Gulf War IllnessesProcedural and Reporting Improvements Are Needed in DOD's Investigative Processes Gao ID: NSIAD-99-59 February 26, 1999
The Defense Department (DOD) has made progress in comprehensively addressing Gulf War illness issues. Its outreach program, which has established a toll-free hotline, a Web site, and a newsletter, has cleared a large backlog of veterans inquiries. It has also helped veterans obtain medical examinations and other services at DOD and VA facilities. Through its investigations and other work, the Office of the Special Assistant for Gulf War Illnesses has called for improvements to DOD's equipment, policies, and procedures and has worked with the military to help better protect U.S. soldiers on a contaminated battlefield. However, in three of the six case narratives (an investigation of soldiers' possible exposures to chemical warfare agents) it reviewed, GAO found such weaknesses as failures to (1) follow up with appropriate individuals to confirm key evidence, (2) identify or ensure the validity of evidence, (3) include important information, and (4) interview key witnesses. In all six cases, the Office did not take advantage of potentially valuable sources of information in DOD's and VA's clinical databases. Despite these weaknesses, GAO agreed with the Office's conclusions about the likelihood of the presence of chemical warfare agents in five of the six cases it reviewed. The one exception involved a Marine Corps personnel who may have been exposed to a chemical warfare agent during a minefield-breaching operation. The Office concluded that exposure in this case was unlikely, although GAO found that the Office had overlooked some information in its possession and did not include all relevant information in its case narrative. GAO believes that the Office should reassess the likelihood of exposure in this case. In GAO's view, the lack of effective quality assurance policies and practices in the Office's investigating and reporting processes contributed to the weaknesses noted.
GAO noted that: (1) DOD has made progress in carrying out its mandate to comprehensively address Gulf-War illnesses-related issues; (2) it has assisted veterans through its outreach program by clearing large backlogs of veterans' inquiries, using a toll-free hot line, setting up a Web site, and publishing a newsletter; (3) in addition, it has assisted veterans in obtaining medical examinations and other services at DOD and Department of Veterans Affairs (VA) facilities; (4) through the course of its investigations and other work, OSAGWI has identified needed improvements in DOD's equipment, policies, and procedures and has worked with various DOD agencies to implement changes designed to provide better protection to U.S. servicemembers on a contaminated battlefield; (5) OSAGWI generally applied appropriate investigative procedures and techniques in conducting its work; (6) however, GAO found that three of the six case narratives it reviewed contained weaknesses such as failures to follow up with appropriate individuals to confirm key evidence, to identify or ensure the validity of some evidence, to include some important information, and to interview some key witnesses; (7) in the remaining three cases, OSAGWI conducted its investigations without evidence of these weaknesses; (8) in all six cases, OSAGWI missed an opportunity to perform more complete investigations because it did not take advantage of potentially valuable sources of relevant information in DOD and VA clinical databases; (9) GAO does not know whether the investigatory and reporting weaknesses it found in its review of these six cases might also exist in the cases that OSAGWI later investigated; (10) despite these weaknesses, GAO agreed with OSAGWI's conclusions about the likelihood of the presence of chemical warfare agents in five of the six cases it reviewed; (11) the one exception involved a potential exposure of U.S. Marine Corps personnel to a chemical warfare agent during a minefield breaching operation; (12) OSAGWI concluded that exposure in this case was unlikely; (13) however, GAO found that OSAGWI had overlooked some information it had in its possession and also did not include all relevant information in its case narrative; (14) after reviewing the overlooked information and considering all relevant information OSAGWI had in its files, GAO believes that OSAGWI should reassess the likelihood of exposure in this case; and (15) GAO believes that the lack of effective quality assurance policies and practices in OSAGWI's investigating and reporting processes contributed to the weaknesses noted.Recommendations
Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.Director: Team: Phone: