Chemical and Biological Defense
DOD and VA Need to Improve Efforts to Identify and Notify Individuals Potentially Exposed during Chemical and Biological Tests Gao ID: GAO-08-366 February 28, 2008Tens of thousands of military personnel and civilians were potentially exposed to chemical or biological substances through Department of Defense (DOD) tests since World War II. DOD conducted some of these tests as part of its Project 112 test program, while others were conducted as separate efforts. GAO was asked to (1) assess DOD's efforts to identify individuals who were potentially exposed during Project 112 tests, (2) evaluate DOD's current effort to identify individuals who were potentially exposed during tests conducted outside of Project 112, and (3) determine the extent to which DOD and the Department of Veterans Affairs (VA) have taken action to notify individuals who might have been exposed during chemical and biological tests. GAO analyzed documents and interviewed officials from DOD, VA, the Department of Labor, and a veterans service organization.
Since 2003, DOD has stopped actively searching for individuals who were potentially exposed to chemical or biological substances during Project 112 tests, but did not provide a sound and documented basis for that decision. In 2003, DOD reported it had identified 5,842 servicemembers and estimated 350 civilians as having been potentially exposed during Project 112, and indicated that DOD would cease actively searching for additional individuals. However, in 2004, GAO reported that DOD did not exhaust all possible sources of information and recommended that DOD determine the feasibility of identifying additional individuals. In response to GAO's recommendation, DOD determined continuing an active search for individuals had reached the point of diminishing returns, and reaffirmed its decision to cease active searches. This decision was not supported by an objective analysis of the potential costs and benefits of continuing the effort, nor could DOD provide any documented criteria from which it made its determination. Since June 2003, however, non-DOD sources--including the Institute of Medicine--have identified approximately 600 additional names of individuals who were potentially exposed during Project 112. Until DOD provides a more objective analysis of the costs and benefits of actively searching for Project 112 participants, DOD's efforts may continue to be questioned. DOD has taken action to identify individuals who were potentially exposed during tests outside of Project 112, but GAO identified four shortcomings in DOD's current effort. First, DOD's effort lacks clear and consistent objectives, scope of work, and information needs that would set the parameters for its efforts. Second, DOD has not provided adequate oversight to guide this effort. Third, DOD has not fully leveraged information obtained from previous research efforts that identified exposed individuals. Fourth, DOD's effort lacks transparency since it has not kept Congress and veterans service organizations fully informed of the progress and results of its efforts. Until DOD addresses these limitations, Congress, veterans, and the American public can not be assured that DOD's current effort is reasonable and effective. DOD and VA have had limited success in notifying individuals potentially exposed during tests both within and outside Project 112. DOD has a process to share the names of identified servicemembers with VA; however, DOD has delayed regular updates to VA because of a number of factors, such as competing priorities. Furthermore, although VA has a process for notifying potentially exposed veterans, it was not using certain available resources to obtain contact information to notify veterans or to help determine whether they were deceased. Moreover, DOD had not taken any action with the civilian names, focusing instead on veterans since the primary impetus for the research has been requests from VA. DOD has refrained from taking action on civilians in part because it lacks specific guidance that defines the requirements to notify civilians. Until these issues are addressed, some identified veterans and civilians will remain unaware of their potential exposure.
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-08-366, Chemical and Biological Defense: DOD and VA Need to Improve Efforts to Identify and Notify Individuals Potentially Exposed during Chemical and Biological Tests
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
February 2008:
Chemical And Biological Defense:
DOD and VA Need to Improve Efforts to Identify and Notify Individuals
Potentially Exposed during Chemical and Biological Tests:
Chemical and Biological Defense:
GAO-08-366:
GAO Highlights:
Highlights of GAO-08-366, a report to congressional requesters.
Why GAO Did This Study:
Tens of thousands of military personnel and civilians were potentially
exposed to chemical or biological substances through Department of
Defense (DOD) tests since World War II. DOD conducted some of these
tests as part of its Project 112 test program, while others were
conducted as separate efforts. GAO was asked to (1) assess DOD‘s
efforts to identify individuals who were potentially exposed during
Project 112 tests, (2) evaluate DOD‘s current effort to identify
individuals who were potentially exposed during tests conducted outside
of Project 112, and (3) determine the extent to which DOD and the
Department of Veterans Affairs (VA) have taken action to notify
individuals who might have been exposed during chemical and biological
tests. GAO analyzed documents and interviewed officials from DOD, VA,
the Department of Labor, and a veterans service organization
What GAO Found:
Since 2003, DOD has stopped actively searching for individuals who were
potentially exposed to chemical or biological substances during Project
112 tests, but did not provide a sound and documented basis for that
decision. In 2003, DOD reported it had identified 5,842 servicemembers
and estimated 350 civilians as having been potentially exposed during
Project 112, and indicated that DOD would cease actively searching for
additional individuals. However, in 2004, GAO reported that DOD did not
exhaust all possible sources of information and recommended that DOD
determine the feasibility of identifying additional individuals. In
response to GAO‘s recommendation, DOD determined continuing an active
search for individuals had reached the point of diminishing returns,
and reaffirmed its decision to cease active searches. This decision was
not supported by an objective analysis of the potential costs and
benefits of continuing the effort, nor could DOD provide any documented
criteria from which it made its determination. Since June 2003,
however, non-DOD sources”including the Institute of Medicine”have
identified approximately 600 additional names of individuals who were
potentially exposed during Project 112. Until DOD provides a more
objective analysis of the costs and benefits of actively searching for
Project 112 participants, DOD‘s efforts may continue to be questioned.
DOD has taken action to identify individuals who were potentially
exposed during tests outside of Project 112, but GAO identified four
shortcomings in DOD‘s current effort. First, DOD‘s effort lacks clear
and consistent objectives, scope of work, and information needs that
would set the parameters for its effort. Second, DOD has not provided
adequate oversight to guide this effort. Third, DOD has not fully
leveraged information obtained from previous research efforts that
identified exposed individuals. Fourth, DOD‘s effort lacks transparency
since it has not kept Congress and veterans service organizations fully
informed of the progress and results of its effort. Until DOD addresses
these limitations, Congress, veterans, and the American public cannot
be assured that DOD‘s current effort is reasonable and effective.
DOD and VA have had limited success in notifying individuals
potentially exposed during tests both within and outside Project 112.
DOD has a process to share the names of identified servicemembers with
VA; however, DOD has delayed regular updates to VA because of a number
of factors, such as competing priorities. Furthermore, although VA has
a process for notifying potentially exposed veterans, it was not using
certain available resources to obtain contact information to notify
veterans or to help determine whether they were deceased. Moreover, DOD
had not taken any action to notify identified civilians, focusing
instead on veterans since the primary impetus for the research has been
requests from VA. DOD has refrained from taking action on notifying
civilians in part because it lacks specific guidance that defines the
requirements to notify civilians. Until these issues are addressed,
some identified veterans and civilians will remain unaware of their
potential exposure.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.GAO-08-366]. For more information, contact Davi
M. D'Agostino at (202) 512-5431 or dagostinod@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
DOD's Decision to Stop Actively Searching for Project 112 Individuals
Was Not Based on a Sound and Documented Cost-Benefit Analysis:
DOD's Effort to Identify Individuals Potentially Exposed during Non-
Project 112 Tests Has Several Shortcomings:
DOD and VA Have Had Limited Success in Notifying Potentially Exposed
Individuals:
Conclusions:
Matters for Congressional Consideration:
Recommendations for Executive Action:
Agencies' Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Comments from the Department of Defense:
Appendix III: Comments from the Department of Veterans Affairs:
Appendix IV: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Number of Servicemembers Identified as Having Been Potentially
Exposed during Project 112:
Table 2: Number of Non-Project 112 Servicemembers Identified by DOD as
of December 2007:
Table 3: Veterans Who VA Has Notified of Their Potential Exposure as of
December 2007:
Table 4: Number of Civilians Potentially Exposed as of December 2007:
Abbreviations:
DOD: Department of Defense:
VA: Department of Veterans Affairs:
OUSD (AT&L): Office of the Undersecretary of Defense for Acquisition,
Technology, and Logistics:
OUSD (P&R): Office of the Under Secretary of Defense for Personnel and
Readiness:
OASD (HA): Office of the Assistant Secretary of Defense for Health
Affairs:
United States Government Accountability Office:
Washington, DC 20548:
February 28, 2008:
The Honorable Ike Skelton:
Chairman:
Committee on Armed Services:
House of Representatives:
The Honorable Vic Snyder:
Chairman:
Subcommittee on Oversight and Investigations:
Committee on Armed Services:
House of Representatives:
The Honorable Mike Thompson:
House of Representatives:
As we have previously reported, since World War II, tens of thousands
of military personnel and civilians have been involved in classified
human experimentation and were potentially exposed to chemical and
biological substances[Footnote 1] through tests conducted or sponsored
by the Department of Defense (DOD).[Footnote 2] Some of these tests and
experiments involved the intentional exposure of people to hazardous
substances such as blister and nerve agents, biological agents,
lysergic acid diethylamide (LSD), and phencyclidine (PCP). In some
cases, healthy adults, psychiatric patients, and prison inmates were
used in these tests and experiments. According to a 1994 staff report
to the Senate Committee on Veterans Affairs, in some instances,
servicemembers who consented to serve as human subjects found
themselves participating in experiments quite different from those
described at the time they volunteered.[Footnote 3] These tests and
experiments were conducted to support weapon development programs,
identify methods to protect the health of military personnel against a
variety of diseases and combat conditions, and analyze U.S. defense
vulnerabilities. From 1962 through 1974, DOD conducted a series of
classified ship-based and land-based chemical and biological warfare
tests involving military and civilian personnel as well as, in some
cases, foreign personnel observers--both military and civilian. These
tests were called Project 112 because in 1962 it was the 112th project
of 150 delineated by the Secretary of Defense involving the classified
testing of chemical and biological agents.
