Defense Health Care
Improvements Needed in Occupational and Environmental Health Surveillance During Deployments to Address Immediate and Long-Term Health Issues Gao ID: GAO-05-632 July 14, 2005Following the 1991 Persian Gulf War, research and investigations into the causes of servicemembers' unexplained illnesses were hampered by inadequate occupational and environmental exposure data. In 1997, the Department of Defense (DOD) developed a militarywide health surveillance framework that includes occupational and environmental health surveillance (OEHS)--the regular collection and reporting of occupational and environmental health hazard data by the military services. GAO is reporting on (1) how the deployed military services have implemented DOD's policies for collecting and reporting OEHS data for Operation Iraqi Freedom (OIF) and (2) the efforts under way to use OEHS reports to address both immediate and long-term health issues of servicemembers deployed in support of OIF.
Although OEHS data generally have been collected and reported for OIF, as required by DOD policy, the deployed military services have used different data collection methods and have not submitted all of the OEHS reports that have been completed. Data collection methods for air and soil surveillance have varied across the services, for example, although they have been using the same monitoring standard for water surveillance. Variations in data collection have been compounded by different levels of training and expertise among service personnel responsible for OEHS. For some OEHS activities, a cross-service working group has been developing standards and practices to increase uniformity of data collection among the services. In addition, while the deployed military services have been conducting OEHS activities, they have not submitted all of the OEHS reports that have been completed during OIF, which DOD officials attribute to various obstacles, such as limited access to communication equipment to transmit reports for archiving. Moreover, DOD officials did not have the required consolidated lists of all OEHS reports completed during each quarter in OIF and therefore could not identify the reports they had not received to determine the extent of noncompliance. To improve OEHS reporting compliance, DOD officials said they were revising an existing policy to add additional and more specific OEHS requirements. DOD has made progress in using OEHS reports to address immediate health risks during OIF, but limitations remain in employing these reports to address both immediate and long-term health issues. OIF was the first major deployment in which OEHS reports have been used consistently as part of operational risk management activities intended to identify and address immediate health risks and to make servicemembers aware of the health risks of potential exposures. While these efforts may help reduce health risks, DOD has no systematic efforts to evaluate their implementation in OIF. In addition, DOD's centralized archive of OEHS reports for OIF has several limitations for addressing potential long-term health effects related to occupational and environmental exposures. First, access to the centralized archive has been limited due to the security classification of most OEHS reports. Second, it will be difficult to link most OEHS reports to individual servicemembers' records because not all data on servicemembers' deployment locations have been submitted to DOD's centralized tracking database. For example, none of the military services submitted location data for the first several months of OIF. To address problems with linking OEHS reports to individual servicemembers, the deployed military services have made efforts to include OEHS monitoring summaries in the medical records of some servicemembers for either specific incidents of potential exposure or for specific locations within OIF. Third, according to DOD and VA officials, no federal research plan has been developed to evaluate the longterm health of servicemembers deployed in support of OIF, including the effects of potential exposures to occupational or environmental hazards.
RecommendationsOur 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:GAO-05-632, Defense Health Care: Improvements Needed in Occupational and Environmental Health Surveillance During Deployments to Address Immediate and Long-Term Health Issues
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2005.
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Report to the Chairman, Subcommittee on National Security, Emerging
Threats, and International Relations, Committee on Government Reform,
House of Representatives:
July 2005:
Defense Health Care:
Improvements Needed in Occupational and Environmental Health
Surveillance during Deployments to Address Immediate and Long-term
Health Issues:
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-632]:
GAO Highlights:
Highlights of GAO-05-632, a report to the Chairman, Subcommittee on
National Security, Emerging Threats, and International Relations,
Committee on Government Reform, House of Representatives:
Why GAO Did This Study:
Following the 1991 Persian Gulf War, research and investigations into
the causes of servicemembers‘ unexplained illnesses were hampered by
inadequate occupational and environmental exposure data. In 1997, the
Department of Defense (DOD) developed a militarywide health
surveillance framework that includes occupational and environmental
health surveillance (OEHS)”the regular collection and reporting of
occupational and environmental health hazard data by the military
services. GAO is reporting on (1) how the deployed military services
have implemented DOD‘s policies for collecting and reporting OEHS data
for Operation Iraqi Freedom (OIF) and (2) the efforts under way to use
OEHS reports to address both immediate and long-term health issues of
servicemembers deployed in support of OIF.
What GAO Found:
Although OEHS data generally have been collected and reported for OIF,
as required by DOD policy, the deployed military services have used
different data collection methods and have not submitted all of the
OEHS reports that have been completed. Data collection methods for air
and soil surveillance have varied across the services, for example,
although they have been using the same monitoring standard for water
surveillance. Variations in data collection have been compounded by
different levels of training and expertise among service personnel
responsible for OEHS. For some OEHS activities, a cross-service working
group has been developing standards and practices to increase
uniformity of data collection among the services. In addition, while
the deployed military services have been conducting OEHS activities,
they have not submitted all of the OEHS reports that have been
completed during OIF, which DOD officials attribute to various
obstacles, such as limited access to communication equipment to
transmit reports for archiving. Moreover, DOD officials did not have
the required consolidated lists of all OEHS reports completed during
each quarter in OIF and therefore could not identify the reports they
had not received to determine the extent of noncompliance. To improve
OEHS reporting compliance, DOD officials said they were revising an
existing policy to add additional and more specific OEHS requirements.
DOD has made progress in using OEHS reports to address immediate health
risks during OIF, but limitations remain in employing these reports to
address both immediate and long-term health issues. OIF was the first
major deployment in which OEHS reports have been used consistently as
part of operational risk management activities intended to identify and
address immediate health risks and to make servicemembers aware of the
health risks of potential exposures. While these efforts may help
reduce health risks, DOD has no systematic efforts to evaluate their
implementation in OIF. In addition, DOD‘s centralized archive of OEHS
reports for OIF has several limitations for addressing potential long-
term health effects related to occupational and environmental
exposures. First, access to the centralized archive has been limited
due to the security classification of most OEHS reports. Second, it
will be difficult to link most OEHS reports to individual
servicemembers‘ records because not all data on servicemembers‘
deployment locations have been submitted to DOD‘s centralized tracking
database. For example, none of the military services submitted location
data for the first several months of OIF. To address problems with
linking OEHS reports to individual servicemembers, the deployed
military services have made efforts to include OEHS monitoring
summaries in the medical records of some servicemembers for either
specific incidents of potential exposure or for specific locations
within OIF. Third, according to DOD and VA officials, no federal
research plan has been developed to evaluate the long-term health of
servicemembers deployed in support of OIF, including the effects of
potential exposures to occupational or environmental hazards.
What GAO Recommends:
GAO recommends that the Secretary of Defense improve deployment OEHS
data collection and reporting and evaluate OEHS risk management
activities. GAO also recommends that the Secretaries of Defense and
Veterans Affairs (VA) jointly develop a federal research plan to
address long-term health effects of OIF deployment. DOD plans to take
steps to meet the intent of our first recommendation and partially
concurred with the other recommendations. VA concurred with our
recommendation for a joint federal research plan.
www.gao.gov/cgi-bin/getrpt?GAO-05-632.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Marcia Crosse at (202)
512-7119.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Deployed Military Services Use Varying Approaches to Collect OEHS Data
and Have Not Submitted All OEHS Reports for OIF:
Progress Made in Using OEHS Reports to Address Immediate Health Risks,
Though Limitations Remain for Addressing Both Immediate and Long-term
Health Issues:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendixes:
Appendix I: Scope and Methodology:
Appendix II: Example of an Occupational and Environmental Health
Surveillance Summary Created by the Air Force during Operation Iraqi
Freedom:
Appendix III: Comments from the Department of Defense:
Appendix IV: Comments from the Department of Veterans Affairs:
Table:
Table 1: Selected DOD Policies for the Collection and Reporting of
Deployment Occupational and Environmental Health Surveillance (OEHS)
Data:
Figures:
Figure 1: Entities Involved in Setting or Implementing Occupational and
Environmental Health Surveillance (OEHS) Policy:
Figure 2: Submittal of Deployment Occupational and Environmental Health
Surveillance (OEHS) Reports to the Centralized Archive:
Abbreviations:
CENTCOM: U.S. Central Command:
CHPPM: U.S. Army Center for Health Promotion and Preventive Medicine:
DHSD: Deployment Health Support Directorate:
DMDC: Defense Manpower Data Center:
DOD: Department of Defense:
HHS: Department of Health and Human Services:
OEF: Operation Enduring Freedom:
OEHS: occupational and environmental health surveillance:
OIF: Operation Iraqi Freedom:
VA: Department of Veterans Affairs:
Letter July 14, 2005:
The Honorable Christopher Shays:
Chairman:
Subcommittee on National Security, Emerging Threats, and International
Relations:
Committee on Government Reform:
House of Representatives:
Dear Mr. Chairman:
The health effects from service in military operations have been of
increasing interest, particularly since the end of the 1991 Persian
Gulf War. Following that war, many servicemembers reported suffering
from unexplained illnesses that they attributed to their service in the
Persian Gulf and expressed concerns regarding possible exposures to
chemical or biological warfare agents or environmental contaminants.
Subsequent research and investigations into the nature and causes of
these illnesses by the Department of Defense (DOD), the Department of
Veterans Affairs (VA), the Department of Health and Human Services
(HHS), the Institute of Medicine, and a Presidential Advisory Committee
were hampered by a lack of servicemember health and deployment data,
including inadequate occupational and environmental exposure data.
During deployments--particularly combat situations--the health of
servicemembers can potentially be affected by exposure to hazardous
agents contained in or produced by weapons systems, as well as exposure
to environmental contamination or toxic industrial materials.
In an effort to address continuing concerns about the health of
servicemembers during and after deployments and to improve health data
collection on potential exposures, DOD developed a militarywide health
surveillance framework in 1997 for use during deployments. A key
component of this framework is occupational and environmental health
surveillance (OEHS), an activity that includes the regular collection
and reporting of occupational and environmental health hazard data by
the military services during a deployment that can be used to monitor
the health of servicemembers and to prevent, treat, or control disease
or injury. DOD has created policies for OEHS data collection during a
deployment and for the submittal of OEHS reports to a centralized
archive within certain time frames. The military services are
responsible for implementing these policies in preparation for
deployments. During a deployment, the military services are unified
under a deployment command structure and are responsible for conducting
OEHS activities in accordance with DOD policy. For this report, we
identify the military services operating in a deployment as deployed
military services.
