater. 

Our review of the Deployment Surveillance Team's database for the
6,624 Army personnel in our universe requiring medical assessments
indicated that 43 percent of the personnel had not received the
required in-theater postdeployment medical assessment, 82 percent had
not received the home unit postdeployment medical assessment, and 41
percent did not have a postdeployment blood sample drawn.\5 Only 429
(6.5 percent) servicemembers met all three requirements--the
in-theater and home unit postdeployment medical assessments and a
postdeployment blood sample drawn and in storage.  We also found that
1,889 (28.5 percent) had not met any of the three requirements.  The
Deployment Surveillance Team's database does not collect information
on the extent to which the tuberculin tests are done at the home
unit. 

During our review of the medical documentation for 618 servicemembers
in 12 selected Army units requiring postdeployment medical
assessments, we found no evidence that the required medical
assessments were conducted for many servicemembers.\6 More
specifically, as shown in
table 2, about 24 percent did not receive the in-theater
postdeployment medical assessment, 21 percent did not receive the
home unit postdeployment medical assessment, 34 percent did not have
a postdeployment blood sample drawn, and 32 percent did not receive
the required tuberculin test. 



                                Table 2
                
                 Medical Assessments for Selected Army
                       Units (as of Feb. 6, 1997)

                                  No in-   No home
                                 theater      unit
                                 medical   medical  No blood        No
                       Records  assessme  assessme    sample  tubercul
Unit                  reviewed        nt        nt     drawn   in test
--------------------  --------  --------  --------  --------  --------
A                           63        12        27        11        42
B                           80         9        13        10        14
C                           66        58        10        59        16
D                           36         7        11        12         9
E                           49         5        16        25        17
F                           48        14         4        33         4
G                           43         7         1         7        12
H                           55         6        17         1        37
I                           46         4         6         4        17
J                           52         4         6        12        11
K                           48        12        13        13        15
L                           32         7         3        22         3
======================================================================
Total                      618       145       127       209       197
Percentage                          23.5      20.6      33.8      31.9
----------------------------------------------------------------------
Of the 618 servicemembers whose medical records we reviewed, only
206, or one-third, had met all four requirements--the in-theater
medical assessment, the home unit medical assessment, the tuberculin
test, and a postdeployment blood sample drawn.  Conversely, 20 (about
3 percent) of the 618 servicemembers had not met any of the four
requirements. 

Different reasons were cited for lack of (1) in-theater medical
assessments and (2) unit medical assessments and the tuberculin tests
conducted at the home unit.  According to Army medical officials in
Germany, the in-theater problem was due to the lack of a centralized
out-processing mechanism for redeploying personnel; whereas the home
unit problem was due to unit commanders not giving enough emphasis to
the medical assessment requirements.  More specifically, the U.S. 
Army Europe (USAREUR) Surgeon attributed the lack of in-theater
medical assessments for Army personnel redeploying to their home
units before August 1996 to the lack of a fully functioning central
out-processing point for redeploying personnel to ensure that they
received the required assessments.  Beginning in August 1996, all
Army personnel redeploying to their home unit from
Bosnia-Herzegovina, Croatia, and Hungary were required to go through
an intermediate staging base in Hungary, where medical assessments
were done.  For redeployments, the USAREUR Surgeon believes that
compliance with the requirement for in-theater medical assessments
would be higher after the staging base became operational.  We did
not validate whether these improvements, in fact, occurred. 

Officials with several medical units responsible for the Army units
we reviewed told us that they have no direct authority over the unit
personnel to require them to obtain the postdeployment medical
assessments or tuberculin tests.  They must rely on unit commanders
to require their personnel to go to the medical clinic for the
assessments. 