Precise information on the number of tests, experiments, and
participants is not available, and the exact numbers will never be
known. However, as a result of questions raised by members of Congress
and veterans since 1993, DOD has undertaken three major initiatives to
identify individuals potentially exposed to chemical or biological
substances during tests it has sponsored or conducted. First, from 1993
to 1997, the former Office of the Assistant Secretary of Defense for
Force Manpower and Personnel within the Office of the Under Secretary
of Defense (OUSD) for Personnel and Readiness (P&R) participated in a
working group with the military services and the Department of Veterans
Affairs (VA) in response to a January 1993 Institute of Medicine
report[Footnote 4] on the exposure of individuals to mustard agents and
lewisite.[Footnote 5] The working group identified approximately 6,400
servicemembers and civilians who were exposed to mustard agents and
other chemical substances.
Second, in August 2000, the acting Secretary of Veterans Affairs wrote
a letter to the Secretary of Defense requesting assistance in obtaining
information about a series of then-classified chemical and biological
tests under DOD's Project 112 program. In response to this request and
subsequent congressional direction in the Bob Stump National Defense
Authorization Act for Fiscal Year 2003,[Footnote 6] the Office of the
Assistant Secretary of Defense (OASD) for Health Affairs (HA) within
OUSD (P&R) conducted an internal DOD investigation into Project
112.[Footnote 7] In a resulting report issued in 2003, DOD identified
5,842 servicemembers and estimated that 350 civilians had been
potentially exposed during Project 112 tests.[Footnote 8] We
subsequently evaluated DOD's efforts, and in May 2004, we reported that
DOD appeared to have accurately identified all major chemical and
biological tests associated with Project 112, but that there likely
were servicemembers and civilian personnel potentially exposed to
substances who had not been identified for various reasons.[Footnote 9]
Third, and in further response to congressional direction in the
Defense Authorization Act for FY 2003, the Office of the Special
Assistant for Chemical and Biological Defense and Chemical
Demilitarization Programs (hereafter referred to as the chemical and
biological defense office) within the OUSD for Acquisition, Technology,
and Logistics (AT&L) issued a task order to a contractor in September
2004 to identify servicemembers and civilian personnel who might have
been exposed to chemical and biological substances outside of Project
112 tests.[Footnote 10] The research being done as a result of this
task order is ongoing as of December 2007.
For this review, you asked us to examine DOD's current effort to
identify and notify individuals who were potentially exposed during
chemical and biological tests conducted or sponsored by DOD, including
tests conducted as a part of DOD's Project 112 program and tests
conducted outside of Project 112. Accordingly, this report (1) assesses
DOD's efforts since 2003 to identify individuals who were potentially
exposed during chemical or biological tests conducted during Project
112, (2) evaluates DOD's current effort to identify individuals who
were potentially exposed during chemical or biological tests conducted
outside of Project 112, and (3) determines the extent to which DOD and
VA have taken action to notify individuals who might have been exposed
during chemical and biological tests.
To evaluate DOD's efforts to identify all individuals who were
potentially exposed to chemical or biological substances during Project
112 tests and tests outside of Project 112, we interviewed and obtained
documentation from cognizant DOD, Institute of Medicine, and contractor
officials. To determine how potentially exposed individuals were
identified, we visited record repository sites where contractors were
conducting research and observed their research and documentation
process. To determine the extent to which DOD and VA have taken action
to notify servicemembers who might have been exposed during chemical
and biological tests, we met with DOD officials to discuss their
efforts to provide names of identified servicemembers to VA and with VA
officials to describe VA's notification process. We evaluated the
reliability of DOD's and VA's databases containing the names of
individuals potentially exposed during chemical and biological tests
and found that there were potential problems with the quality and
reliability of the information. Although we determined that the
information was sufficiently reliable for the purposes of our review,
this report discusses weaknesses with DOD's information, and our
recommendation to address them. Consequently, the number of individuals
whom we report as having been identified and notified is based on
information from DOD's and VA's databases and is approximate. We also
met with representatives from a veterans service organization to gain
their perspectives on DOD and VA efforts to identify and notify
veterans potentially exposed to chemical and biological substances
during DOD tests. Because DOD identified civilians who might have been
exposed to chemical or biological substances, we also met with DOD and
Department of Labor officials to ascertain their roles and
responsibilities in notifying such civilians. Additional information on
our scope and methodology appears in appendix I. We conducted this
performance audit from June 2007 to February 2008 in accordance with
generally accepted government auditing standards. Those standards
require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives.
Results in Brief:
DOD stopped actively searching for individuals who were potentially
exposed to chemical or biological substances during Project 112 tests
in 2003, but has yet to provide a sound and documented basis for its
decision. In 2003, DOD reported it had identified 5,842 servicemembers
and estimated 350 civilians as having been potentially exposed during
Project 112, and indicated that DOD would cease actively searching for
additional individuals, but that it would investigate any new
information that might be presented and share any additional or changed
information with VA and the public. In 2004, after reviewing DOD's
efforts, we reported that DOD did not exhaust all possible sources of
information during its investigation of Project 112, and we recommended
that DOD determine the feasibility of identifying additional
individuals.[Footnote 11] Sound management principles require that such
a determination be based on an objective analysis of the related costs
and benefits. However, in response to our recommendation, DOD
determined continuing an active search for individuals had reached the
point of diminishing returns, and reaffirmed its decision to cease
active searches. DOD officials could not provide us with a supporting
analysis based on objective data. Nor could they provide any documented
criteria which they used to make their determination, since OASD (HA)
was not required to provide any support or basis for the decision.
However, since June 2003, non-DOD sources have identified approximately
600 additional names of servicemembers and civilians who were
potentially exposed as a result of Project 112. For example, in 2007,
the Institute of Medicine identified 394 individuals not previously
identified by DOD while researching the long-term health effects of
participants in the shipboard hazard and defense tests, which were a
subset of Project 112 tests. In light of the increasing number of
individuals who have been identified since DOD ceased actively
searching, until DOD makes a sound and documented decision about the
costs and benefits of actively searching for Project 112 participants,
DOD's efforts may continue to be questioned. We are recommending that
DOD perform and document a sound, methodologically defensible analysis
of the costs and benefits of searching for individuals who may have
been exposed to chemical or biological substances during Project 112
tests and share this analysis with Congress.