In early 2003, servicemembers were deployed again to the Persian Gulf
in support of Operation Iraqi Freedom (OIF), and you and others raised
anew concerns about potential exposure to hazardous agents or
environmental contaminants. We are reporting on (1) how the deployed
military services have implemented DOD's policies for collecting and
reporting OEHS data for OIF and (2) the efforts under way to use OEHS
reports to address both the immediate and long-term health issues of
servicemembers deployed in support of OIF.
To conduct our work, we reviewed pertinent policies, guidance, and
reports related to collecting and reporting OEHS data obtained from
officials at the Deployment Health Support Directorate (DHSD), the
military services, and the Joint Staff, which supports the Chairman of
the Joint Chiefs of Staff.[Footnote 1] We also conducted site visits to
the Army, Navy, and Air Force health surveillance centers that develop
standards and guidance for conducting OEHS.[Footnote 2] We interviewed
DOD officials and reviewed reports and documents identifying
occupational and environmental health risks and outlining
recommendations for addressing risks at deployment sites. We
interviewed officials at the U.S. Army's Center for Health Promotion
and Preventive Medicine (CHPPM), which archives OEHS reports, both
classified and unclassified, for all the military services. We also
interviewed officials and military service representatives at DOD's
Defense Manpower Data Center (DMDC) on the status of a centralized
deployment tracking database to identify deployed servicemembers and
record their locations within the theater of operations. Additionally,
we interviewed VA officials on their experience in obtaining and using
OEHS reports from OIF to address the health care needs of veterans.
Finally, we interviewed DOD and VA officials to examine whether the
agencies have planned or initiated health research using OEHS reports.
We determined that the data from CHPPM's OEHS archive and DMDC's
Contingency Tracking System were sufficiently reliable for the purposes
of this report. To assess the reliability of the data, we (1) confirmed
that the data included the elements that we requested and were
consistent with provided documentation and (2) conducted detailed fact-
finding interviews with CHPPM and DMDC officials to understand how the
databases were created and to determine the limitations of the data. We
conducted our work from September 2004 through June 2005 in accordance
with generally accepted government auditing standards. (See app. I for
further detail on our scope and methodology.)
Results in Brief:
Although OEHS data generally have been collected and reported for OIF,
as required by DOD policy, the deployed military services have used
different data collection methods and have not submitted all of the
OEHS reports that have been completed. Data collection methods for air
and soil surveillance have varied across the services, for example,
although they have been using the same monitoring standard for water
surveillance. Compounding these differences among the services were the
varying levels of training and expertise among the deployed military
service personnel who were responsible for conducting OEHS activities,
resulting in differing practices for implementing data collection
standards. For some OEHS activities, a cross-service working group,
called the Joint Environmental Surveillance Working Group, has been
developing standards and practices to increase uniformity of data
collection among the services. In addition, the deployed military
services have not submitted to CHPPM all OEHS reports that have been
completed during OIF, in accordance with DOD policy. While 239 of the
277 OIF bases had at least one OEHS report submitted to CHPPM's
centralized archive as of December 2004, CHPPM could not measure the
magnitude of noncompliance because not all of the required consolidated
lists that identify all OEHS reports completed during each quarter in
OIF had been submitted. Therefore, CHPPM could not compare the reports
that it had received against the list of reports that had been
completed. According to CHPPM officials, obstacles to reporting
compliance may have included a lack of understanding by some within the
deployed military services about the type of OEHS reports that should
have been submitted or the lower priority given to report submission
compared to other deployment mission activities. Also, while CHPPM is
responsible for OEHS archiving, it has no authority to enforce report
submission requirements. To improve OEHS reporting compliance, DOD
officials said they were revising an existing policy to add additional
and more specific OEHS requirements.
DOD has made progress using OEHS reports to address immediate health
risks during OIF, but limitations remain in employing these reports to
address both immediate and long-term health issues. OIF was the first
major deployment in which OEHS reports have been used consistently as
part of operational risk management activities intended to identify and
address immediate health risks. These activities included health risk
assessments that described and measured the potential hazards at a
site, risk mitigation activities intended to reduce potential exposure,
and risk communication efforts undertaken to make servicemembers aware
of the possible health risks of potential exposures. While these
efforts may help reduce health risks, there is no assurance that they
have been effective because DOD has not systematically evaluated the
implementation of OEHS risk management activities in OIF. Despite
progress in the use of OEHS information to identify and address
immediate health risks, CHPPM's centralized archive of OEHS reports for
OIF has limitations for addressing potential long-term health effects
related to occupational and environmental exposures for several
reasons. First, access to CHPPM's OEHS archive has been limited because
most OEHS reports are classified--which restricts their use by VA,
medical professionals, and interested researchers. Second, it will be
difficult to link most OEHS reports to individual servicemembers
because not all data on servicemembers' deployment locations have been
submitted to DOD's centralized tracking database. For example, none of
the military services submitted location data for the first several
months of OIF. To address problems with linking OEHS reports to
individual servicemembers, the deployed military services have made
efforts to include OEHS summaries in the medical records of some
servicemembers for either specific incidents of potential exposure or
for specific locations within OIF, such as air bases. Third, according
to DOD and VA officials, no comprehensive federal research plan
incorporating the use of the archived OEHS reports has been developed
to address the long-term health consequences of service in OIF.
We are making recommendations to the Secretary of Defense to ensure
that cross-service guidance be developed to implement DOD's revised
policy for OEHS during deployments and to ensure that the military
services jointly establish and implement procedures to evaluate the
effectiveness of risk management strategies during deployments. We are
also recommending that the Secretary of Defense and the Secretary of
Veterans Affairs work together to develop a federal research plan to
follow the health of OIF servicemembers over time that would include
the use of OEHS reports. In commenting on a draft of this report, DOD
did not concur with our original recommendation that the military
services jointly develop guidance to implement DOD's revised policy for
OEHS during deployments; rather, the agency stated that cross-service
guidance meeting the intent of our recommendation would be developed by
the Joint Staff instead of the military services. In response, we
modified the wording of our recommendation to clarify our intent that
joint guidance be developed. DOD partially concurred with our other
recommendations. VA concurred with our recommendation to work with DOD
to jointly develop a federal research plan to follow the long-term
health of OIF servicemembers.
Background:
On March 19, 2003, the United States launched military operations in
Iraq. As of the end of February 2005, an estimated 827,277
servicemembers had been deployed in support of OIF. Deployed
servicemembers, such as those in OIF, are potentially subject to
occupational and environmental hazards that can include exposure to
harmful levels of environmental contaminants such as industrial toxic
chemicals, chemical and biological warfare agents, and radiological and
nuclear contaminants. Harmful levels include high-level exposures that
result in immediate health effects.[Footnote 3] Health hazards may also
include low-level exposures that could result in delayed or long-term
health effects. Occupational and environmental health hazards may
include contamination from the past use of a site, from battle damage,
from stored stockpiles, from military use of hazardous materials, or
from other sources.
Federal OEHS Policy:
As a result of numerous investigations that found inadequate data on
deployment occupational and environmental exposures to identify the
potential causes of unexplained illnesses among veterans who served in
the 1991 Persian Gulf War, the federal government has increased efforts
to identify potential occupational and environmental hazards during
deployments. In 1997, a Presidential Review Directive called for a
report by the National Science and Technology Council to establish an
interagency plan to improve the federal response to the health needs of
veterans and their families related to the adverse effects of
deployment.[Footnote 4] The Council published a report that set a goal
for the federal government to develop the capability to collect and
assess data associated with anticipated exposure during deployments.
Additionally, the report called for the maintenance of the capability
to identify and link exposure and health data by Social Security number
and unit identification code. Also in 1997, Public Law 105-85 included
a provision recommending that DOD ensure the deployment of specialized
units to theaters of operations to detect and monitor chemical,
biological, and similar hazards.[Footnote 5] The Presidential Review
Directive and the public law led to a number of DOD instructions,
directives, and memoranda, which have guided the collection and
reporting of deployment OEHS data. See table 1 for a list of selected
DOD policies for collecting and reporting deployment OEHS data.
Table 1: Selected DOD Policies for the Collection and Reporting of
Deployment Occupational and Environmental Health Surveillance (OEHS)
Data:
Date: August 1997;
Policy: Department of Defense Instruction 6490.3, "Implementation and
Application of Joint Medical Surveillance for Deployment" (under
revision);
OEHS data collection: Directs military services to deploy specialized
units to conduct environmental health assessments of potential exposure
to occupational and environmental hazards.
Date: February 2002;
Policy: Office of the Chairman, The Joint Chiefs of Staff, Memorandum
MCM-0006-02, "Updated Procedures for Deployment Health Surveillance and
Readiness";
OEHS data collection: Directs the combatant command--which is
responsible for the deployment--to develop and maintain an appropriate
OEHS program for the deployment; Directs deployed military commands to
continuously review and update environmental health assessments
throughout deployments using data collected in the theater;
OEHS reporting: Directs deployed military commands to ensure that
requirements are met for reporting and archiving OEHS data and sets out
requirements for record keeping and reporting.
Date: May 2003;
Policy: Under Secretary of Defense for Personnel and Readiness,
Memorandum, "Improved Occupational and Environmental Health
Surveillance Reporting and Archiving";
OEHS reporting: Directs the Joint Staff to issue additional guidance
for more comprehensive OEHS reporting requirements for Operation Iraqi
Freedom and provides specific guidance for required reports that should
be submitted for archiving, and time frames for submittal.
Date: June 2003;
Policy: The Joint Staff, Memorandum DJSM-0613-03, "Improved
Occupational and Environmental Health Surveillance (OEHS) Reporting and
Archiving";
OEHS reporting: Directs personnel involved in OEHS to submit all
deployment OEHS reports to the U.S. Army Center for Health Promotion
and Preventive Medicine (CHPPM) and to provide complete lists (on a
quarterly basis) of all deployment OEHS reports that were completed to
CHPPM as well as to the medical commander of the deployment.
Source: DOD.
[End of table]
DOD Entities Involved with Setting and Implementing OEHS Policy:
DHSD makes recommendations for DOD-wide policies on OEHS data
collection and reporting during deployments to the Office of the
Assistant Secretary of Defense for Health Affairs. DHSD is assisted by
the Joint Environmental Surveillance Working Group, established in
1997, which serves as a coordinating body to develop and make
recommendations for DOD-wide OEHS policy.[Footnote 6] The working group
includes representatives from the Army, Navy, and Air Force health
surveillance centers, the Joint Staff, other DOD entities, and VA.