Further, home unit medical assessments and the tuberculin test, when
done, were frequently done much later than required.  The home unit
postdeployment medical assessments are required to be conducted
within 30 days of servicemembers' departure from the theater.  The
30-day time frame was established to ensure that the required medical
assessments are done soon after servicemembers return to their home
unit and, from an epidemiological standpoint, if medical problems
exist, to be better able to associate the medical problems to the
members' service while deployed.  As shown in table 3, most of the
home unit medical assessments that were completed for the selected 12
Army units were done much later than the 30 days required--averaging
98 days following departure from the theater.  Similarly, the
tuberculin tests, required to be done soon after 90 days of the
members' departure from the theater, if done, were done later--an
average of 142 days. 



                                Table 3
                
                Timeliness (average days from departure
                 from theater) for the Army's Home Unit
                 Postdeployment Medical Assessments and
                Tuberculin Tests for Selected Army Units

                                             Average days
                                --------------------------------------
                                 Home unit medical     Tuberculin test
                                   assessment (30-             (90-day
Unit                              day requirement)        requirement)
------------------------------  ------------------  ------------------
A                                            178.8               173.9
B                                             95.1               109.0
C                                            212.0               236.9
D                                             76.8               113.6
E                                             33.9               131.2
F                                             58.9               133.6
G                                             11.4               104.5
H                                             48.1               125.0
I                                             17.3               106.9
J                                             85.0               123.3
K                                            178.8               159.2
L                                            169.2               166.1
Average for all units                         98.6               142.0
----------------------------------------------------------------------
Such delays in doing the home unit medical assessments, particularly
if the assessment also involves the drawing of a postdeployment blood
sample, pose concerns regarding epidemiological analyses.  With such
delays, it is much more difficult to isolate which health problems
were attributable to members' service during deployments and which
were contracted after their return to home stations.  Also, the delay
in doing the assessments could delay the referral of the
servicemember for further evaluation and treatment based on this
medical assessment. 

Our review of medical records may have resulted in more medical
assessments being done than would otherwise have occurred.  In fact,
we were told that our planned review of medical records in Germany,
which was announced in December 1996, encouraged certain units to
complete their home unit postdeployment medical assessments and
tuberculin tests in anticipation of our arrival.  Four of the 12
units (units A, C, K, and L) completed over 80 percent of the
required home unit postdeployment medical assessments and tuberculin
tests in January and February 1997, even though the servicemembers
had returned to their home units
5 to 8 months earlier.  This delay explains much of the timeliness
problems experienced by these units discussed earlier.  As shown in
table 4, the percentage of Army personnel who did not have the home
unit postdeployment medical assessment and the tuberculin test was
much higher as of December 31, 1996, before our medical records
review--increasing from 20.6 percent to 44.5 percent for home unit
postdeployment medical assessments and from 31.9 percent to 58.7
percent for tuberculin tests. 



                                Table 4
                
                 Medical Assessments for Selected Army
                      Units (as of Dec. 31, 1996)

                                           No home unit
                                 Records        medical  No tuberculin
Unit                            reviewed     assessment           test
-------------------------  -------------  -------------  -------------
A                                     63             57             50
B                                     80             13             14
C                                     66             51             59
D                                     36             11             12
E                                     49             16             46
F                                     48              8             20
G                                     43              1             13
H                                     55             17             37
I                                     46              6             17
J                                     52             15             26
K                                     48             48             39
L                                     32             32             30
======================================================================
Total                                618            275            363
Percentage                                         44.5           58.7
----------------------------------------------------------------------

--------------------
\5 The Deployment Surveillance Team's database may understate the
extent to which the in-theater and home unit postdeployment medical
assessments were conducted based on the results of our review of
medical records for selected Army units. 

\6 Documentation reviewed included data in both the Deployment
Surveillance Team database and the servicemember's permanent medical
record.  Our analysis reflects the existence of in-theater and home
unit postdeployment medical assessments in either the Deployment
Surveillance Team database or the servicemembers' medical records. 