DOD has taken actions to identify individuals who were potentially
exposed during chemical or biological tests outside of Project 112, but
we identified four shortcomings in DOD's current effort. First, DOD's
effort lacks clear and consistent objectives, scope of work, and
information needs that would set the parameters for this effort. For
example, DOD believes it should focus its efforts on individuals who
were potentially exposed during chemical or biological tests as
directed by the Defense Authorization Act for FY 2003, but the VA would
like to have information on individuals who have been potentially
exposed to chemical or biological substances during testing,
transportation, and storage since VA is responsible for adjudicating
all claims by servicemembers, regardless of how they were exposed. We
found inconsistent objectives provided by DOD to the contractor and
determined they were the result of various executive, congressional,
and DOD directions establishing different expectations. Second, until
June 2007, OUSD (AT&L)'s chemical and biological defense office had not
assigned an official to oversee the contractor's effort, nor had the
officials from that office visited any repositories where the
contractor had proposed or completed work, resulting in little
substantive oversight of the contractor. Numerous factors affect the
office's ability to provide oversight, including a lack of consistent
leadership, a shortage of personnel, and a lack of defined roles and
responsibilities. Third, OUSD (AT&L)'s chemical and biological defense
office did not fully leverage all available prior knowledge and
research of DOD and non-DOD entities to identify and use information
they developed on individuals potentially exposed during DOD's chemical
and biological tests. For example, in the current effort, OUSD (AT&L)'s
chemical and biological defense office had not contacted or coordinated
with former members of the OUSD (P&R) task force, or the non-DOD
scientists who developed data from another study on servicemembers who
were potentially exposed. Such coordination could have helped DOD
identify and prioritize site visits and ensure that the contractor was
not duplicating efforts. Fourth, DOD had not worked with veterans and
veterans service organizations to identify DOD projects or tests
outside Project 112 that may have exposed members of the armed forces
to chemical or biological substances, as required by the Defense
Authorization Act for FY 2003, and has not kept Congress and veterans
service organizations fully informed about its efforts. Until DOD
addresses these shortcomings, DOD leadership and Congress have little
assurance of the reasonableness and effectiveness of DOD's current
effort. We are recommending that DOD take a number of specific steps to
enhance these efforts.
DOD and VA have had limited success in notifying individuals
potentially exposed during chemical or biological tests, both within
and outside of Project 112. While DOD has a process and has shared the
names of identified servicemembers with VA, we identified three
shortcomings. First, the transmission of information between DOD and VA
has been inconsistent because, according to DOD officials, the exchange
of information does not follow a specific schedule, there are competing
priorities for resources, and DOD has experienced database management
issues. Second, although VA has a process for sending notification
letters to veterans who have been identified as having been potentially
exposed, VA has not used certain available resources to obtain contact
information. To date, VA has sent notification letters to 48 percent of
the names that DOD has provided to them and that they may be able to
contact. VA officials noted that while the total number of notification
letters sent is 48 percent of the number of names that DOD has provided
to them and that they may be able to contact, it represents all of the
individuals for whom they were able to obtain contact information. A
number of factors VA cannot control have impeded its ability to notify
veterans, such as missing social security numbers. However, we found
that VA was not using certain available resources to obtain contact
information to notify servicemembers who could be identified and
notified, or to help determine whether they were deceased. For example,
VA officials told us that they were using credit bureau databases as a
source for contact information, and they had not regularly coordinated
with the Internal Revenue Service to use their databases and had not
coordinated directly with the Social Security Administration to obtain
contact information from veterans receiving social security benefits or
to identify deceased veterans using the agency's death index. Third,
while we previously recommended that DOD address the appropriateness of
and responsibility for reporting new information related to civilians
who were identified and DOD concurred with our recommendation,[Footnote
12] DOD has not taken any action to notify approximately 1,900
civilians who were potentially exposed during chemical or biological
tests. DOD officials told us they have primarily focused on
servicemembers since the primary impetus for the research has been
requests for information from VA. In addition, DOD has not notified
these civilians in part because it lacks specific guidance that defines
the requirements, roles, responsibilities, and mechanisms to notify
civilians or transmit civilian exposure information to the appropriate
agency for notification. Specifically, while the Defense Authorization
Act for FY 2003 required DOD to identify its tests or projects that may
have exposed members of the armed forces to chemical or biological
substances, it did not specifically address civilian personnel who may
have been affected by these tests. Furthermore, there does not appear
to be a requirement for DOD or other federal agencies, such as the
Department of Labor, to notify civilians of their potential exposure.
Until DOD and VA address these shortcomings, some veterans and
civilians will remain unaware of their potential exposure. To ensure
that civilians who were potentially exposed to chemical or biological
substances as a result of tests conducted or sponsored by DOD are aware
of their circumstances, we are suggesting that Congress consider
requiring the Secretary of Defense, in consultation with the Secretary
of Labor, to develop specific guidance that ensures that civilians who
were potentially exposed to chemical or biological substances as a
result of tests conducted or sponsored by DOD are aware of their
circumstances. We are also recommending that DOD and VA take steps to
improve their efforts to share, obtain, and use available information
and to more effectively notify servicemembers who may have been exposed
to chemical or biological substances during DOD tests.
We provided DOD, VA, and the Department of Labor with a draft copy of
this report for comment. DOD generally agreed with five
recommendations, but disagreed with the recommendation to conduct and
document a cost-benefit analysis associated with continuing the search
for additional Project 112 participants, and to provide Congress with
the results of this analysis. The department noted that it has made a
full accounting of its Project 112 efforts to date and has no credible
leads to continue this research. However, because the department has
not adequately addressed our May 2004 recommendation to determine the
feasibility of addressing unresolved issues associated with Project 112
and a number of non-DOD sources have identified additional names of
individuals potentially exposed during Project 112 since DOD's 2003
report to Congress, we are suggesting Congress consider requiring the
Secretary of Defense to conduct and document an analysis that includes
a full accounting of information known, and the related costs,
benefits, and challenges associated with continuing the search for
additional Project 112 participants; and to provide Congress with the
results of this analysis. VA agreed with one recommendation and
partially agreed with another recommendation that pertained to their
activities, and the Department of Labor did not provide us with any
comments. The departments' comments and our evaluation of them are
discussed on pages 30-32. DOD and VA also provided technical comments,
which we incorporated as appropriate. DOD's and VA's comments are
reprinted in appendices II and III, respectively.
Background:
On January 6, 1993, the Institute of Medicine published a report that
discussed secret U.S. chemical weapons programs during World War
II.[Footnote 13] The report found that an estimated 60,000 military
personnel participated as human experimental subjects in tests of
exposure to mustard agents and lewisite and unknown numbers of
additional servicemembers may have been exposed to these substances
through their participation in the production, transportation, and/or
storage of these chemical substances. On February 18, 1993, we issued a
report that found VA lacked information about individuals who were
exposed during secret DOD chemical tests.[Footnote 14] After Members of
Congress, the President of the United States, and the Secretary of
Defense exchanged a series of letters about this issue in 1993, the
Deputy Secretary of Defense issued an agencywide memo that released all
individuals from any nondisclosure restrictions that might have been
placed on them, tasked the secretaries of the military departments to
undertake efforts to declassify and provide to VA as soon as possible
information about individuals who were potentially exposed, and
directed OUSD (P&R) to establish a task force to monitor the status of
DOD's efforts. As a result, OUSD (P&R), the military services, and VA
developed the Chemical Weapons Exposure Study Task Force to identify
DOD personnel exposed to chemical substances during testing, training,
transport, production, and storage. By conducting site visits and other
research efforts, the task force identified approximately 6,400
servicemembers and civilians who were potentially exposed to mustard,
lewisite, and other chemical substances. The office created a database
with information about these individuals (hereafter referred to as OUSD
(P&R) database) and, according to OUSD (P&R), sent certificates of
commendation to more than 700 individuals for whom it could find
contact information. In addition to its own research, OUSD (P&R), on
behalf of the task force, issued a task order for a contractor to
analyze, extract, and develop a database of information on all
volunteers and/or other subjects potentially exposed to live chemical
or biological substances. The contractor developed a database and
issued a series of reports that identified the locations of human
exposures to chemical substances, including those resulting from tests
and a variety of other activities such as transportation, production,
storage, and disposal.[Footnote 15] Congress continued to look into
this issue during 1994 through a series of hearings and a staff report
that was prepared for the U.S. Senate's Committee on Veteran
Affairs.[Footnote 16]
The issue of servicemembers being used as human subjects during DOD's
chemical and biological tests received high-level attention again in
2000, when the acting Secretary of Veterans Affairs wrote a letter to
the Secretary of Defense requesting assistance in obtaining information
about a series of then-classified chemical and biological tests under
DOD's Project 112 program. OASD (HA) officials consequently initiated
some actions to identify potentially exposed individuals. Subsequently,
DOD, VA, and Congress exchanged a series of correspondence about the
need to identify individuals who were potentially exposed during these
tests. Eventually, the Defense Authorization Act for FY 2003 required
DOD to submit to Congress and the Secretary of Veterans Affairs a
comprehensive plan for the review, declassification, and submittal to
VA of all DOD records and information on Project 112 that are relevant
to the provision of benefits by the Secretary of Veterans Affairs to
members of the armed forces who participated in that project. During
this effort, DOD identified 5,842 servicemembers and estimated that 350
civilians had been potentially exposed during Project 112 tests, and
this information was entered into a Project 112 database. The act
further required the Comptroller General to evaluate the plan and its
implementation.