Each service has a health surveillance center--CHPPM, the Navy
Environmental Health Center, and the Air Force Institute for
Operational Health--that provides training, technical guidance and
assistance, analytical support, and support for preventive medicine
units[Footnote 7] in theater in order to carry out deployment OEHS
activities in accordance with DOD policy. In addition, these consulting
centers have developed and adapted military exposure guidelines for
deployment using existing national standards for human health exposure
limits and technical monitoring procedures (e.g., standards of the U.S.
Environmental Protection Agency and the National Institute for
Occupational Safety and Health) and have worked with other agencies to
develop new guidelines when none existed. (See fig. 1.)
Figure 1: Entities Involved in Setting or Implementing Occupational and
Environmental Health Surveillance (OEHS) Policy:
[See PDF for image]
[End of figure]
Deployment OEHS Reports:
DOD policies and military service guidelines require that the
preventive medicine units of each military service be responsible for
collecting and reporting deployment OEHS data.[Footnote 8] Deployment
OEHS data are generally categorized into three types of reports:
baseline, routine, or incident-driven.
* Baseline reports generally include site surveys and assessments of
occupational and environmental hazards prior to deployment of
servicemembers and initial environmental health site assessments once
servicemembers are deployed.[Footnote 9]
* Routine reports record the results of regular monitoring of air,
water, and soil, and of monitoring for known or possible hazards
identified in the baseline assessment.
* Incident-driven reports document exposure or outbreak
investigations.[Footnote 10]
There are no DOD-wide requirements on the specific number or type of
OEHS reports that must be created for each deployment location because
reports generated for each reflect the specific occupational and
environmental circumstances unique to that location. CHPPM officials
said that reports generally reflect deployment OEHS activities that are
limited to established sites such as base camps or forward operating
bases; [Footnote 11] an exception is an investigation during an
incident outside these locations. Constraints to conducting OEHS
outside of bases include risks to servicemembers encountered while in
combat and limits on the portability of OEHS equipment. In addition,
DHSD officials said that preventive medicine units might not be aware
of every potential health hazard and therefore might be unable to
conduct appropriate OEHS activities.
OEHS Reporting and Archiving Activities during Deployment:
According to DOD policy, various entities must submit their completed
OEHS reports to CHPPM during a deployment. The deployed military
services have preventive medicine units that submit OEHS reports to
their command surgeons[Footnote 12] who review all reports and ensure
that they are sent to a centralized archive that is maintained by
CHPPM.[Footnote 13] Alternatively, preventive medicine units can be
authorized to submit OEHS reports directly to CHPPM for archiving. (See
fig. 2.)
Figure 2: Submittal of Deployment Occupational and Environmental Health
Surveillance (OEHS) Reports to the Centralized Archive:
[See PDF for image]
[A] The command surgeons of deployed preventive medicine units are
either Joint Task Force command surgeons or military service component
command surgeons. In OIF, there are two Joint Task Forces, each with a
command surgeon. In addition, the Army, Navy, Air Force, and Marine
Corps have their own subordinate component commands in a deployment,
each with a command surgeon.
[End of figure]
According to DOD policy, baseline and routine reports should be
submitted within 30 days of report completion.[Footnote 14] Initial
incident-driven reports should be submitted within 7 days of an
incident or outbreak. Interim and final reports for an incident should
be submitted within 7 days of report completion. In addition, the
preventive medicine units are required to provide quarterly lists of
all completed deployment OEHS reports to the command surgeons. The
command surgeons review these lists, merge them, and send CHPPM a
quarterly consolidated list of all the deployment OEHS reports it
should have received.
To assess the completeness of its centralized OEHS archive, CHPPM
develops a quarterly summary report that identifies the number of
baseline, routine, and incident-driven reports that have been submitted
for all bases in a command. Additionally, this report summarizes the
status of OEHS report[Footnote 15] submissions by comparing the reports
CHPPM received with the quarterly consolidated lists from the command
surgeons that outline each of the OEHS reports that have been
completed. For OIF, CHPPM is required to provide a quarterly summary
report to the commander of U.S. Central Command[Footnote 16] on the
deployed military services' compliance with deployment OEHS reporting
requirements.
Uses of Deployment OEHS Reports:
During deployments, military commanders can use deployment OEHS reports
completed and maintained by preventive medicine units to identify
occupational and environmental health hazards[Footnote 17] and to help
guide their risk management decision making. Commanders use an
operational risk management process to estimate health risks based on
both the severity of the risks to servicemembers and the likelihood of
encountering specific hazards. The operational risk management process,
which varies slightly across the services, includes:
* risk assessment, including hazard identification, to describe and
measure the potential hazards at a location;
* risk control and mitigation activities intended to reduce potential
exposures; and:
* risk communication efforts to make servicemembers aware of possible
exposures, any risks to health that the exposures may pose, the
countermeasures to be employed to mitigate exposure or disease, and any
necessary medical measures or follow-up required during or after the
deployment.
Commanders balance the risk to servicemembers of encountering
occupational and environmental health hazards while deployed, even
following mitigation efforts, against the need to accomplish specific
mission requirements.
Along with health encounter[Footnote 18] and servicemember location
data, archived deployment OEHS reports are needed by researchers to
conduct epidemiologic studies on the long-term health issues of
deployed servicemembers. These data are needed, for example, by VA,
which in 2002 expanded the scope of its health research to include
research on the potential long-term health effects of hazardous
military deployments on servicemembers. In a letter to the Secretary of
Defense in 2003, VA said it was important for DOD to collect adequate
health and exposure data from deployed servicemembers to ensure VA's
ability to provide veterans' health care and disability compensation.
VA noted in the letter that much of the controversy over the health
problems of veterans who fought in the 1991 Persian Gulf War could have
been avoided had more extensive surveillance data been collected. VA
asked in the letter that it be allowed access to any unclassified data
collected during deployments on the possible exposure of servicemembers
to environmental hazards of all kinds.
Deployed Military Services Use Varying Approaches to Collect OEHS Data
and Have Not Submitted All OEHS Reports for OIF:
The deployed military services generally have collected and reported
OEHS data for OIF, as required by DOD policy. However, the deployed
military services have not used all of the same OEHS data collection
standards and practices, because each service has its own authority to
implement broad DOD policies. To increase data collection uniformity,
the Joint Environmental Surveillance Working Group has made some
progress in devising cross-service standards and practices for some
OEHS activities. In addition, the deployed military services have not
submitted all of the OEHS reports they have completed for OIF to
CHPPM's centralized archive, as required by DOD policy. However, CHPPM
officials said that they could not measure the magnitude of
noncompliance because they have not received all of the required
quarterly consolidated lists of OEHS reports that have been completed.
To improve OEHS reporting compliance, DOD officials said they were
revising an existing policy to add additional and more specific OEHS
requirements.
Data Collection Standards and Practices Vary by Service, Although
Preliminary Efforts Are Under Way to Increase Uniformity:
OEHS data collection standards[Footnote 19] and practices have varied
among the military services because each service has its own authority
to implement broad DOD policies and the services have taken somewhat
different approaches. For example, although one water monitoring
standard has been adopted by all military services, the services have
different standards for both air and soil monitoring. As a result, for
similar OEHS events, preventive medicine units may collect and report
different types of data. Each military service's OEHS practices for
implementing data collection standards also have differed, due to the
varying levels of training and expertise among the service's preventive
medicine units. For example, CHPPM officials said that Air Force and
Navy preventive medicine units had more specialized personnel with a
narrower focus on specific OEHS activities than Army preventive
medicine units, which included more generalist personnel who conducted
a broader range of OEHS activities. Air Force preventive medicine units
generally have included a flight surgeon, a public health officer, and
bioenvironmental engineers. Navy preventive medicine units generally
have included a preventive medicine physician, an industrial hygienist,
a microbiologist, and an entomologist. In contrast, Army preventive
medicine unit personnel generally have consisted of environmental
science officers and technicians.
DOD officials also said other issues could contribute to differences in
data collected during OIF. DHSD officials said that variation in OEHS
data collection practices could occur as a result of resource
limitations during a deployment. For example, some preventive medicine
units may not be fully staffed at some bases. A Navy official also said
that OEHS data collection can vary as different commanders set
guidelines for implementing OEHS activities in the deployment theater.
To increase the uniformity of OEHS standards and practices for
deployments, the military services have made some progress--
particularly in the last 2 years--through their collaboration as
members of the Joint Environmental Surveillance Working Group. For
example, the working group has developed a uniform standard, which has
been adopted by all the military services, for conducting environmental
health site assessments, which are a type of baseline OEHS
report.[Footnote 20] These assessments have been used in OIF to
evaluate potential environmental exposures that could have an impact on
the health of deployed servicemembers and determine the types of
routine OEHS monitoring that should be conducted. Also, within the
working group, three subgroups--laboratory, field water, and equipment-
-have been formed to foster the exchange of information among the
military services in developing uniform joint OEHS standards and
practices for deployments. For example, DHSD officials said the
equipment subgroup has been working collaboratively to determine the
best OEHS instruments to use for a particular type of location in a
deployment. Another effort by the working group included devising a
joint standard for the amount of OEHS data needed to sufficiently
determine the severity of potential health hazards at a site. However,
DOD officials estimated in late 2004 that it would take 2 years or more
for this standard to be completed and approved.
Deployed Military Services Have Not Submitted All Required OEHS Reports
for OIF, and the Magnitude of Noncompliance Is Unknown:
The deployed military services have not submitted all the OEHS reports
that the preventive medicine units completed during OIF to CHPPM for
archiving, according to CHPPM officials. Since January 2004, CHPPM has
compiled four summary reports that included data on the number of OEHS
reports submitted to CHPPM's archive for OIF. However, these summary
reports have not provided information on the actual magnitude of
noncompliance with report submission requirements because CHPPM has not
received all consolidated lists of completed OEHS reports that should
be submitted quarterly. These consolidated lists were intended to
provide a key inventory of all OEHS reports that had been completed
during OIF. Because there are no requirements on the specific number or
type of OEHS reports that must be created for each base, the quarterly
consolidated lists are CHPPM's only means of assessing compliance with
OEHS report submission requirements. Our analysis of data supporting
the four summary reports[Footnote 21] found that, overall, 239 of the
277 bases[Footnote 22] had at least one OEHS baseline (139) or routine
(211) report submitted to CHPPM's centralized archive through December
2004.[Footnote 23]
DOD officials suggested several obstacles that may have hindered OEHS
reporting compliance during OIF. For example, CHPPM officials said
there are other, higher priority operational demands that commanders
must address during a deployment, so OEHS report submission may be a
lower priority. In addition, CHPPM officials said that some of the
deployed military services' preventive medicine units might not
understand the types of OEHS reports to be submitted or might view them
as an additional paperwork burden. CHPPM and other DOD officials added
that some preventive medicine units might have limited access to
communication equipment to send reports to CHPPM for
archiving.[Footnote 24] CHPPM officials also said that while they had
the sole archiving responsibility, CHPPM did not have the authority to
enforce OEHS reporting compliance for OIF; this authority rests with
the Joint Staff and the commander in charge of the deployment.