         CENTRALIZED COLLECTION OF
         ASSESSMENT DATA
-------------------------------------------------------- Letter :4.3.3

A complete and accurate database is needed to effectively monitor the
extent to which required medical assessments are done.  The medical
surveillance plan includes provisions for the centralized collection
and maintenance of a database for the in-theater and home unit
postdeployment medical assessments done for servicemembers deployed
under Operation Joint Endeavor.  The medical units processing the
in-theater and home unit medical assessments are required to send
copies of the assessment forms to DOD's Deployment Surveillance Team. 
The team uses the data to prepare statistical reports on how well the
medical assessment program is being implemented. 

We tested the completeness of the surveillance team's centralized
database for the in-theater and home unit postdeployment medical
assessments conducted for the 618 servicemembers whose medical
records we reviewed.  We found that the database was incomplete for
both assessments--understating considerably the number of home unit
medical assessments done.  More specifically, the database omitted 57
(12 percent) of the 473 in-theater medical assessments done and 174
(52 percent) of the 332 home unit medical assessments done for the
618 service members whose medical records we reviewed.\7


--------------------
\7 Our analyses reflected the completeness of the database as of
January 21, 1997, for in-theater medical assessments completed before
September 1, 1996, and for home unit medical assessments completed
before December 1, 1996.  This provided a minimum of almost 2 months
for the medical assessment forms to be sent from Germany and
incorporated into the Deployment Surveillance Team's database. 


      COMPLETE AND ACCURATE
      MEDICAL RECORDS
---------------------------------------------------------- Letter :4.4

Complete and accurate medical records documenting all medical care
for the individual servicemember are essential for the delivery of
high quality medical care.  They are also important for
epidemiological analyses following military deployments. 

The Presidential Advisory Committee and the Institute of Medicine
reported problems concerning the completeness and accuracy of medical
record-keeping during the Gulf War.  During the Gulf War,
interactions between the deployed forces and medical care providers
in the theater were frequently not recorded in servicemembers'
permanent medical records.  This problem was particularly common for
immunizations given in the theater.  The Institute of Medicine
characterized DOD's and the Department of Veterans Affairs' medical
records systems as fragmented, disorganized, and incomplete. 

Under the Operation Joint Endeavor medical surveillance plan,
postdeployment in-theater and home unit medical assessment forms are
required to be included in servicemembers' permanent medical records. 
Similarly, Army regulations require documentation in servicemembers'
permanent medical records of all immunizations received in theater
and visits made by servicemembers to health units such as battalion
aid stations.\8 Because the tick-borne encephalitis vaccine is
classified by the Food and Drug Administration as an investigational
drug, specific requirements apply for documenting its use in
servicemembers' medical records. 

We tested the completeness of the permanent medical records for
selected Army active duty servicemembers who had deployed under
Operation Joint Endeavor.  Our review disclosed that many of the
medical records were incomplete regarding documentation reflecting
that (1) in-theater medical assessments were conducted, (2)
servicemembers had received the tick-borne encephalitis vaccine, and
(3) visits had been made by servicemembers to battalion aid stations. 
All of these documentation problems pertain to medical care in the
theater. 

Regarding postdeployment medical assessments, we found that 91 (19
percent) of the 473 servicemembers with a postdeployment in-theater
medical assessment and 9 (1.8 percent) of the 491 servicemembers with
a postdeployment home unit medical assessment did not have the
assessments documented in their medical records. 

USAREUR Surgeon officials attributed these documentation problems to
the practice of allowing servicemembers to hand-carry the in-theater
assessment forms to their home unit for insertion to their permanent
medical records.  The officials said the assessment forms were
frequently lost.  We noted that such documentation problems occurred
less frequently for the home unit medical assessments because they
were done at the home unit and as such did not need to be forwarded
from the theater to the servicemembers' home units. 