The Defense Authorization Act for FY 2003 also required DOD to work
with veterans and veterans service organizations to identify DOD
projects or tests outside of Project 112 that may have exposed members
of the armed forces to chemical or biological substances. In June 2004,
we reported that DOD had not yet begun its investigation to identify
such projects or tests and recommended that the Secretary of Defense
direct the appropriate office(s) to finalize and implement a plan for
identifying DOD projects and tests conducted outside of Project 112
that might have exposed servicemembers to chemical or biological
substances and ensure that the plan addresses the scope, reporting
requirements, milestones, and responsibilities for those involved in
completing this effort.[Footnote 17] According to an OASD (HA)
official, OASD (HA) made an informal agreement with OUSD (AT&L) to
undertake this effort since OASD (HA) did not have the resources to
conduct an investigation itself or to fund a contractor to do the
research. In September 2004, OUSD (AT&L)'s chemical and biological
defense office issued a task order to fulfill this provision of the
legislation. The research being done as a result of this task order is
ongoing as of December 2007.
DOD's Decision to Stop Actively Searching for Project 112 Individuals
Was Not Based on a Sound and Documented Cost-Benefit Analysis:
In June 2003, after having identified several thousand servicemembers
and hundreds of civilians as having been potentially exposed to
chemical or biological substances during Project 112, DOD stopped
actively searching for additional individuals. According to a
knowledgeable DOD official, this decision was made without a sound and
documented cost-benefit analysis. The Defense Authorization Act for FY
2003 required DOD to review records and information necessary to
identify members of the armed forces who were or may have been exposed
to chemical or biological substances as a result of Project 112.
Subsequently, in June 2003, DOD issued a report to Congress that stated
that 5,842 servicemembers and an estimated 350 civilians might have
been exposed during Project 112 tests. The report also indicated that
DOD had ceased its active search for individuals potentially exposed
during Project 112 tests and that it would investigate any new
information that may be presented as well as share any additional or
changed information with VA and the public.
In 2004, we reported that DOD performed a reasonable investigation of
servicemembers who were potentially exposed to the substances used
during Project 112 tests. However, we found that DOD had not exhausted
all possibilities for identifying additional servicemembers and
civilian personnel who had been potentially exposed. Therefore, we
recommended that DOD determine the feasibility of addressing these
unresolved issues. In response to our recommendation, DOD determined
continuing an active search for individuals had reached the point of
diminishing returns, and reaffirmed its decision to cease active
searches. This decision was not supported by any objective analysis of
the potential costs and benefits of continuing the effort. Instead,
this decision was made by officials in OASD (HA) who had a working
knowledge of Project 112 tests and the contents of chemical and
biological test record repositories. These officials concluded that the
record repositories that had been searched contained the majority of
Project 112 documents; therefore, they believed that the bulk of
exposures related to Project 112 tests had already been identified.
Furthermore, the officials decided that the application of resources
necessary to continue searching for Project 112 exposures would result
in a diminishing return on their investment. The Office of Management
and Budget has stated that a good cost-benefit analysis should include
a statement of the assumptions, the rationale behind them, and a review
of their strengths and weaknesses.[Footnote 18] This could include a
full accounting of information known, related costs, benefits, and
challenges of continuing to search for additional Project 112
participants. Moreover, our prior work has shown that there are
elements integral to a sound cost-benefit analysis.[Footnote 19] For
example, the analysis should include a thorough evaluation of the
social benefits and costs of investments, identify objectives to ensure
a clear understanding of the desired outcome, and include a list of the
relevant impacts to ensure that all aspects are considered. DOD could
not provide us with a quantitative analysis based on objective data or
any documented criteria because OASD (HA) was not required to provide
any support or basis for the decision.
Since DOD's June 2003 report to Congress and its decision to cease
actively searching for additional exposures, additional individuals who
may have been exposed as a result of Project 112 tests have been
identified through various non-DOD sources, as shown in table 1. For
example, the Institute of Medicine conducted a study on the long-term
health effects of participation in the shipboard hazard and defense
tests that were conducted as a subset of Project 112.[Footnote 20] This
study identified 394 individuals who had been potentially exposed and
who were previously unknown to DOD. According to DOD and Institute of
Medicine officials, the additional names were discovered when the
Institute of Medicine applied a more inclusive methodology in its
research. In addition, our previous work in 2004 reported that DOD did
not exhaust all possible sources of information during its
investigation of Project 112 and our own research for that report
resulted in the identification of 39 additional potentially exposed
servicemembers.[Footnote 21] For example, DOD had limited success in
identifying exposures during land-based tests because it was unable to
find documentation, and it did not specifically search for individual
civilian personnel in its investigation because it considered them to
be outside of its scope. Furthermore, DOD officials have told us that
veterans who participated in Project 112 tests have contacted DOD on
their own initiative in search of information and documentation related
to their exposures, which has resulted in 165 additional veterans being
identified as having been potentially exposed during these tests.
Table 1: Number of Servicemembers Identified as Having Been Potentially
Exposed during Project 112:
Total number of Project 112 names identified as of December 2007:
6,440.
DOD's 2003 Report to Congress: 5,842.
Number of names identified since DOD's 2003 report: 598.
Number of names identified since DOD's 2003 report: Institute of
Medicine research (394 names): [Empty].
Number of names identified since DOD's 2003 report: Veterans' inquiries
(165 names); [Empty].
Number of names identified since DOD's 2003 report: GAO research (39
names); [Empty].
Source: GAO analysis of DOD data.
Note: The number of individuals that we report as identified is based
on information from DOD's and VA's databases and is approximate. Cases
reported in this table may reflect duplicates. Naming nomenclature
(suffixes, nicknames, abbreviations, etc.) makes it difficult to
eliminate all potential duplicate names. When in doubt, DOD treats
cases as separate individuals.
[End of table]
DOD's current effort to identify individuals who may have been exposed
to chemical or biological substances during activities outside of
Project 112, discussed in the following section of this report, has
also resulted in the discovery of information related to Project 112
tests. Specifically, the DOD contractor has found evidence that
individuals who DOD already knew were potentially exposed to substances
during at least one known Project 112 test were also potentially
exposed during other Project 112 tests.
In light of the increasing number of individuals who have been
identified since DOD ceased actively searching, until DOD makes a sound
and documented decision regarding the cost and benefits of actively
searching for individuals potentially exposed during Project 112 tests,
Congress and veterans may continue to question the completeness and
accuracy of DOD's effort.
DOD's Effort to Identify Individuals Potentially Exposed during Non-
Project 112 Tests Has Several Shortcomings:
Although DOD has taken action to identify individuals who were
potentially exposed during chemical or biological tests outside of
Project 112, we identified several shortcomings in the current effort.
Specifically, we found that DOD's approach was hampered by (1) a lack
of clear and consistent objectives, scope of work, and information
needs; (2) management and oversight weaknesses; (3) a limited use of
the work of other entities that previously identified exposed
individuals; and (4) a lack of transparency in DOD's efforts.
DOD Issued a Task Order to Identify Individuals Potentially Exposed
during Tests Conducted Outside of Project 112:
In response to the Defense Authorization Act for FY 2003 and our May
2004 recommendation that DOD finalize and implement a plan to identify
individuals who were potentially exposed during tests conducted outside
of Project 112, DOD issued a task order in September 2004. The task
order identified four sets of tasks that the contractor was to
undertake to accomplish the task order's objectives within 3 years--
perform literature searches, conduct and review on-site data
collections, data mine existing databases, and augment a database
maintained by the contractor. The contractor has issued monthly reports
on its work to OUSD (AT&L)'s chemical and biological defense office,
which indicate that the contractor has taken action on each of these
tasks. OUSD (AT&L)'s chemical and biological defense office and the
contractor have agreed that the on-site reviews will be conducted at a
total of 18 sites that were identified and prioritized based on
established criteria, such as relevance and number of documents
expected to be present. As of October 2007, the contractor has
completed on-site data collection at 5 of these 18 sites, and as of
December 2007 was collecting data at 3 additional sites.