DOD has several efforts under way to improve OEHS reporting compliance.
CHPPM officials said they have increased communication with deployed
preventive medicine units and have facilitated coordination among each
service's preventive medicine units prior to deployment. CHPPM has also
conducted additional OEHS training for some preventive medicine units
prior to deployment, including both refresher courses and information
about potential hazards specific to the locations where the units were
being deployed. In addition, DHSD officials said they were revising an
existing policy (DOD Instruction 6490.3; see table 1) to add additional
and more specific OEHS requirements. However, at the time of our
review, a draft of the revision had not been released and, therefore,
specific details about these revisions were not available.
Progress Made in Using OEHS Reports to Address Immediate Health Risks,
Though Limitations Remain for Addressing Both Immediate and Long-term
Health Issues:
DOD has made progress using OEHS reports to address immediate health
risks during OIF, but limitations remain in employing these reports to
address both immediate and long-term health issues. During OIF, OEHS
reports have been used as part of operational risk management
activities intended to assess, mitigate, and communicate to
servicemembers any potential hazards at a location. While there have
been no systematic efforts by DOD or the military services to establish
a system to monitor the implementation of OEHS risk management
activities, DHSD officials said relatively low rates of disease and
nonbattle injury in OIF were considered an indication of OEHS
effectiveness. In addition, DOD's centralized archive of OEHS reports
for OIF is limited in its ability to provide information on the
potential long-term health effects related to occupational and
environmental exposures for several reasons, including limited access
to most OEHS reports because of security classification, incomplete
data on servicemembers' deployment locations, and the lack of a
comprehensive federal research plan incorporating the use of archived
OEHS reports.
Progress Made in Using Deployment OEHS Data and Reports in Risk
Management, but DOD Does Not Monitor Implementation of These Efforts:
To identify and reduce the risk of immediate health hazards in OIF, all
of the military services have used preventive medicine units' OEHS data
and reports in an operational risk management process. A DOD official
said that while DOD had begun to implement risk management to address
occupational and environmental hazards in other recent deployments, OIF
was the first major deployment to apply this process throughout the
deployed military services' day-to-day activities, beginning at the
start of the operation.[Footnote 25] The operational risk management
process includes risk assessments of deployment locations, risk
mitigation activities to limit potential exposures, and risk
communication to servicemembers and commanders about potential hazards.
* Risk Assessments. Preventive medicine units from each of the services
have generally used OEHS information and reports to develop risk
assessments that characterized known or potential hazards when new
bases were opened in OIF. CHPPM's formal risk assessments have also
been summarized or updated to include the findings of baseline and
routine OEHS monitoring conducted while bases are occupied by
servicemembers, CHPPM officials said. During deployments, commanders
have used risk assessments to balance the identified risk of
occupational and environmental health hazards, and other operational
risks, with mission requirements. Alternatively, some preventive
medicine units have addressed hazards identified through risk
assessments without initially involving a commander. A Navy official
said that, for example, if a preventive medicine unit found elevated
bacteria levels when monitoring a drinking water purification system,
the unit would likely order that the system be shut down and corrected
and then notify the commander of the action in a summary report of OEHS
activities. Generally, OEHS risk assessments for OIF have involved
analysis of the results of air, water, or soil monitoring.[Footnote 26]
CHPPM officials said that most risk assessments that they have received
characterized locations in OIF as having a low risk of posing health
hazards to servicemembers.[Footnote 27]
* Risk Control and Mitigation. Using risk assessment findings,
preventive medicine units have recommended risk control and mitigation
activities to commanders that were intended to reduce potential
exposures at specific locations. For OIF, risk control and mitigation
recommendations at bases have included such actions as modifying work
schedules, requiring individuals to wear protective equipment, and
increasing sampling to assess any changes and improve confidence in the
accuracy of the risk estimate.
* Risk Communication. Risk assessment findings have also been used in
risk communication efforts, such as providing access to information on
a Web site or conducting health briefings to make servicemembers aware
of occupational and environmental health risks during a deployment and
the recommended efforts to control or mitigate those risks, including
the need for medical follow-up. Many of the risk assessments for OIF we
reviewed recommended that health risks be communicated to
servicemembers.
The experience at Port Shuaiba, Kuwait, provides an illustration of the
risk management process. Officials determined that Port Shuaiba, which
had a moderate risk rating in numerous OEHS risk assessments, had the
highest assessed risk for potential environmental exposures identified
in OIF. The site is a deepwater port used for bringing in heavy
equipment in support of OIF, and a large number of servicemembers have
been permanently or temporarily stationed at this site. CHPPM officials
said reported concerns about air quality problems, such as sulfur
dioxide emissions and windblown dust and sand particles, and the
concentration of a large number of industrial facilities[Footnote 28]
at Port Shuaiba led to this risk characterization as a result of
multiple OEHS risk assessments conducted before and during
OIF.[Footnote 29] Risk mitigation recommendations that have been
implemented at Port Shuaiba include increasing air monitoring to
continuous, 24-hour sampling; implementing the use of standard
protective equipment, such as goggles and face kerchiefs; and using
dust suppression measures, such as laying gravel over the entire
location to reduce dust. CHPPM officials said they were uncertain
whether some other risk mitigation recommendations for Port Shuaiba had
been implemented, such as requiring servicemembers to stay inside
buildings or tents as much as possible when air pollution levels are
high or increasing the number of servicemembers available for
operations to reduce the duration of shifts. On the basis of
recommendations from the risk assessments, military officials have been
attempting to transfer the activities at Port Shuaiba to a nearby port
that does not have industrial facilities,[Footnote 30] but
servicemembers have continued to live and work at the site, though in
greatly reduced numbers, CHPPM officials said. CHPPM officials said
they have recommended extensive risk communication activities at Port
Shuaiba, including providing information to servicemembers in town hall
meetings and through posters and handouts in dining facilities. In
addition, CHPPM officials said they have worked with commanders to
allow CHPPM to provide briefings about the identified and potential
health hazards as soon as new military units arrive at Port Shuaiba.
While risk management activities have become more widespread in OIF
compared with previous deployments, DOD officials have not conducted
systematic monitoring of deployed military services' efforts to conduct
OEHS risk management activities. As of March 2005, neither DOD nor the
military services had established a system to examine whether required
risk assessments had been conducted, or to record and track resulting
recommendations for risk mitigation or risk communication activities.
In the absence of a systematic monitoring process, CHPPM officials said
they conducted ad hoc reviews of implementation of risk management
recommendations for sites where continued, widespread OEHS monitoring
has occurred, such as at Port Shuaiba and other locations with elevated
risks. DHSD officials said they have initiated planning for a
comprehensive quality assurance program for deployment health that
would address OEHS risk management, but the program was still under
development.
DHSD and military service officials said that developing a monitoring
system for risk management activities would face several challenges. In
response to recommendations for risk mitigation and risk communication
activities, commanders may have issued written orders and guidance that
were not always stored in a centralized, permanent database that could
be used to track risk management activities. Additionally, DHSD
officials told us that risk management decisions have sometimes been
recorded in commanders' personal journals or diaries, rather than
issued as orders that could be stored in a centralized, permanent
database.
In lieu of a monitoring system, DHSD officials said the rates of
disease and nonbattle injury in OIF are considered by DOD as a general
measure or indicator of OEHS effectiveness. As of January 2005, OIF had
a 4 percent total disease and nonbattle injury rate--in other words, an
average of 4 percent of servicemembers deployed in support of OIF had
been seen by medical units for an injury or illness in any given week.
This rate is the lowest DOD has ever documented for a major deployment,
according to DHSD officials. For example, the total disease and
nonbattle injury rate for the 1991 Gulf War was about 6.5 percent, and
the total rate for Operation Enduring Freedom in Central Asia has been
about 5 percent. However, while this indicator provides general
information on servicemembers' health status, it is not directly linked
to specific OEHS activities and therefore is not a clear measure of
their effectiveness.
Access to Most Archived OEHS Reports Is Limited by Security
Classification:
Access to archived OEHS reports by VA, medical professionals, and
interested researchers has been limited by the security classification
of most OEHS reports.[Footnote 31] Typically, OEHS reports are
classified if the specific location where monitoring activities occur
is identified. VA officials said they would like to have access to OEHS
reports in order to ensure appropriate postwar health care and
disability compensation for veterans, and to assist in future research
studies. However, VA officials said that they did not expect access to
OEHS reports to improve until OIF has ended because of security
concerns.
Although access to OEHS reports has been restricted, VA officials said
they have tried to anticipate likely occupational and environmental
health concerns for OIF based on experience from the 1991 Persian Gulf
War and on CHPPM's research on the medical and environmental health
conditions that exist or might develop in the region. Using this
information, VA has developed study guides for physicians on such
topics as health effects from radiation and traumatic brain injury and
also has written letters for OIF veterans about these issues.
DOD has begun reviewing classification policies for OEHS reports, as
required by the Ronald W. Reagan National Defense Authorization Act for
Fiscal Year 2005.[Footnote 32] A DHSD official said that DOD's newly
created Joint Medical Readiness Oversight Committee is expected to
review ways to reduce or limit the classification of data, including
data that are potentially useful for monitoring and assessing the
health of servicemembers who have been exposed to occupational or
environmental hazards during deployments.
Difficulties Exist in Linking Archived OEHS Reports to Individual
Servicemembers, but Some Efforts Are Under Way to Include Information
in Medical Records:
Linking OEHS reports from the archive to individual servicemembers will
be difficult because DOD's centralized tracking database for recording
servicemembers' deployment locations currently does not contain
complete or comparable data. In May 1997, we reported that the ability
to track the movement of individual servicemembers within the theater
is important for accurately identifying exposures of servicemembers to
health hazards.[Footnote 33] However, DMDC's centralized database has
continued to experience problems in obtaining complete, comparable data
from the services on the location of servicemembers during deployments,
as required by DOD policies.[Footnote 34] DMDC officials said the
military services had not reported location data for all servicemembers
for OIF. As of October 2004, the Army, Air Force, and Marine Corps each
had submitted location data for approximately 80 percent of their
deployed servicemembers, and the Navy had submitted location data for
about 60 percent of its deployed servicemembers.[Footnote 35]
Additionally, the specificity of location data has varied by service.