During the deployment to Bosnia, servicemembers deploying to regions
with a threat of tick-borne encephalitis were given the choice of
being vaccinated with an investigational drug vaccine.\9 To determine
whether the medical records included documentation of servicemembers
receiving the vaccine, we obtained a list from the U.S.  Army Medical
Research Institute of Infectious Diseases (USAMRIID)\10 of
servicemembers that received the vaccine and reviewed 588 medical
records of servicemembers in selected Army units shown as having
received the vaccine.  As shown in table 5, 141 (24 percent) of these
servicemembers' permanent medical records did not document the
vaccinations. 



                                Table 5
                
                Documentation of Tick-Borne Encephalitis
                    Vaccinations in Servicemembers'
                       Permanent Medical Records

                                                     No     Percentage
                           Number taking  documentation         not in
                             the vaccine     in medical        medical
Unit                        per USAMRIID        records        records
-------------------------  -------------  -------------  -------------
I                                     96             29           30.2
M                                     55             19           34.6
N                                    135             22           16.3
O                                    176              7            4.0
P                                    126             64           50.8
======================================================================
Total                                588            141           24.0
----------------------------------------------------------------------
To test the completeness of the permanent medical records for visits
made to battalion aid stations by servicemembers while deployed to
Bosnia-Herzegovina during Operation Joint Endeavor, we selected
50 entries from the sign-in logs for three battalion aid stations and
reviewed those members' medical records for documentation of the
visit.  As shown in table 6, about 29 percent of the battalion aid
station visits were not documented in the members' permanent medical
records. 



                                Table 6
                
                 Documentation of Battalion Aid Station
                  Visits in Permanent Medical Records

                               Number of
                           battalion aid             No     Percentage
                                 station  documentation         not in
                                  visits     in medical        medical
Unit                            reviewed        records        records
-------------------------  -------------  -------------  -------------
F                                     50             12           24.0
M                                     50             20           40.0
N                                     50             12           24.0
======================================================================
Total                                150             44           29.3
----------------------------------------------------------------------
Army medical officials pointed out that servicemembers had deployed
to the theater only with an abstract of their permanent medical
records and that any medical documentation generated in the theater
should have been routed back to the servicemembers' home units for
inclusion in their medical records, but in many instances, this did
not occur.  They also mentioned that permanent medical records are
still essentially kept in a paper-based system and are therefore
subject to having information misfiled or lost. 

To address medical documentation problems, the Presidential Advisory
Committee recommended that DOD direct its attention toward
computerizing its theater medical records.  An Assistant Surgeon
General of the Army also told us that he believes the solution to
such documentation problems is the development of a deployable
computerized patient record.  DOD has a project underway with the
goal to have a paperless, filmless computerized medical record for
every servicemember, while on active duty, by fiscal year 2000. 
Further objectives of the project are to standardize medical
record-keeping DOD-wide; ensure that medical record information is
complete, accurate, and available when needed; and prevent active
duty members with disqualifying conditions from being deployed.  In
addition, plans call for the computerized medical record to document
and update the baseline health status of each active duty member,
support the recognition of deployment-related illnesses, and provide
a mechanism for reporting the medical readiness of the active duty
force. 

Recognizing that DOD's paper-based medical records are not sufficient
to support the growing interest in epidemiology driven by the Gulf
War experience, the project officials recommended the development of
some type of electronic mechanism to capture health service data for
each active duty member at all echelons of care during military
operations.  Several options for obtaining and recording the
necessary information are being considered, but the basic concept
involves providing each servicemember with a computerized card or tag
that can receive and store computerized health information.  When the
member reports to a medical unit for care, the card can be updated
with the member's complaint, diagnosis, and treatment (including
X-rays).  This information would be collected by computer and
reported to a central location by the medical unit to allow for
overall summarization of medical problems and treatments in a given
theater. 

Long-term recommendations of project officials call for deploying a
triservice computerized patient record throughout DOD by fiscal year
2000.  Also recommended is the establishment of linkages to external
systems through the inclusion of a global positioning history for
each individual.  Such a record could support the geographical
location history developed and being refined by USACHPPM and assist
in prospective or retrospective data analysis of factors such as
chemical/biological risk exposures to specific troops in the theater. 