During its site visits, the contractor's staff searches a variety of
documents for information that pertains to human exposure to chemical
or biological substances.[Footnote 22] The documents that are
identified as having relevant information are then scanned into an
electronic file and the information from those documents--such as the
individual's name, the substance to which the subject was exposed, and
the activity that resulted in the exposure--is entered into a database.
The contractor conducts a quality assurance review before this
information is delivered to OASD (HA) officials. OASD (HA) officials
told us that they perform a detailed review of this information, query
the contractor to resolve errors or inconsistencies, and make
modifications to the information provided by the contractor if they
have received or read other information that they believe could add
contextual sophistication. Once OASD (HA) officials complete their
review of the information, it is added to the DOD chemical and
biological test database that they maintain (hereafter referred to as
the OUSD (AT&L) task order database). While the database information is
not provided to OUSD (AT&L)'s chemical and biological defense office,
the contractor's monthly report to this office includes the number of
identified individuals that the contractor has provided to OASD (HA).
The task order identified specific locations for the contractor to
review and was supposed to be completed in September 2007; however, the
contractor was unable to complete its work within the 3-year schedule
and has subsequently received a 3-year extension. This task order is
valued at almost $4.5 million, and the estimated value of the extension
is between $2.5 million and $3.7 million. Based on the project's June
2007 concept of operations plan, which DOD developed as a result of
this review, the contractor is expected to meet the project's
objectives and complete collection and analysis of information obtained
from 18 data collection sites by September 2010. Since the remaining
sites have been prioritized based on expected level of information and
other criteria, DOD officials believe that the remaining data
collection efforts could be completed more quickly.
DOD's Current Effort Lacks Clear and Consistent Objectives, Scope of
Work, and Information Needs:
DOD's current effort to identify individuals potentially exposed to
chemical or biological substances lacks clear and consistent
objectives, scope of work, and information needs, which affects DOD's
ability to know whether it has accomplished the project's goals. First,
the objectives of DOD's current effort are inconsistent. The Defense
Authorization Act for FY 2003, which was the genesis for DOD's current
effort, directed the Secretary of Defense to identify DOD projects or
tests outside of Project 112 that may have exposed members of the armed
forces to chemical or biological substances. However, the focus of the
current effort has expanded to include other exposures, including those
resulting from immunizations, transportation, storage, and occupational
accidents. This occurred because the documents that are guiding this
effort, including the project's September 2004 statement of work and
its June 2007 concept of operations plan, have been used
interchangeably to define the scope of the work.
We identified a difference of opinion between DOD and VA regarding the
overall focus of the contractor's research efforts. Officials in OUSD
(AT&L)'s chemical and biological defense office stated that they
believe the contractor should focus only on identifying participants in
DOD tests since the Defense Authorization Act for FY 2003 was the
genesis of this task order, and they believe that the primary interest
is in individuals who were not aware of their exposures or are unable
to report their exposures due to the classified nature of the tests.
They also believe that individuals accidentally exposed at a work
location might be protected under occupational health regulations and
statutes. However, VA officials stated that they would prefer that DOD
provide information on all exposures, including those not associated
with DOD tests, since VA is responsible for adjudicating all claims by
servicemembers, regardless of how they were exposed. The contractor
conducting the search has included all types of exposures in its
research, which according to DOD and contractor officials is based on
VA's stated preferences.
Second, the scope of DOD's current effort is unclear. Specifically,
while the Defense Authorization Act for FY 2003 directed DOD to
identify only members of the armed forces, the task order's 2004
statement of work and the June 2007 concept of operations plan state
that the objective of the project is to collect information on all
servicemembers and civilian personnel who might have been exposed from
1946 to present. However, DOD's current effort has not included an
active search of civilian personnel. Instead, at the direction of DOD,
the contractor is collecting information on civilians who may have been
exposed to chemical or biological substances when it comes across those
names while searching for servicemembers. DOD officials stated that
they focused their efforts on servicemembers because VA has actively
requested information about servicemembers from DOD for years and the
department has not received any inquiries about the civilians. At the
time of our review, the contractor had collected information on
approximately 700 civilian personnel who were potentially exposed to
chemical or biological substances.
Third, the amount and type of information that the contractor needs to
collect for this effort has been expanded from the original task order
requirement. The task order specifies that the information to be
collected should identify potential human exposure events, the names of
test programs, chemical and biological substances involved, and the
names of volunteers or participants. However, DOD has expanded the
information that the contractor should collect, which may be
lengthening the time for the contractor to complete its work. For
example, in February 2007, officials from one of the repository sites
provided the contractor a CD with names and exposure information for
2,300 individuals who were exposed to a series of biological tests at
Fort Detrick, Maryland, known as Operation Whitecoat. However, as of
October 2007, the contractor had not provided DOD with these names
because it was adding information, such as the test objective and
summary, and exposure and treatment information. Since most of these
2,300 individuals had been previously aware of their exposures due to
Fort Detrick's independent outreach efforts, a DOD official who has
worked with these individuals has stated that it is unclear how much
additional information the contractor needs to collect about this
group. While OASD (HA) officials have said that the additional
information has been helpful for their needs, they and VA officials
have also acknowledged that the identity of the chemical or biological
substance to which an individual was potentially exposed is the most
pertinent information.[Footnote 23]
Without consistent guidance about the objectives, scope of work, and
information necessary to meet DOD's goals and objectives, DOD's current
effort might not produce the desired results. After discussing this
issue with DOD officials, in December 2007 officials in OUSD (AT&L)'s
chemical and biological defense office stated that they plan to revise
the task order's statement of work, concept of operations plan, and a
DOD implementation plan to clarify the scope of work and the focus of
the research to servicemembers--the original focus as identified in the
Defense Authorization Act for FY 2003.
DOD's Current Effort Has Lacked Adequate Oversight:
Until recently, DOD's current effort has lacked adequate oversight of
the contractor activities and results. We have previously reported that
providing effective oversight is essential and, at times, DOD's
oversight was wanting, as it did not always task personnel with
oversight duties or establish clear lines of accountability.[Footnote
24] While OUSD (AT&L)'s chemical and biological defense office
established three different points of contact throughout the life of
the task order who participated in meetings when the work started in
2004 and assisted the contractor undertaking the effort in accessing
repository sites when requested, these points of contact were not
performing active oversight activities nor were they designated as the
project manager for this effort. During our review, officials in OUSD
(AT&L)'s chemical and biological defense office realized that their
predecessors had not selected a project manager and selected one of the
office's civilian employees to oversee the effort.
We also found that DOD had not visited any of the repository sites
where the contractor had proposed or completed its research to ensure
that the work was effectively and efficiently meeting the task order's
objectives. We visited the three repository sites where the contractor
was conducting its work during our review. At one location, a
knowledgeable DOD official expressed concerns to us that the
contractor's presence and research in one of the site's libraries might
not be needed. However, since officials in OUSD (AT&L)'s chemical and
biological defense office had not visited the site or met with site
officials, they were unaware of these concerns and therefore were
unable to decide whether the contractor should be conducting work at
that particular site or whether the research funds and time should be
spent at a site that they believe might provide more relevant
information.
In addition, until June 2007, OUSD (AT&L)'s chemical and biological
defense office had not regularly evaluated the effectiveness or
efficiency of the contractor's work. For example, at the time of our
review, officials in OUSD (AT&L)'s chemical and biological office told
us that they did not know the extent to which each of the task order's
four tasks was meeting its objective to identify servicemembers and
civilians who were potentially exposed to chemical or biological
substances during testing and other activities. Therefore, DOD was not
in a position to determine whether the task order needed to be modified
to focus DOD's resources and the contractor's research efforts to those
tasks that will best meet its objectives.
Further, while the contractor had implemented its own quality
assurance/quality control process that was approved by OUSD (AT&L)'s
chemical and biological defense office, the office had not taken any
action to independently assess the accuracy and characterization of the
information that the contractor was providing to the OASD (HA), which
maintains DOD's databases of potentially exposed individuals. As a
result, officials in OUSD (AT&L)'s chemical and biological defense
office, who are responsible for overseeing the contractor's efforts,
have limited knowledge about the accuracy and characterization of the
information that was being collected.