For example, the Marine Corps has provided location of servicemembers
only by country, whereas each of the other military services has
provided more detailed location information for some of their
servicemembers, such as base camp name or grid coordinate locations.
Furthermore, the military services did not begin providing detailed
location data until OIF had been ongoing for several months.
DHSD officials said they have been revising an existing policy[Footnote
36] to provide additional requirements for location data that are
collected by the military services, such as a daily location record
with grid coordinates or latitude and longitude coordinates for all
servicemembers. Though the revised policy has not been published, as of
May 2005 the Army and the Marine Corps had implemented a new joint
location database in support of OIF that addresses these revisions.
During OIF, some efforts have been made to include information about
specific incidents of potential and actual exposure to occupational or
environmental health hazards in the medical records of servicemembers
who may be affected. According to DOD officials, after preventive
medicine units have investigated incidents involving potential
exposure, they generally have developed narrative summaries of events
and the results of any medical procedures for inclusion in affected
servicemembers' medical records. Additionally, rosters were generally
developed of servicemembers directly affected and of servicemembers who
did not have any acute symptoms but were in the vicinity of the
incident. For example, in investigating an incident involving a
chemical agent used in an improvised explosive device, CHPPM officials
said that two soldiers who were directly involved were treated at a
medical clinic, and their treatment and the exposure were recorded in
their medical records. Although 31 servicemembers who were providing
security in the area were asymptomatic, doctors were documenting this
potential exposure in their medical records.
In addition, the military services have taken some steps to include
summaries of potential exposures to occupational and environmental
health hazards in the medical records of servicemembers deployed to
specific locations. The Air Force has created summaries of these
hazards at deployed air bases and has required that these be placed in
the medical records of all Air Force servicemembers stationed at these
bases. (See app. II for an example.) However, Air Force officials said
no follow-up activities have been conducted specifically to determine
whether all Air Force servicemembers have had the summaries placed in
their medical records. In addition, the Army and Navy jointly created a
summary of potential exposure for the medical records of servicemembers
stationed at Port Shuaiba. Since December 2004, port officials have
made efforts to make the summary available to servicemembers stationed
at Port Shuaiba so that these servicemembers can include the summary in
their medical records. However, there has been no effort to
retroactively include the summary in the medical records of
servicemembers stationed at the port prior to that time.
No Federal Research Plan Exists for Using OEHS Reports to Follow the
Health of OIF Servicemembers over Time:
According to DOD and VA officials, no federal research plan that
includes the use of archived OEHS reports has been developed to
evaluate the long-term health of servicemembers deployed in support of
OIF, including the effects of potential exposure to occupational or
environmental hazards. In February 1998 we noted that the federal
government lacked a proactive strategy to conduct research into Gulf
War veterans' health problems and suggested that delays in planning
complicated researchers' tasks by limiting opportunities to collect
critical data.[Footnote 37] However, the Deployment Health Working
Group, a federal interagency body responsible for coordinating research
on all hazardous deployments, recently began discussions on the first
steps needed to develop a research plan for OIF.[Footnote 38] At its
January 2005 meeting, the working group tasked its research
subcommittee to develop a complete list of research projects currently
under way that may be related to OIF.[Footnote 39] VA officials noted
that because OIF is ongoing, the working group would have to determine
how to address a study population that changes as the number of
servicemembers deployed in support of OIF changes.[Footnote 40]
Although no coordinated federal research plan has been developed, there
are some separate federal research studies under way that may follow
the health of OIF servicemembers. For example, in 2000 VA and DOD
collaborated to develop the Millennium Cohort study, a 21-year
longitudinal study evaluating the health of both deployed and
nondeployed military personnel throughout their military careers and
after leaving military service. According to the principal
investigator, the Millennium Cohort study was designed to examine the
health effects of specific deployments if enough servicemembers in that
deployment enrolled in the study. However, the principal investigator
said that as of February 2005 researchers had not identified how many
servicemembers deployed in support of OIF had enrolled in the study.
Additionally, a VA researcher has received funding to study mortality
rates among OIF servicemembers. According to the researcher, if
occupational and environmental data are available, the study will
include the evaluation of mortality outcomes in relation to potential
exposure for OIF servicemembers.
Conclusions:
Since the 1991 Persian Gulf War, DOD has made progress in improving
occupational and environmental health data collection through its
development of a militarywide health surveillance framework for use
during deployments. However, these efforts still could be strengthened.
OEHS data that the deployed military services have collected during OIF
may not always be comparable because of variations among the services'
data collection standards and practices. As a result of these
variations, the amount and comprehensiveness of data for servicemembers
from one military service may be more extensive than for servicemembers
from another service. Additionally, the deployed military services'
uncertain compliance with OEHS report submission requirements casts
doubts on the completeness of CHPPM's OEHS archive. These data
shortcomings, in conjunction with the incomplete data in DOD's
centralized tracking database of servicemembers' deployment locations,
limit CHPPM's ability to respond to requests for OEHS information about
possible exposure to occupational and environmental health hazards of
those who are serving or have served in OIF. Other limitations may also
impede the comprehensiveness of the archived OEHS reports, including
the inability to collect OEHS data outside of base camps and a lack of
knowledge of all potential health hazards. Nonetheless, these
limitations do not outweigh the need to collect data on known or
expected hazards in order to make every effort to address potential
health issues. DHSD officials have said they are revising an existing
policy on OEHS data collection and reporting to add additional and more
specific OEHS requirements. However, unless the military services take
measures to direct those responsible for OEHS activities to proactively
implement the new requirements, the services' efforts to collect and
report OEHS data may not improve.
DOD's risk management efforts during OIF represent a positive step in
helping to mitigate potential environmental and occupational risks of
deployment. But the effects of such efforts are unknown without
systematic monitoring of the deployed military services' implementation
activities. Rates of disease and nonbattle injury have been used as an
overall surrogate outcome measure for risk management in OIF, but DOD
and the military services currently are unable to ascertain how and to
what extent risk management efforts have contributed to the relatively
low disease and nonbattle injury rate for OIF.
Although OEHS reports alone are not sufficient to identify the causes
of potential long-term health effects in deployed servicemembers, they
are an integral component of research to evaluate the long-term health
of deployed servicemembers. However, efforts by a joint DOD and VA
working group to develop a federal research plan for OIF that would
include examining the effects of potential exposure to occupational and
environmental health hazards have just begun, despite similarities in
deployment location to the 1991 Persian Gulf War. Unless DOD addresses
OEHS data collection and reporting weaknesses and develops a federal
research plan for OIF with VA, the departments ultimately may face the
same criticisms they faced following the first Gulf War over their
inability to adequately address the long-term health issues of
servicemembers.
Recommendations for Executive Action:
We are making recommendations aimed at improving the collection and
reporting of OEHS data during deployments and improving OEHS risk
management. To improve the collection and reporting of OEHS data during
deployments and the linking of OEHS reports to servicemembers, we
recommend that the Secretary of Defense ensure that cross-service
guidance is created to implement DOD's policy, once that policy has
been revised, which addresses improvements to conducting OEHS
activities and to reporting the locations of servicemembers during
deployment.
To improve the use of OEHS reports to address the immediate health
risks of servicemembers during deployments, we recommend that the
Secretary of Defense ensure that the military services jointly
establish and implement procedures to evaluate the effectiveness of
risk management efforts.
To better anticipate and understand the potential long-term health
effects of deployment in support of OIF, we recommend that the
Secretary of Defense and the Secretary of Veterans Affairs work
together to develop a federal research plan to follow the health of
these servicemembers that would include the use of archived OEHS
reports.
Agency Comments and Our Evaluation:
We requested comments on a draft of this report from DOD and VA. Both
agencies provided written comments that are reprinted in appendixes III
and IV. DOD also provided technical comments that we incorporated where
appropriate.
In commenting on this draft, DOD did not concur with our recommendation
that the military services jointly develop implementation guidance for
DOD's policy on OEHS during deployments, once that policy has been
revised. However, DOD stated that officials are planning steps that
will meet the intent of our recommendation to improve the collection
and reporting of OEHS data during deployments. DHSD officials stated
that cross-service implementation guidance for the revised policy on
deployment OEHS would be developed by the Joint Staff instead of by the
individual military services, as we originally recommended. We believe
that the development of cross-service implementation guidance is a
critical element needed to improve OEHS data collection and reporting
during deployments, regardless of the entity responsible for developing
this guidance. Therefore, we modified the wording of our recommendation
to clarify our intent that joint guidance be developed.
DOD partially concurred with our recommendation that the military
services jointly establish and implement procedures to evaluate the
effectiveness of risk management efforts. DOD stated that OEHS reports
would be of no value for "immediate" health risks, except for incident-
driven reports, and assumed that we were referring to health risks that
may occur once servicemembers return from a deployment. However, our
findings describe the OEHS operational risk management process that is
specifically conducted during a deployment, including risk assessment,
risk mitigation, and risk communication activities that are used to
identify and reduce the risk of immediate health hazards. Additionally,
DOD stated that it has procedures in place to evaluate OEHS risk
management through a jointly established and implemented lessons
learned process. Because the lessons learned process was not raised by
agency officials during our review, we did not determine whether it
would systematically monitor or evaluate the effectiveness of OEHS risk
management activities. However, in further discussions, DHSD officials
told us that they were not aware of any lessons learned reports related
to OEHS risk management for OIF.
DOD partially concurs with our recommendation that DOD and VA work
together to develop a federal research plan to follow the health of
servicemembers deployed in support of OIF that would include the use of
archived OEHS reports. Although DOD states that it agrees with the
importance of following the health of its servicemembers, its response
focuses on initiatives for the electronic exchange of clinical health
information with VA. In further discussions, DHSD officials explained
that analysis of this clinical information could lead to the
development of research hypotheses and, ultimately, research questions
that would guide federal health research. Although DOD officials stated
that they have not yet linked any occupational or environmental
exposures to specific adverse health effects, there is no certainty
that long-term health effects related to these types of exposures will
not appear in veterans of OIF. Federal research has not clearly
identified the causes of unexplained illnesses reported by
servicemembers who served in the 1991 Persian Gulf War, and OIF
servicemembers are serving in the same region for longer periods of
time.
Separately, VA concurred with our recommendation to work jointly with
DOD to develop a federal research plan to follow the health of OIF
servicemembers. VA confirmed that the Deployment Health Working Group,
which includes DOD officials, had initiated steps in January 2005
toward developing a comprehensive joint federal surveillance plan to
evaluate the long-term health of servicemembers returning from both OIF
and Operation Enduring Freedom (OEF). However, more importantly, the
difference in VA and DOD's responses to this recommendation illustrates
a disconnect between each agency's understanding of whether and how
such a federal research plan should be established. Therefore,
continued collaboration between the agencies to formulate a mutually
agreeable process for proactively creating a federal research plan
would be beneficial in facilitating both agencies' ability to
anticipate and understand the potential long-term health effects
related to OIF deployment versus taking a more reactive stance in
waiting to see what types of health problems may surface.