--------------------
\8 A battalion aid station, which is integral to all combat
battalions, provides forward battlefield medical care such as
immediate emergency treatment, evacuation and clinical stabilization
of sick and injured servicemembers, and routine outpatient medical
care. 

\9 An investigational drug is a new drug, antibiotic drug, or
biological drug or product that has not been licensed by the Food and
Drug Administration for general use in the United States.  As such,
the Food and Drug Administration regulates its use. 

\10 USAMRIID maintains a list of servicemembers that received the
tick-borne encephalitis vaccine. 


   DOD'S IMPLEMENTATION OF A
   MEDICAL SURVEILLANCE PLAN IN
   SOUTHWEST ASIA
------------------------------------------------------------ Letter :5

In December 1996, the CINC, U.S.  Central Command, issued guidance
that included medical surveillance requirements for all forces
deployed in Southwest Asia.  This guidance is similar to the medical
surveillance plan for Operation Joint Endeavor.  While implementation
of the medical surveillance plan for Southwest Asia began only
recently in January 1997, a Joint Staff official told us the plan is
being implemented.  The official said that an epidemiology team and
the Navy's forward medical laboratory were deployed to the theater to
provide on-site medical surveillance.  In addition, the official said
that predeployment and postdeployment medical assessments are being
conducted for the servicemembers in the Southwest Asia theater.  We
did not test, however, the services' implementation of the Southwest
Asia medical surveillance requirements. 

DOD officials told us that they delayed issuing a specific medical
surveillance plan for Southwest Asia because DOD was developing a
joint medical surveillance policy that would cover such deployments. 
However, when the time required to develop a joint policy took longer
than expected, the Joint Staff encouraged the CINC (U.S.  Central
Command) to issue specific medical surveillance requirements for the
deployment. 

Prior to the issuance of the December 1996 guidance, DOD had
conducted some medical surveillance activities, including
environmental sampling, in the Southwest Asia theater but had not
required medical assessments and postdeployment blood samples for
servicemembers deployed there.  We believe that the delay in
requiring medical assessments and postdeployment blood samples raises
concerns, given that U.S.  forces have been deployed to this region
continuously since the end of the Gulf War and many veterans who
served in this region began to complain of medical problems soon
after the end of the conflict. 


   CONCLUSIONS AND RECOMMENDATIONS
------------------------------------------------------------ Letter :6

Overall, DOD has taken initiatives to overcome the medical
surveillance problems experienced during the Gulf War.  It is evident
that positive steps have been taken to establish a joint policy that
will emphasize the importance of medical surveillance and provide for
a more uniform approach for doing such surveillance in future
deployments.  DOD's recent experience in Operation Joint Endeavor,
during which it tried to institute corrective policies and processes
to overcome problems experienced during the Gulf War, provides
lessons learned that DOD can apply in its ongoing efforts to develop
a DOD-wide joint medical surveillance policy.  However, the joint
policy has been under development for over 2 years. 

Some of the problems we found in implementing the medical
surveillance during Operation Joint Endeavor--the failure to assess
all servicemembers' health in theater and after return to their home
units and to consistently document medical care provided in
theater--raise serious questions about DOD's ability to effectively
implement medical surveillance policies during another high-conflict
deployment like the Gulf War.  We recognize that complete
record-keeping may be more difficult during times of high intensity
combat activities; however, complete record-keeping is still
necessary for an effective medical surveillance system. 

In light of the problems discussed in this report, we recommend that
the Secretary of Defense direct the Assistant Secretary of Defense
for Health Affairs, along with the military services, the Joint
Chiefs of Staff, and the Unified Commands, as appropriate, to

  -- complete expeditiously and implement a DOD-wide policy on
     medical surveillance for all major deployments of U.S.  forces,
     using lessons learned during Operation Joint Endeavor and the
     Gulf War;

  -- develop procedures to ensure that medical surveillance policies
     are implemented to include emphasizing (a) the need for unit
     commanders to ensure that all servicemembers receive the
     required medical assessments in a timely manner and (b) the need
     for medical personnel to maintain complete and accurate medical
     records; and

  -- develop procedures for providing accurate and complete medical
     assessment information to the centralized database. 