Review and assessment of the contractor-provided data by the project
manager are important because we identified potential problems with the
accuracy of that information. For example, our work indicated that
there are discrepancies between the number of individuals reported by
the contractor in its monthly reports to OUSD (AT&L)'s chemical and
biological office and the number of individuals that exist in OASD
(HA)'s database that could not be adequately explained. In addition, at
the time of our review, the characterization in the contractor's
monthly reports provided to OUSD (AT&L)'s chemical and biological
defense office that all of these individuals were potentially exposed
during chemical or biological tests gave the wrong impression to the
project manager. For example, while the contractor has characterized
the individuals it has identified as having been involved in DOD's
chemical and biological "tests", an unknown number of these exposures
resulted from immunizations, transportation, occupational, and storage
accidents. This number also includes individuals who might have been
associated with the tests but who were not exposed to any substances,
such as those who participated in physical exercises to test the
durability of chemical and biological suits or who could have been part
of a test control group. OASD (HA) officials were able to identify at
least 1,800 names in the database that were not exposed to any
substances, which leaves about 7,100 names in the database that have
been potentially exposed to chemical or biological substances, as shown
in table 2.[Footnote 25] DOD and contractor officials stated that they
have included these names in the database so that they could
appropriately respond to these individuals' concerns if they contact
DOD or VA. Specifically, according to DOD, including these names in the
database enables the department to refute any claims by individuals who
participated in tests where they were not exposed to any chemical or
biological substances.
Table 2: Number of Non-Project 112 Servicemembers Identified by DOD as
of December 2007:
Number of names in OUSD (AT&L) task order database: 8,979;
Number of names in OUSD (AT&L) task order database: Number of names in
OUSD (AT&L) task order database that have been identified as having
been potentially exposed to a chemical or biological substance: 7,120;
Number of names in OUSD (AT&L) task order database: Number of names in
OUSD (AT&L) task order database that have not been exposed to any
chemical or biological substances; 1,859;
Number of names awaiting entry into database: 844;
Total: 9,823.
Source: GAO analysis of DOD data.
Note: The number of individuals that we report as identified is based
on information from DOD's and VA's databases and is approximate. Cases
reported in this table may reflect duplicates. Naming nomenclature
(suffixes, nicknames, abbreviations, etc.) makes it difficult to
eliminate all potential duplicate names. When in doubt, DOD treats
cases as separate individuals.
[End of table]
We identified a variety of factors affecting the ability of OUSD
(AT&L)'s chemical and biological defense office to provide oversight,
including a lack of consistent leadership, inadequate internal
controls, a shortage of personnel, and a lack of defined roles and
responsibilities. For example, the position that was identified as the
office's point of contact for the task order is a 1-year position.
Consequently, the contractor has had to work with three different
individuals during the first 3 years of the task order. The official
holding this position during our review requested and was granted a 2-
year extension in this position, and thus he has been able to implement
a number of internal controls to improve the oversight and
accountability of this project. In addition, until September 2007, the
respective roles and responsibilities of OUSD (AT&L)'s chemical and
biological defense office and OASD (HA) had not been clearly
identified. In September 2007, in response to our review, OUSD (AT&L)'s
chemical and biological defense office and OASD (HA) signed an
implementation plan that identified their respective roles and
responsibilities.
DOD Did Not Fully Leverage the Work of Other Entities that Identified
Exposed Individuals:
In planning, executing, and evaluating DOD's current effort, OUSD
(AT&L)'s chemical and biological defense office did not fully leverage
the work of other entities that had previously identified exposed
individuals. Multiple DOD and non-DOD organizations have conducted a
variety of independent efforts since the early 1990s, through which
they have identified thousands of individuals who were potentially
exposed during chemical or biological tests. These entities possess
specific information about the tests--to include the location of test
records--and the personnel conducting the work developed institutional
knowledge. While OUSD (AT&L)'s chemical and biological defense office
leveraged Project 112 information from the OASD (HA), it did not
leverage information available from other DOD and non-DOD sources. For
example, between 1993 and 1997, the joint DOD-VA task force identified
approximately 6,400 individuals who were potentially exposed to sulfur
mustard, lewisite, and other chemical substances. OUSD (P&R) led the
effort by using some of its own personnel to conduct the research and
visit several repository sites in addition to issuing a task order for
a contractor--the same contractor DOD is currently using to research
and identify tests and exposures--to develop a database containing
information on the location, chemicals tested, and dates of the
chemical weapons research program. During this period, OUSD (P&R)
personnel involved with the research became very knowledgeable about
the issues, collected boxes of information, and issued various reports.
OUSD (P&R) officials transferred the names of the individuals who were
identified to OASD (HA) officials in April 2005. According to OUSD
(P&R) officials, however, officials in OUSD (AT&L)'s chemical and
biological defense office had not met with any of the personnel with
institutional knowledge or examined any of the documents that OUSD
(P&R) still maintained. Since OUSD (P&R)'s reports identified locations
of exposures, officials in OUSD (AT&L)'s chemical and biological
defense office could have used this information as another source to
help validate and prioritize the repository sites proposed by the
contractor for its current effort, and to eliminate potential
redundancy.
Furthermore, as a result of independent research efforts by the
Institute of Medicine about the health effects of DOD chemical tests
using human subjects, the organization developed a database that
contained the names and addresses of more than 4,000 servicemembers who
were potentially exposed to chemical substances during a series of
tests at Edgewood, Maryland. However, OUSD (AT&L)'s chemical and
biological defense office was not aware of this database since the
office had not coordinated with the organization. Institute of Medicine
officials told us that they believe the names and contact information
in this database could help DOD with its efforts since the names were
collected from the same locations where the contractor for DOD's
current effort is doing its research. Subsequent to our September 2007
meeting with the Institute of Medicine, its officials contacted OASD
(HA) to establish the protocols to transfer the names of identified
individuals to DOD so that it can determine whether these individuals
are already included in any of DOD's databases. Without communicating
and coordinating with DOD and non-DOD organizations that have
previously conducted similar efforts, DOD's current effort will not be
able to take advantage of existing information so that it can focus its
resources on the areas where information is missing.
DOD's Current Effort Lacks Transparency:
DOD's current effort lacks transparency since it has not worked with
veterans, and it has not kept Congress and veterans service
organizations fully informed about the status of its efforts. Although
DOD officials conducted outreach to veterans during its Project 112
research effort and the Defense Authorization Act for FY 2003 required
DOD to work with veterans and veterans service organizations to
identify projects and tests outside of Project 112 that may have
exposed members of the armed forces to chemical and biological
substances, DOD has not included veterans and veterans service
organizations during its current effort. DOD also has not kept
Congress, veterans, and the public informed on the status of its
current effort as it did during its Project 112 investigation.
Specifically, in 2002, DOD established a public internet site to
provide interested persons with information on what happened during
those tests that might have affected the health of those who served.
The internet site included a status report on DOD's efforts so that
veterans and others could monitor the progress, and it also contained
reports, documents, and links to related internet sites. The internet
site, which was operated by OASD (HA), has not been updated with
information about DOD's current effort to identify individuals outside
of Project 112. Representatives from a veterans service organization
that has pursued information regarding DOD's use of servicemembers as
human subjects told us they were not aware of DOD's current effort and
they believe DOD has not been transparent and forthcoming with the
information that it has obtained. These officials stated that the
continuous lack of collaboration and transparency has negatively
affected the level of trust veterans and the veterans service
organization have in DOD regarding its commitment to fully identify and
disclose information regarding these tests. The representatives stated
that it is imperative for DOD to be as transparent as possible so that
Congress, veterans, and the public have reason to believe the cloak of
secrecy regarding these tests has been lifted and individuals who were
potentially exposed could receive appropriate medical care and
benefits. DOD officials acknowledged the importance of keeping veterans
informed so that they know that these tests are no longer classified,
they are entitled to a medical screening for long-term health effects,
and they can assist in DOD's efforts to identify other individuals who
might have been exposed. Until DOD is more transparent about its
efforts to identify individuals who were potentially exposed during
these previously classified tests, Congress, veterans, and the public
could have reason to believe that the cloak of secrecy has not been
lifted and not realize the reasonableness, effectiveness, success, and
challenges of DOD's current effort.
DOD and VA Have Had Limited Success in Notifying Potentially Exposed
Individuals:
DOD and VA have had limited success in notifying individuals who were
potentially exposed to chemical and biological substances during
Project 112 tests or testing that occurred outside of Project 112 due
to several factors. First, DOD has inconsistently transmitted
information about identified servicemembers to VA. Second, VA has not
used all available resources to obtain contact information for
servicemembers who were identified as having been potentially exposed.
Finally, DOD has not taken any actions to notify civilians who have
been identified.