In its response, VA also contends that we overstate problems related to
its ability to access DOD's classified occupational and environmental
health data. VA notes that it has staff with the necessary security
clearances to examine classified OEHS reports, so that there is no
barrier to access. However, during our review VA officials expressed
concerns that they did not have OEHS data and that access to the data
was difficult. Even if VA staff have security clearances that enable
them to examine OEHS data, any materials that arise from the use of
classified documents, such as research papers or other publications,
would likely be restricted. Therefore, these results would have limited
use, as they cannot be broadly shared with other researchers and the
general public. Nonetheless, VA maintains that development of a
systematic method to tabulate and organize the exposure data is needed,
as is a complete roster of OIF and OEF veterans, pre-and post-
deployment health screening data, and a complete roster of the most
seriously injured veterans. We agree that a systematic method to
organize and share OEHS data is important. This issue could be
addressed within the efforts to develop a federal research plan.
As arranged with your office, unless you release its contents earlier,
we plan no further distribution of this report until 30 days after its
issuance date. At that time, we will send copies of this report to the
Secretary of Defense and the Secretary of Veterans Affairs. We will
also provide copies to others upon request. In addition, the report
will be available at no charge on GAO's Web site at [Hyperlink,
http://www.gao.gov].
If you or your staff has any questions about this report, please call
me at (202) 512-7119. Bonnie Anderson, Karen Doran, John Oh, Danielle
Organek, and Roseanne Price also made key contributions to this report.
Sincerely yours,
Signed by:
Marcia Crosse:
Director, Health Care:
[End of section]
Appendixes:
Appendix I: Scope and Methodology:
To describe how the military services have implemented the Department
of Defense's (DOD) policies for collecting and reporting occupational
and environmental health surveillance (OEHS) data for Operation Iraqi
Freedom (OIF), we reviewed pertinent DOD policies and military
services' guidance that delineated the requirements for OEHS data
collection and reporting. We interviewed officials at the Deployment
Health Support Directorate (DHSD) and the Joint Staff to obtain a broad
overview of DOD's OEHS activities in OIF. We also interviewed officials
at each of the military services' health centers--the U.S. Army Center
for Health Promotion and Preventive Medicine (CHPPM), the Navy
Environmental Health Center, and the Air Force Institute for
Operational Health--to obtain information about each service's OEHS
data collection standards and practices, training of preventive
medicine units for OIF, obstacles that could hinder OEHS data
collection and reporting, and efforts to improve reporting compliance.
Additionally, we interviewed members of the Joint Environmental
Surveillance Working Group to discuss the purpose and structure of the
working group and efforts related to increasing the uniformity of OEHS
standards and practices for deployments.
To determine if the military services were submitting OEHS reports to
CHPPM's centralized archive, we obtained and reviewed CHPPM's quarterly
summary reports, which provided the total number of bases that have
submitted at least one report in each of the categories of baseline,
routine, or incident-driven reports for the U.S. Central Command's
(CENTCOM) area of responsibility, details about consolidated lists of
reports, and information about other OEHS reporting compliance issues.
The summary reports did not show report submission by individual bases
or, other than for the first summary report, separately identify OIF
bases from all others in the CENTCOM area of responsibility. For each
of the summary reports, CHPPM provided us with supporting documents
that included lists of the bases specific to OIF and, for each base,
whether it had submitted baseline, routine, or incident-driven reports.
We attempted to include only unique OIF bases in our analysis; however,
CHPPM officials told us that a few duplicate OIF bases may be included
in our analysis due to reasons such as frequent base openings and
closures and base name changes. We used these supporting documents to
identify the number and percentage of bases with and without baseline
or routine reports during the reporting periods. Incident-driven
reports reflect OEHS investigations of unexpected incidents and would
not be submitted to CHPPM's archive according to any identified
pattern. Therefore, we did not review the services' submission of
incident-driven reports. Because OEHS reports generally are classified,
we did not report on the specifics contained in these reports.
We determined that the data from CHPPM's OEHS archive were sufficiently
reliable for the purposes of this report by (1) confirming the data
included the elements that we requested and were consistent with
provided documentation and (2) conducting detailed fact-finding
interviews with CHPPM officials to understand how the data were
obtained and to determine the limitations of the data. To characterize
the OEHS reports for OIF submitted to CHPPM, we discussed the numbers
of reports submitted and characterized the categories of reports using
percentages. While the OEHS reports were contained in a computerized
archive, there was no formal database in which the information from the
reports could have been extracted into data fields. Instead, the
archived reports were Microsoft Word documents, Microsoft Excel
spreadsheets, Adobe Acrobat files, scanned images, or e-mail text that
were organized by either military base or type of report. Therefore,
there was no specific database with data fields that could be examined
through a data reliability test.
To identify the efforts to use OEHS reports to address the more
immediate health issues of servicemembers deployed in support of OIF,
we reviewed DOD policies and documents describing the operational risk
management process. Additionally, we reviewed 28 risk assessment
reports and the risk mitigation efforts and risk communication
activities that resulted from these assessments. We also reviewed and
summarized risk management activities for Port Shuaiba, Kuwait. We
interviewed officials from CHPPM responsible for OEHS risk management
activities at Port Shuaiba and discussed quality assurance efforts
related to these activities. We also interviewed officials from DHSD
about additional OEHS-related quality assurance programs.
To identify the efforts under way to use OEHS reports to address the
long-term health issues of servicemembers deployed in support of OIF,
we interviewed Department of Veterans Affairs (VA) and DOD officials to
examine access to OEHS reports and use of OEHS reports for VA, and
reviewed laws relating to classification of documents. Additionally, we
reviewed relevant VA documents to determine the ways in which VA can
use OEHS reports and to determine its efforts to anticipate OEHS issues.
To determine the difficulties in linking OEHS reports to the individual
records of servicemembers, we interviewed officials and military
representatives at DOD's Defense Manpower Data Center (DMDC) regarding
the status of the Contingency Tracking System, a centralized tracking
database to identify deployed servicemembers and track their movements
within the theater of operations. To help identify problems with this
system, we asked DMDC to provide information about the amount of
location data submitted by each military service to this database. To
assess the reliability of the data submitted by each military service,
we (1) interviewed DMDC officials about limitations of the system and
(2) confirmed that the data included the elements we requested and were
consistent with provided documentation. We tested the data
electronically to ensure that the numbers were accurately calculated.
Given our research questions and discussions with DMCD officials
regarding the centralized system, we determined that these data were
reliable for our purposes.
We interviewed CHPPM officials to examine efforts to include
information from investigations of potential exposures to occupational
and environmental health hazards in servicemembers' medical records,
and reviewed summary documents related to potential occupational and
environmental exposures. We also interviewed Army, Air Force, and Navy
officials to discuss these summary documents and determine efforts in
place to ensure that these documents were placed in the medical
records. We also examined other documents, including DOD policies,
federal laws, and interagency coordinating council meeting minutes
relating to OEHS.
We interviewed DOD and VA officials to determine whether a federal
research plan using OEHS reports had been developed to evaluate the
long-term health of servicemembers deployed in support of OIF. We also
reviewed documents, including the meeting minutes of an interagency
group and documents relating to a current collaborative study between
DOD and VA. We performed our work from September 2004 through June 2005
in accordance with generally accepted government auditing standards.
[End of section]
Appendix II: Example of an Occupational and Environmental Health
Surveillance Summary Created by the Air Force during Operation Iraqi
Freedom:
PREVIOUS EDITION IS USABLE:
AUTHORIZED FOR LOCAL REPRODUCTION:
CHRONOLOGICAL RECORD OF MEDICAL CARE:
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each
entry):
ENVIRONMENTAL/OCCUPATIONAL HEALTHWORKPLACE EXPOSURE DATA:
This assessment covers individuals deployed to BAGHDAD AIR BASE (BDAB),
IRAQ for the time period 15 DEC 03 to 30 APR 2004.
Purpose: To comply with the deployment health surveillance requirements
of Presidential Review Directive 5 and JCSM 0006-02, Updated Procedures
for Deployment Health Surveillance and Readiness. CENTAF/SG officially
sanctions use of this form and recommends it be maintained in the
individual s permanent medical record with the DD Form 2796, Post
Deployment Health Assessment, covering the same time period.
Camps Sather and Griffin, the primary AF locations on Baghdad
International Airport (BIAP), were part of the Iraqi Military Training
portion of BIAP. However, this specific area was not heavily used. The
small Iraqi terminal on site was for military guests and distinguished
visitors. Base housing and training was on the other side of the main
road outside Camp Sather. While there is farming around BIAP, we are
not aware of any specific farming activities within Camp Sather;
however, there is evidence of flooded fields in/around Camp Griffin. We
are also not aware of any major spills within the BIAP AF cantonment.
BDAB refers to both Camps Sather and Griffin.
Environmental Exposure Data and Risk Assessment:
1. Airborne Dust: The level of airborne particulate matter is high
throughout the Middle East due to wind blown dust and sand. Expected
health effects associated with exposures to airborne particulates
include eye, nose, and throat irritation, sneezing, coughing, sinus
congestion, sinus drainage, and aggravation of asthma conditions. Based
on air sampling performed in and around BIAP, the overall health risk
to personnel from exposure to airborne dust is assessed as low. PM sub
10 and manganese air samples taken in late May 2003 indicated
concentrations nearly double their respective military exposure
guidelines. However, no long-term health affects are anticipated for
personnel as for a period less than two years.
2. Airborne Emissions From Petroleum Production/Other Nearby
Industrial/Disposal Activities: There are multiple industrial
activities near BIAP. Chemical storage and processing plants are
located within 5-10 miles of BIAP, primarily to the east and south.
However, operations at these facilities are severely limited in the
aftermath of combat activities in/around BIAP. Multiple industrial
activities, to include manufacturing, construction, and petroleum
refining are located in the greater Baghdad metropolitan area. With the
prevailing winds from the northwest, BIAP is located downwind from only
a few industrial activities, primarily light to medium manufacturing
facilities. Routine exposure of BIAP personnel to airborne emissions
from off-base industrial sources is assessed as minimal to nonexistent,
with no increased risk to health resulting from routine exposure. Army
units in/around BIAP no longer burn out human and other waste products,
and no units BIAP burn trash/garbage. There is no health risk expected
from these intermittent exposures.