We also recommend that the Secretary of Defense direct the Deputy
Under Secretary of Defense for Requirements and Resources to
investigate the completeness of information in the DMDC personnel
deployment database and take corrective actions to ensure that the
deployment information is accurate for servicemembers who deploy to a
theater. 


   AGENCY COMMENTS AND OUR
   EVALUATION
------------------------------------------------------------ Letter :7

In commenting on a draft of this report, DOD agreed with the accuracy
of the report.  It agreed that substantial improvements in medical
surveillance and record-keeping were needed based on the Gulf War
experience and that some improvements in these areas were applied in
the deployment to Bosnia.  Likewise, DOD stated that it will apply
the lessons from the Bosnia deployment to refine its policy for
future medical surveillance during deployments. 

DOD concurred with each of our four recommendations and stated that
with the support of the services, the Chairman of the Joint Chiefs of
Staff, and the intelligence community, it will aggressively work to
continue to make improvements.  For example, DOD stated that, in
August 1997, it will disseminate the DOD instruction and directive
establishing a DOD-wide policy on medical surveillance.  DOD also
indicated that it has reviewed its master personnel database
deficiencies and developed recommendations to improve its ability to
maintain accurate information on servicemembers who deploy.  DOD
indicated that on February 10, 1997, a message was sent to all
unified commanders reemphasizing the importance of a comprehensive
medical surveillance program to ensure force readiness and
sustainment.  DOD noted that it has standardized predeployment and
postdeployment questionnaires and has started an automation
initiative to enhance accuracy of the centralized database. 

We believe these initiatives, if properly implemented, could greatly
enhance the medical surveillance program.  However, DOD's response
did not indicate what its specific procedures will be for
institutionalizing these efforts to ensure that all medical
surveillance requirements will be met.  For example, further
procedural improvements would be needed to routinely monitor units'
compliance with the medical surveillance requirements and
periodically evaluate the accuracy and completeness of the
centralized database. 

DOD's comments are presented in appendix II. 


---------------------------------------------------------- Letter :7.1

We are sending copies of this report to the Chairmen and Ranking
Minority Members, Senate and House Committees on Appropriations; the
Secretaries of Defense, the Army, the Navy, and the Air Force; and
the Chairman, Joint Chiefs of Staff.  Copies will also be made
available to others upon request. 

Please contact me at (202) 512-5140 if you or your staff have any
questions concerning this report.  Major contributors to this report
are listed in appendix III. 

Mark E.  Gebicke
Director, Military Operations
 and Capabilities Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

For this report, we interviewed officials and obtained pertinent
documentary evidence from officials at the Office of the Assistant
Secretary of Defense for Health Affairs; the Joint Staff; and the
Offices of the Surgeons General at Army, Navy, and Air Force
Headquarters in Washington, D.C.  We also interviewed and obtained
documents from officials at the Department of Defense's (DOD)
Deployment Surveillance Team and the Persian Gulf Illness
Investigation Team at Falls Church, Virginia, and from the U.S.  Army
Center for Health Promotion and Preventive Medicine at Aberdeen
Proving Ground, Maryland; the Institute of Medicine's Medical
Follow-up Agency; the Presidential Advisory Committee on Gulf War
Veterans' Illnesses; the Defense Manpower Data Center in Monterey,
California; the U.S.  European Command Surgeon's Office; the U.S. 
Army Europe Surgeon's Office; and the U.S.  Air Force Europe
Surgeon's Office. 

To assess the extent to which the required medical assessments,
described above, were conducted, we (1) obtained information from the
DOD Deployment Surveillance Team's database in Falls Church,
Virginia, and (2) reviewed the medical records for active duty
servicemembers in 12 selected Army units in Germany who deployed to
Operation Joint Endeavor. 