DOD Has Inconsistently Transmitted Information to VA:
While DOD and VA have a process in place to share the names of
servicemembers who are identified as having been potentially exposed to
chemical and biological substances, the transmission of information
between the two agencies has been inconsistent. To date, DOD has
provided information to VA as agreed upon through an informal
arrangement. Under the arrangement, DOD generally provides VA with the
servicemember's name, as well as any information related to the
potential exposure that DOD uncovered during its investigation, such as
the chemical or biological substance that was used, the dosage of the
chemical or biological substance, and the date of the exposure. As of
October 2007, DOD had used this process to transmit to VA approximately
20,700 names of servicemembers who had been potentially exposed to
chemical or biological substances.[Footnote 26] The informal
arrangement between DOD and VA did not establish a schedule for the
exchange of information, so DOD provides newly acquired exposure
information to VA in batches of varying size and at inconsistent
intervals. When we began our work we found that DOD had not provided VA
with any updates after September 2006 even though, as of June 2007, DOD
had added approximately 1,800 additional servicemember names to its
chemical and biological exposure database. Subsequent to our inquiries,
however, DOD provided VA with an update in September 2007. According to
DOD officials, regular updates to VA have been delayed because of a
number of factors, including competing priorities such as current
military operations, lack of personnel, database management issues, and
lack of an impetus to take a proactive approach. Although limited
personnel and competing priorities might be valid issues, until DOD
provides regular updates of identified servicemembers to VA in a timely
manner, VA will be unable to notify identified veterans about their
potential exposure to chemical or biological substances.
VA Has Not Used Certain Available Resources to Notify Veterans:
VA has not used certain available resources to obtain contact
information for and to notify veterans who were identified as having
been potentially exposed to chemical or biological substances. To
notify veterans who were potentially exposed to chemical or biological
substances during DOD tests, VA matches the list of potentially exposed
veterans it obtains from DOD against its own database of veterans to
find either contact information or a Social Security number. If no
Social Security number is located, VA matches the available veterans'
information to information contained in the National Personnel Records
Center. Once a Social Security number is obtained, VA usually uses a
private credit bureau and on occasion has used the Internal Revenue
Service database to obtain contact information for the veteran. In
responding to a draft of this report, VA notes that it uses the credit
bureau for a variety of reasons, including its up-to-date data
transmissions from the Social Security Administration, expedience in
responding, and general accuracy of information. As shown in table 3,
as of December 2007, VA had obtained contact information for and sent
notification letters to 48 percent of the names that DOD provided to
them and that they may be able to contact.[Footnote 27] VA officials
noted that while the total number of notification letters sent is 48
percent of the number of names that DOD has provided to them and that
they may be able to contact, it represents all of the individuals for
whom they were able to obtain contact information.
Table 3: Veterans Who VA Has Notified of Their Potential Exposure as of
December 2007:
Number of names DOD has provided to VA;
OUSD (P&R): 6,739;
Project 112: 6,440;
OUSD (AT&L) task order: 7,531;
Total: 20,710.
Names with no numeric identifier (e.g., social security number or
service number);
OUSD (P&R): 666;
Project 112: 385;
OUSD (AT&L) task order: none;
Total: 1,051.
Names of veterans known to be deceased;
OUSD (P&R): 2,157;
Project 112: 733;
OUSD (AT&L) task order: 500;
Total: 3,390.
Possible number of veterans to be notified (i.e., veterans who have an
identifier and are not documented as deceased);
OUSD (P&R): 3,916;
Project 112: 5,322;
OUSD (AT&L) task order: 7,031;
Total: 16,269.
Number of notification letters mailed by VA;
OUSD (P&R): 319[A];
Project 112: 4,438;
OUSD (AT&L) task order: 2,987;
Total: 7,744.
Percentage of veterans sent notification letters for those known not to
be deceased and for which VA has a numeric identifier;
OUSD (P&R): 8%;
Project 112: 83%;
OUSD (AT&L) task order: 42%;
Total: 48%.
Source: GAO analysis of VA data.
Note: The number of individuals that we report as notified is based on
information from DOD's and VA's databases and is approximate. Cases
reported in this table may reflect duplicates.
[A] OUSD (P&R) officials told us that they also sent 722 "Certificates
of Commendation" to veterans who had been identified and for whom
contact information could be obtained. It is unknown whether these
certificates were sent to veterans who also received notification
letters from VA.
[End of table]
A number of factors beyond VA's control have impeded its ability to
notify veterans of their potential exposure to chemical or biological
substances. For example, some records have been lost or destroyed, and
existing documentation contains limited information and often does not
identify names of participants, while others were not turned in by the
scientists who were conducting the research. When the records can be
found, they do not necessarily identify the participants, but may
instead refer to control numbers that were issued to the participants,
which cannot be cross-referenced to other documents for identification.
For those records that do include identification of participants, the
information may contain only the participants' initials, nicknames, or
only first or last names. Also, since a number of these records do not
include the participant's military service number or social security
number, it is difficult to determine the exact identity of these
individuals. Further, the contact information that VA is able to obtain
may not be accurate. For example, more than 860 notification letters
have been returned as undeliverable to VA.
However, VA is not using other available resources to obtain contact
information to notify veterans. For example, while VA told us that it
was using a company that is able to provide current contact information
as a source, it had not coordinated with the Social Security
Administration to obtain contact information for veterans receiving
social security benefits or to identify deceased veterans using the
agency's death index and had not regularly used the Internal Revenue
Service's information. VA officials acknowledged that they had not
directly used the death index and that a memorandum of understanding
with the Social Security Administration might facilitate a new way to
accomplish this. However, they noted the credit bureau receives weekly
updates from the Social Security Administration's death index. VA
officials also acknowledged that it planned to make more frequent use
of IRS databases. Until VA implements a more effective process to
obtain contact information for veterans, some veterans will remain
unaware of their potential exposure or the availability of health exams
and the potential for benefits directly related to an exposure.
DOD Has Not Notified Civilians Due in Part to a Lack of Specific
Guidance:
DOD has not taken any actions to notify civilians who have been
identified as having been potentially exposed during Project 112 tests
and other chemical and biological tests, due in part to a lack of
specific guidance defining the requirements to notify civilians. The
Defense Authorization Act for FY 2003 required DOD to identify its
tests or projects that may have exposed members of the armed forces to
chemical or biological substances, but did not specifically address
civilian personnel who may have been affected by these tests. However,
in our 2004 report we recommended that DOD address the appropriateness
of and responsibility for reporting new information, such as the
identification of additional potentially exposed servicemembers,
civilian employees, contractors, and foreign nationals who participated
in the tests. In its response to our report, DOD concurred with our
recommendation and stated that it would determine the appropriate
reporting channels for civilian employees, contractors, and foreign
national participants who were identified as being potentially
exposed.[Footnote 28] However, DOD has not taken any action with the
approximately 1,900 civilian names that it maintains, as shown in table
4. Instead, DOD has focused its efforts on the identification and
notification of servicemembers who were potentially exposed. DOD
officials stated that they have focused on identifying and notifying
servicemembers since the primary impetus for their efforts to identify
and notify individuals who may have been exposed has been requests for
information from veterans and VA.
Table 4: Number of Civilians Potentially Exposed as of December 2007:
Civilians identified during OASD (HA) investigation of Project 112:
882.
Civilians identified during OASD (HA) investigation of Project 112:
327.
Civilians identified during OUSD (AT&L)'s chemical and biological
office task order: 715.
Total number of civilians identified as being potentially exposed:
1,924.
Source: GAO analysis of DOD data.
Note: The number of individuals that we report as identified and
notified is based on information from DOD's and VA's databases and is
approximate. Cases reported in this table may reflect duplicates.
Naming nomenclature (suffixes, nicknames, abbreviations, etc.) makes it
difficult to eliminate all potential duplicate names. When in doubt,
DOD treats cases as separate individuals.
[End of table]
OASD (HA) has not acted in part because it is unclear whether it is
required to notify civilians or transmit civilian exposure information
to another agency for notification. During our review, DOD and
Department of Labor officials stated that they were unaware of a
requirement for them to notify civilians of their potential exposure.
However, our April 2005 report about civilian and contractor exposures
to chemical substances in Vietnam identified compensation programs that
might be available for civilians who were exposed during these chemical
and biological tests if they come forward and present evidence that
they were potentially exposed.[Footnote 29] Specifically, federal
employees can file claims for workers compensation with their employing
agency, which refers the claims to the Department of Labor under the
Federal Employees Compensation Act. Employees who work under contract
to the U.S. government can file workers compensation claims through
their employers with the employers' insurance carrier. Without an
effort to develop and provide guidance for notifying civilians, those
civilians who have been identified may not be aware of their potential
exposure.