3. Endemic Diseases: Leishmaniasis (both cutaneous and visceral) occurs
in Iraq at a sporadic level. On-base vector surveillance, during
transmission season, yielded many sand flies from unbated traps, some
of which tested positive for leishmaniasis. Risk to BDAB personnel is
assessed as low, so long as the sand fly burden is kept under control.
Cases may not present with symptoms until 4-6 months post-redeployment.
Malaria is present in Iraq, but to date has not been a significant
issue in the Baghdad area. Anopheles mosquitoes are present on BIAP and
95% of endemic malaria is Plasmodium vivax. CENTCOM reporting
instructions require personnel to treat uniforms with permethrin and
apply DEET to exposed skin as necessary to prevent bites. Sanitation
varies within the country, but typically is well below U.S. standards.
Consuming local food or water poses a significant risk to personnel for
bacterial diarrhea. Personnel were advised to consume only food, water,
and ice from approved sources. Tuberculosis (TB) disease risk
assessment for Iraq is low. Unless individuals had exposure to anyone
known or suspected of having active TB, worked closely with refugees or
prisoners, or had prolonged contact with the local populace, a post-
deployment tuberculin skin test is not required. Plague is restricted
to focal areas; enzootic foci historically have existed along the
Tigris-Euphrates River--extending to Kuwait. Plague risk assessment is
low.
4. Drinking Water: Bottled water is the source of 100% of the drinking
water used on BDAB. All bottled water comes from approved sources and
is tested by 447 EMEDS to ensure water quality meets all applicable
standards. BDAB has a water distribution system that is supplied via
truck by US Army reverse osmosis purification units located at North
Palace, using water from a lake fed by the Tigris River. Tap water is
considered non-potable and only recommended for cleaning and hygiene
purposes.
5. Hazardous Animals and Insects: Several species of venomous snakes,
scorpions and spiders have been identified on base. Generally, they are
limited in number and BDAB personnel experience minimal sightings or
contact. Unless otherwise specified in the medical record, individual
reported no adverse contact (i.e. bites). Feral cats and dogs have also
been noted in the area. Rats and mice have been a nuisance; one rat
bite was reported in the summer of 2003.
6. Waste Sites/Waste Disposal: Hazardous waste storage on BDAB is
limited to used and off-spec POL products, and small spill cleanup
residue. Currently, proper handling, storage, and disposal of
industrial waste generated on base (mainly oil, fuel and hydraulic
fluid) are strictly enforced. Airborne exposure to base personnel from
stored waste is assessed as minimal to nonexistent. No obvious signs of
significant past spills or tank leakage were noted when coalition
forces occupied BIAP, although POL personnel did drain and remove
several extant tanks. Trash and garbage are containerized and routinely
collected by contractors. Latrines are pumped out by trucks and waste
is disposed off-BIAP.
7. Nuclear, Biological or Chemical (NBC) Weapon Exposure: There has
been no evidence of any use, storage, release, or exposure of NBC
agents to personnel at this site.
8. Agricultural Emissions: Surrounding land is moderately agricultural.
Many farms are within 1-2 miles of the perimeter fence, with numerous
potentially flooded fields for rice cultivation. Aerial photos previous
to May 2003 revealed that much of BIAP, including parts of the AF
cantonment, were rice cultivation areas. While we haven'''t witnessed
any significant application, herbicide/pesticide use probably routinely
occurs just outside the base. However, airborne exposure to base
personnel is assessed as minimal to nonexistent.
9. Depleted Uranium (DU): DU is a component of some aircraft present
and/or transient on/through BDAB. There is no evidence of DU munitions
having been expended at BIAP. Therefore, there is no potential airborne
exposure to DU. Exposure is classified as far below permissible
exposure levels.
10. Hazardous Materials: There are only a few permanent structures on
BDAB. Both lead-based paint and potential asbestos-containing material
have been tentatively identified in various locations on BIAP; however,
personnel are not performing activities that involve routine exposure,
thereby minimizing health risk. There were multiple sites where Iraqi
hazardous materials caches were located; however, personnel exposures
were minimized/eliminated by removing or limiting access to the
materials.
Occupational Exposure Data and Risk Assessment:
1. Noise: Aircraft, aircraft ground equipment, generators and other
equipment produce hazardous noise. Workers routinely exposed to
hazardous noise are those working on or near the flight line and/or in
selected industrial shops. These workers have comparable noise exposure
at home station and are on the hearing conservation program. For all
individuals, appropriate hearing protection is provided for protection
against hazardous noise. Additionally, the whole of Camp Sather is
within 300 yards of an extremely active flightline.
2. Heat Stress: Daily temperature range: Mar - Oct from 75 F to 125 F;
Nov - Feb from 55 F to 95 F. Personnel are continually educated on heat
stress dangers, water intake and work/rest cycles. Unless separately
documented, individual had no heat related injury.
3. Airborne Exposure to Chemical Hazards: Unless specified in a duty-
specific supplement, individual exposure to chemical inhalation is
considered similar to duties performed at home station. On base
industrial activities include routine aircraft, equipment and
installation maintenance. Generally, majority of the chemicals used on
BDAB are oils, greases, lubricants, hydraulic fluids and fuel. Little
to no corrosion control activities are performed and no solvent tanks
exist on site. No industrial activity is performed that generates, or
has been expected to generate, airborne exposures above permissible
exposure levels or medical action levels.
4. Chemical Contact and Eye Protection: Unless specified in a job-
specific supplement, individual exposure to chemical contact is
considered similar to duties performed at home station. Workers are
provided appropriate protective equipment (i.e. nitrile/rubber gloves,
goggles, safety glasses and face shields) when and where needed.
5. Radiation: Ionizing radiation is emitted from medical/dental x-ray
and OSI operations, and low-level radioactive materials present in
equipment such as chemical agent monitors and alarms. No worker has
been identified as exceeding 10% of the 5 REM/year OS HA permissible
exposure level. Radio frequency (RF) radiation is emitted from multiple
radar systems and communication equipment. Systems are marked with
warning signs and communication workers receive appropriate training.
Unless otherwise documented, no worker has been identified as exceeding
RF-radiation permissible exposure limits. Significant UV radiation from
the sun is expected on exposed unprotected skin. BDAB personnel have
been advised to minimize sun exposure through the use of sunscreen and
wear of sleeves down. Additionally, BDAB is a high light level
environment. Many cases of photosensitivity dermatitis were observed.
Some were no doubt exacerbated by the use of doxycycline for malaria
prophylaxis. Unless otherwise stated in medical record, individual
reported no radiation/light related injuries.
6. Ergonomics: Individual exposure to ergonomic stress from job related
duty is substantially similar to duties performed at home station, with
potential moderate increase in lifting involved with unique deployment
requirements such as erection of tents and shelters. Unless otherwise
stated in medical record, individual reported no ergonomic stress
related injuries.
7. Bloodborne Pathogens: Individual exposure to bloodborne pathogens
from job related duty is considered similar to duties performed at home
station. Applicable workers are provided appropriate protective
equipment and have been placed on the bloodborne pathogen program.
Unless otherwise stated elsewhere in the medical record, individual
reported no significant unprotected exposures.
//SIGNED//:
HOSPITAL OR MEDIAL FACILITY: 447 EMEDS, Baghdad Air Base Iraq:
RELATIONSHIP TO SPONSOR: Self:
PATIENT S IDENTIFICATION: (For typed or written entries, give: Name
last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE:
Medical Record:
STANDARD FORM 600 (REV. 6-97) Prescribed by GSAHCMR:
FIRMR (41 CFR) 201-9.202-1:
STANDARD FORM 600 (REV. 6-97) BACK:
[End of section]
Appendix III: Comments from the Department of Defense:
THE ASSISTANT SECRETARY OF DEFENSE:
HEALTH AFFAIRS:
WASHINGTON, D. C. 20301-1200:
JUN 17 2005:
Ms. Marcia Crosse:
Director, Health Care:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Crosse:
This is the Department of Defense (DoD) response to the GAO draft
report, "DEFENSE HEALTH CARE: Improvements Needed in Occupational and
Environmental Health Surveillance to Address Immediate and Long-Term
Health Issues, " May 13, 2005 (GAO-05-632/GAO Code 290338). The
Department partially concurs with the GAO draft report. Deployment
occupational and environmental health surveillance is a key component
of protecting the health of our deployed personnel and it is a
paramount concern of the Department of Defense and my office. Working
with the Military Services, the Joint Staff, and the Combatant
Commands, we are making substantive progress in addressing the
immediate and long-term health issues associated with deployment
environmental exposures.
We nonconcur with Recommendation 1. The DoD is revising DoD Instruction
6490.3 (to be re-titled, "Deployment Health Surveillance and
Readiness"). Preliminary coordination and review has begun, and all
Military Services and the Joint Staff are part of that process. The
Joint Staff will draft jointly developed, cross-Service implementation
guidance, as needed, for this instruction once it is complete.
We partially concur with Recommendation 2. The Occupational and
Environmental Health Surveillance (OEHS) reports would be of no value
for "immediate" health risks, except for incident-driven reports to the
on-scene commander. Therefore, we assume the GAO is referring to those
health risks that may occur following the servicemembers' return from
deployment. We also believe this recommendation was intended to address
deployment OEHS risk management and not every risk management decision
a commander makes. The DoD already has procedures in place to evaluate
risk management decisions through a jointly established and implemented
lessons learned process, including lessons pertaining to OEHS risk
management.
We partially concur with Recommendation 3. We agree on the importance
of following the health of our servicemembers and are committed to
sharing medically significant health care information as servicemembers
transition from the DoD to the Department of Veterans Affairs. Along
with the Departments of Health and Human Services and Veterans Affairs,
we have announced a set of uniform standards for the electronic
exchange of clinical health information to be adopted across the
federal government. These standards are part of the foundation of the
National Health Information Infrastructure that will serve consumers,
patients, health care providers, and public health professionals.
Standardized information exchange, with privacy and security
protections, will make it easier for health care providers to share
relevant patient information and for public health professionals to
identify emerging public health threats. Standardized information
exchange also makes portable electronic medical records more easily
achievable. We will make medically significant OEHS records available
through this system when the technology matures sufficiently to make
that feasible.
The Department appreciates the opportunity to comment on the GAO draft
report. Additional comments are enclosed. Our primary point of contact
is Dr. Michael Kilpatrick, Deputy Director, Deployment Health Support
Directorate, at 703-578-8504.