To determine the overall status of DOD's efforts to implement its
Operation Joint Endeavor medical surveillance policy, in January
1997, we requested the Deployment Surveillance Team to provide us
with information from its database showing those servicemembers in
units who deployed to and spent at least 30 days in the countries of
Bosnia-Herzegovina, Croatia, and Hungary from the start of Operation
Joint Endeavor and had returned to their home units by August 31,
1996.  The cutoff date was selected to provide sufficient time for
units to forward in-theater and home unit assessment forms and blood
samples to the United States and have that information entered into
the team's database.  The team then extracted data from its database
showing which of these servicemembers had received the required
assessments and had a postdeployment blood sample in storage at the
central blood repository.  This information showed each service's
overall compliance with the Operation Joint Endeavor medical
surveillance assessment requirements. 

After obtaining this information, we decided to limit our review of
servicemembers' medical records to selected Army units because the
Army is the largest participant of the services in Operation Joint
Endeavor.  To select the Army units from which we would review
servicemembers' medical records, we requested the Deployment
Surveillance Team to sort the deployment data we had requested by
unit, rank-ordered by the units with the largest number of personnel
requiring postdeployment medical assessments, without regard to the
unit's rate of compliance with the requirements.  We then selected
the 12 units in Germany with the largest numbers of personnel
requiring medical assessments.  These selected units provided a range
of different types of units and were located in multiple locations in
central Germany.  At the responsible medical unit for the selected
units, we requested the medical records for those servicemembers on
the Deployment Surveillance Team list who required medical
assessments to be done.  We reviewed the medical records for those
servicemembers who were still in the unit and whose medical records
were not currently in use by the medical unit at the time of our
review.  In reviewing these 618 medical records, we determined
whether the record included an (1) in-theater medical assessment
form, (2) the home unit medical assessment form, and (3)
documentation that the required tuberculin test had been done. 

To determine whether servicemembers who had received the tick-borne
encephalitis vaccine had this documented in their medical records, we
obtained a list from the U.S.  Army Medical Research Institute of
Infectious Diseases of all servicemembers who had received one or
more doses of the vaccine in units who deployed during Operation
Joint Endeavor.  From this list, we selected five units located in
Germany from the listing and reviewed 588 servicemembers' medical
records to determine whether the medical records documented the
vaccinations. 

To determine whether servicemembers' visits to Army battalion aid
stations were documented in the members' permanent medical records,
we selected three battalion aid stations that deployed to
Bosnia-Herzegovina during Operation Joint Endeavor and selected 50
entries from each battalion aid station's sign-in patient logs.  We
then reviewed the medical records of those servicemembers to
determine whether the visits had been documented. 

To ensure that we did not overlook any of the appropriate
documentation in the medical records during our examinations, the
unit medical staff reviewed all of those records in which we could
not find required documentation and verified that our examination was
accurate.  We also discussed reasons for missing documentation in the
medical records with officials at the responsible medical units in
Germany for those units whose medical records we reviewed. 

We conducted our review from October 1996 to April 1997 in accordance
with generally accepted government auditing standards. 




(See figure in printed edition.)Appendix II
COMMENTS FROM THE DEPARTMENT OF
DEFENSE
=========================================================== Appendix I



(See figure in printed edition.)



(See figure in printed edition.)



(See figure in printed edition.)


MAJOR CONTRIBUTORS TO THIS REPORT
========================================================= Appendix III

NATIONAL SECURITY AND
INTERNATIONAL AFFAIRS DIVISION,
WASHINGTON, D.C. 

Sharon A.  Cekala, Associate Director
Donald L.  Patton, Assistant Director

NORFOLK FIELD OFFICE

Steve J.  Fox, Evaluator-in-Charge
Lynn C.  Johnson, Evaluator
William L.  Mathers, Evaluator

*** End of document. ***