Signed by:
William Winkenwerder, Jr., MD
Enclosure: As stated:
[End of section]
Appendix IV: Comments from the Department of Veterans Affairs:
THE DEPUTY SECRETARY OF VETERANS AFFAIRS:
WASHINGTON:
June 13, 2005:
Ms. Marcia Crosse:
Director:
Health Care Team:
U. S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. Crosse:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, DEFENSE HEALTH CARE:
Improvements Needed in Occupational and Environmental Health
Surveillance to Address Immediate and Long-term Health Issues, (GAO-05-
632). While the Department agrees with GAO's overall conclusions and
the intent of the recommendations, VA believes the reviewers should
emphasize several key issues that directly impact VA's capability to
anticipate and study potential long-term health effects for service
members deployed in support of Operation Iraqi Freedom. The enclosure
discusses this in more detail.
VA appreciates the opportunity to comment on your draft report.
Sincerely yours,
Gordon H. Mansfield:
Enclosure:
Enclosure:
THE DEPARTMENT OF VETERANS AFFAIRS (VA) COMMENTS TO GOVERNMENT
ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT:
DEFENSE HEALTH CARE: Improvements Needed in Occupational and
Environmental Health Surveillance to Address Immediate and Long-term
Health Issues (GAO-05-632):
To better anticipate and understand the potential long-term health
effects of deployment in support of OIF, we recommend that the
Secretary of Defense and the Secretary of Veterans Affairs work
together to develop a federal plan to follow the health of these
service members that would include the use of archived OEHS reports.
Concur-The Department of Veterans Affairs (VA) agrees with GAO's
conclusions and the intent of the recommendations. VA would like to
emphasize several key issues that directly impact the Department's
capability to anticipate and study potential long-term health effects
for service members deployed in support of Operation Iraqi Freedom
(OIF). The plan to follow the health of these service members over
time, using Department of Defense's (DoD) archived occupational and
environmental health surveillance (OEHS) data, is already well
underway. In its Joint Strategic Plan, the VA/DoD Health Executive
Council (HEC) has clearly identified long-term medical and
environmental surveillance as a major goal. The HEC-chartered DoD/VA
Deployment Health Work Group and its research sub-group are assessing
the types of research strategies that will be required to evaluate the
long-term health of veterans returning from both OIF and Operational
Enduring Freedom (OEF). GAO accurately reports that this work group has
begun this task by initiating an ongoing evaluation of relevant
research that is planned or underway. Following this evaluation, a
comprehensive joint federal surveillance plan will be developed.
GAO points out identified concerns about beginning studies on a veteran
population that is rapidly changing. Since an established study
population cannot be identified now, most of the meaningful studies
will have to be conducted at the end of the current conflict. At that
point, VA anticipates a solid framework will be in place to expedite
related research. Part of this effort will be to include use of all
environmental and occupational exposure data that DoD has collected
during these deployments.
GAO suggests that the most pressing issue is VA's ability to access the
DoD collected occupational and environmental health data. Merely having
access to a significant amount of the uncorrelated raw data currently
available is not the complete answer. Instead, VA maintains that what
is needed is development of a systematic method to tabulate and
organize the exposure data so that it will be useable for research and
other scientific purposes. For example, VA's fundamental data needs
are: 1) a complete roster of all OIF/OEF veterans; 2) pre and post-
deployment health screening data, and 3) a complete roster of the most
seriously injured veterans to help VA plan for the necessary seamless
transition of this group. Aggregation of the raw OEHS data is a far
more important concern than the security classification limitations
highlighted in GAO's report. VA has staff who possess the necessary
security clearances to examine these reports, so there should be no
barrier to access.
VA is committed to fostering close, cooperative ties with DoD in
assuring seamless transition and research efforts. VA and DoD have
already undertaken a mortality study and a longitudinal morbidity study
of OIF and OEF veterans. These two studies will form a strong
foundation for future epidemiological research on this new veteran
population. Additionally, the federal government expended more than
$250 million to study the health risks for veterans from the first Gulf
War in 1991, and information generated from those assessments is
applicable to veterans serving in Iraq and nearby countries.
(290338):
FOOTNOTES
[1] The Chairman of the Joint Chiefs of Staff is the principal military
adviser to the President, the National Security Council, and the
Secretary of Defense.
[2] The Navy supports OEHS activities for the Marine Corps.
[3] Harmful levels of environmental contaminants are determined by the
concentration of the substance and the duration of exposure.
[4] Presidential Review Directive, National Science and Technology
Council - 5 (Apr. 21, 1997). The National Science and Technology
Council is a cabinet-level council that helps coordinate federal
science, space, and technology research and development for the
President.
[5] National Defense Authorization Act for Fiscal Year 1998. Pub. L.
No. 105-85, §768, 111 Stat. 1629, 1828 (1997) ("Sense of Congress").
[6] The working group makes recommendations for deployment OEHS policy
to the Deputy Assistant Secretary of Defense for Force Health
Protection and Readiness, who serves as the director of DHSD.
[7] Each military service has preventive medicine units, though they
may be named differently. Throughout this report, we use the term
preventive medicine unit to apply to the units fielded by all military
services.
[8] While in the deployment location, preventive medicine units create
and store reports both electronically and using paper-based formats.
[9] Some bases can have more than one baseline report.
[10] DOD officials said the analysis of servicemembers' responses to a
post-deployment health assessment questionnaire is another means to
identify potential exposures that should be investigated. These
assessments, designed to identify health issues or concerns that may
require medical attention, use a questionnaire that is to be completed
in theater and asks servicemembers if they believe they have been
exposed to a hazardous agent.
[11] Throughout the report we refer to both base camps and forward
operating bases collectively as bases. A forward operating base is
usually smaller than a base camp in troop strength and infrastructure
and is normally constructed for short-duration occupation.
[12] The command surgeons of deployed preventive medicine units are
either Joint Task Force command surgeons or military service component
command surgeons. In OIF, there are two Joint Task Forces, each with a
command surgeon. In addition, the Army, Navy, Air Force, and Marine
Corps have their own subordinate component commands in a deployment,
each with a command surgeon.
[13] DOD has designated CHPPM as the entity responsible for archiving
all OEHS reports from deployments.
[14] DOD policy does not prescribe a time frame for how long preventive
medicine units have to complete a report.
[15] CHPPM also receives some deployment OEHS data that have not been
incorporated into a report, such as tables of water sampling
measurements.
[16] The U.S. Central Command is the combatant command responsible for
all OIF operations.
[17] Along with deployment OEHS reports, commanders also examine
medical intelligence, operational data, and medical surveillance (such
as reports of servicemembers seen by medical units for injury or
illness) to identify occupational and environmental health hazards.
[18] Examples of health encounter data are medical records of in-
patient and out-patient care, health assessments completed by
servicemembers before and after a deployment, and blood serum samples.
[19] OEHS standards generally set out technical requirements for
monitoring, including the type of equipment needed and the appropriate
frequency of monitoring.
[20] This standard was approved in October 2003.
[21] Incident-driven reports reflect OEHS investigations of unexpected
incidents and would not be submitted to CHPPM's archive according to
any identified pattern. Therefore, we did not comment on the services'
submission of incident-driven reports.
[22] The U.S. Central Command has established and closed bases
throughout the OIF deployment; therefore, the number of bases for each
summary report varied.
[23] A base may have had both baseline and routine reports submitted to
the OEHS archive.
[24] DOD officials said that during a deployment, preventive medicine
units share the military's classified communication system with all
other deployed units and transmission of OEHS reports might be a lower
priority than other mission communications traffic. Also, preventive
medicine units might not deploy with communications equipment.
[25] OEHS risk management began to be employed during previous
deployments, such as Operation Joint Guardian in Kosovo and Operation
Enduring Freedom in Central Asia, but it was not formally adopted as a
tool to assess deployment health hazards until 2002. See Office of the
Chairman, The Joint Chiefs of Staff, Memorandum MCM-0006-02, "Updated
Procedures for Deployment Health Surveillance and Readiness," Feb. 1,
2002.
[26] An Army operational risk management field manual describes the
steps in determining risk level, including identifying the hazard,
assessing the severity of the hazard, and determining the probability
that the hazard will occur. DOD has also developed technical guides
that detail toxicity thresholds and associated potential health effects
from exposure to hazards.
[27] Risk assessments are used to designate identified occupational or
environmental health risks as posing a low, moderate, high, or
extremely high risk to servicemembers.
[28] Industrial facilities located at Port Shuaiba include a fertilizer
plant; natural gas processing and liquid petroleum gas storage
facilities; a concrete company; petrochemical, hydrochloric acid,
chlorine, caustic soda, and methanol plants; and three petroleum
refineries.
[29] OEHS activities have been conducted at Port Shuaiba since 1999.
[30] Port Shuaiba has been the only deepwater port able to accommodate
the unloading of heavy military equipment in support of OIF; however,
efforts are under way to refurbish a nearby port to provide this
capability.
[31] Individuals desiring to review classified documents must have the
appropriate level of security clearance and a need to access the
information. VA officials have been able to access some OEHS data on a
case-by-case basis.
[32] Pub. L. No. 108-375, §735, 118 Stat. 1811, 1999 (2004).
[33] GAO, Defense Health Care: Medical Surveillance Improved Since Gulf
War, but Mixed Results in Bosnia, GAO/NSIAD-97-136 (Washington D.C.:
May 13, 1997).
[34] DOD policy requires DMDC to maintain a system that collects
information on deployed forces, including daily-deployed strength, in
total and by unit; grid coordinate locations for each unit (company
size and larger); and inclusive dates of individual servicemembers'
deployment. See DOD Instruction 6490.3, "Implementation and Application
of Joint Medical Surveillance for Deployment," Aug. 7, 1997. In
addition, a 2002 DOD policy requires combatant commands to provide DMDC
with rosters of all deployed personnel, their unit assignments, and the
unit's geographic locations while deployed. See Office of the Chairman,
The Joint Chiefs of Staff, Memorandum MCM-0006-02, "Updated Procedures
for Deployment Health Surveillance and Readiness," Feb. 1, 2002.
[35] The military services submitted location data for both OIF and
Operation Enduring Freedom in Central Asia; DMDC officials said they
were unable to separate the data from the two operations.
[36] DOD Instruction 6490.3, "Implementation and Application of Joint
Medical Surveillance for Deployment," Aug. 7, 1997.
[37] GAO, Gulf War Illnesses: Federal Research Strategy Needs
Reexamination, GAO/T-NSIAD-98-104 (Washington D.C.: Feb. 24, 1998).
[38] The Deployment Health Working Group includes representatives from
DOD, VA, and HHS.
[39] This effort also includes identifying research for Operation
Enduring Freedom.
[40] Epidemiologic studies generally have a fixed study population that
does not vary over time, according to VA officials.
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