Conclusions:
Since World War II, potentially tens of thousands of military personnel
and civilians have been exposed to chemical or biological substances
during previously classified DOD tests. As this population becomes
older, it will become more imperative for DOD and VA to identify and
notify these individuals in a timely manner because they might be
eligible for health care or other benefits. While DOD has concluded
that continuing an active search for individuals potentially exposed
during Project 112 has reached a point of diminishing returns, it has
not conducted an informed cost-benefit analysis, which could guide DOD
in identifying the extent to which it might need to take additional
actions. Without conducting a sound and documented cost-benefit
analysis that includes a full accounting of information known and the
challenges associated with continuing to search for Project 112
participants, DOD will not be in a position to make an informed and
transparent decision about whether any of the remaining investigative
leads could result in meaningful opportunities to identify additional
potentially exposed individuals. Furthermore, until DOD conducts such
an analysis, Congress, veterans, and the public may continue to
question the completeness and accuracy of DOD's efforts. Moreover,
while DOD has undertaken efforts to identify and notify individuals who
were potentially exposed during tests outside of Project 112, the
department has not worked with veterans and veterans service
organizations during its current effort as required by the Defense
Authorization Act for FY 2003, and it has not coordinated its efforts
with other DOD and non-DOD organizations. Until DOD and VA undertake
more effective and efficient efforts to identify and notify potentially
exposed individuals--including consistent guidance about the scope of
work, such as clearly defined goals and objectives and agreement on the
type and amount of information that is necessary to collect; effective
internal controls and oversight practices; coordination with other
entities to leverage existing information; regular updates to VA; and
utilization of all available resources--Congress, veterans, and the
public may continue to question DOD and VA's commitment to this effort.
Furthermore, in the absence of transparency about these previously
classified tests and DOD's efforts to identify individuals who were
potentially exposed, Congress, veterans, and the public could have
reason to believe that the cloak of secrecy has not been lifted and may
not understand the success and challenges of DOD's current effort.
While DOD and VA have developed a process for notifying servicemembers
who were potentially exposed, it is unclear whether DOD or any other
agency, such as the Department of Labor, is required to notify
potentially exposed civilians who are identified. Therefore, without
specific guidance that defines the requirements, roles and
responsibilities, and mechanisms to notify civilians who have been
potentially exposed to chemical or biological substances, these
individuals might continue to be unaware of their circumstances.
Matters for Congressional Consideration:
We are suggesting the Congress consider the following two matters:
* To provide greater transparency and resolve outstanding questions
related to DOD's decision to cease actively searching for the
identification of individuals associated with Project 112, Congress
should consider requiring the Secretary of Defense to consult with and
address the concerns of VA, veterans, and veterans service
organizations; to conduct and document an analysis that includes a full
accounting of information known, and the related costs, benefits, and
challenges associated with continuing the search for additional Project
112 participants; and to provide Congress with the results of this
analysis. Our draft report addressed this recommendation to the
Secretary of Defense; however, because DOD disagreed, we elevated this
to a matter for congressional consideration.
* To ensure that civilians who were potentially exposed to chemical or
biological substances as a result of tests conducted or sponsored by
DOD are aware of their circumstances, Congress should consider
requiring the Secretary of Defense, in consultation with the Secretary
of Labor, to develop specific guidance that defines the requirements,
roles and responsibilities, and mechanisms to notify civilians who have
been potentially exposed to chemical or biological substances.
Recommendations for Executive Action:
To ensure a sound and documented process for DOD's decision regarding
the identification of individuals associated with Project 112, we
recommend that the Secretary of Defense direct the Office of the Under
Secretary of Defense for Personnel and Readiness to conduct and
document an analysis that includes a full accounting of information
known, and the related costs, benefits, and challenges associated with
continuing the search for additional Project 112 participants, and to
provide Congress with the results of this analysis. In developing the
analysis, DOD should consult with and address the identified concerns
of VA, veterans, and veterans service organizations.
To ensure that DOD's current effort to identify individuals who were
potentially exposed during chemical and biological tests outside of
Project 112 are more efficient, effective, and transparent, and to
ensure that its databases contain accurate information, we recommend
that the Secretary of Defense direct the Office of Under Secretary of
Defense for Acquisition, Technology, and Logistics to take the
following four actions:
* in coordination with the Office of the Under Secretary of Defense for
Personnel and Readiness and the Secretary of Veterans Affairs, modify
the guidance about the scope of work for its current effort, such as
the statement of work and concept of operations plan, to clearly define
consistent, reasonable, and acceptable goals and objectives, and the
type and amount of information that will need to be collected to meet
these goals and objectives;
* implement effective internal controls and oversight practices, such
as periodic site visits, regular assessments of the contactor's
efforts, and quality assurance reviews of the information provided by
the contractor;
* coordinate and communicate with other entities that previously
identified exposed individuals to leverage existing information,
including institutional knowledge and documents; and:
* make its efforts transparent with regular updates to Congress, the
public, and veterans service organizations.
To ensure that DOD has taken appropriate action in its efforts to
notify servicemembers who were potentially exposed, we recommend that
the Secretary of Defense direct the Office of the Under Secretary of
Defense for Personnel and Readiness to take appropriate action to
address the factors--such as competing priorities and database
management weaknesses--affecting DOD's ability to forward the names of
potentially exposed individuals to VA in a timely and effective manner.
To ensure that all veterans who have been identified as having been
potentially exposed to chemical or biological substances have been
notified, we recommend that the Secretary of Veterans Affairs take
steps to increase its use of available resources, such as the Internal
Revenue Service, to implement a more efficient and effective process
for obtaining contact information for living veterans.
Agencies' Comments and Our Evaluation:
We requested comments from DOD, VA, and the Department of Labor on a
draft copy of this report. DOD generally agreed with five
recommendations, but disagreed with the first recommendation to conduct
and document a cost-benefit analysis associated with continuing the
search for additional Project 112 participants, and to provide Congress
with the results of this analysis. VA agreed with one recommendation
and partially agreed with another recommendation that pertained to its
activities. The Department of Labor did not provide us any comments.
Because DOD disagreed with the recommendation to conduct and document a
cost-benefit analysis associated with continuing the search for
additional Project 112 participants and has not adequately addressed
our May 2004 recommendation to determine the feasibility of addressing
unresolved issues associated with Project 112, we added a Matter for
Congress to consider directing the Secretary of Defense to conduct such
an analysis. DOD and VA also provided technical comments, which we
incorporated as appropriate. DOD's and VA's comments are reprinted in
appendices II and III, respectively.
DOD agreed to and has in some cases begun taking action to respond to
five of the recommendations. Specifically, DOD stated that it has
already coordinated on updating program goals and objectives for the
identification of individuals who were potentially exposed during
chemical and biological tests outside of Project 112 and is revising
the statement of work, implementation plan, and concept of operations
to ensure consistent guidance and deliverables. DOD also stated that it
has taken steps to increase oversight of the project and has
established an implementation plan with OASD (HA) delineating oversight
responsibilities. In addition, DOD stated that it will take steps to
determine if other organizations are conducting similar work to
identify potentially exposed individuals and will coordinate and
leverage all available information. The department also stated that it
will expand its current efforts to update the public and make efforts
more transparent. Finally, DOD and VA are in the process of discussing
short-term and long-term improvements necessary for improving the
transfer of information to VA in a timely and effective manner. We
believe these are positive steps that, when completed, will address the
intent of our recommendations.
DOD did not agree with the first recommendation to conduct and document
an analysis that includes a full accounting of information known, and
the related costs, benefits, and challenges associated with continuing
the search for additional Project 112 participants, and to provide
Congress with the results of this analysis. DOD stated that it believes
it made a full accounting of its efforts available to Congress in 2003,
that it has not received any credible leads that would allow DOD to
continue its research, and that it currently knows of no other
investigative leads that would meaningfully supplement what it believes
to be a total picture of Project 112. However, as discussed in our May
2004 report, we identified a number of credible leads that could
possibly result in additional Project 112 information. In addition, as
discussed in this report, almost 600 additional individuals who were
potentially exposed during Project 112 (more than a 10 percent
increase) have been identified by non-DOD sources since DOD's 2003
report to Congress and its decision to cease actively searching for
additional exposures. In light of the increasing number of individuals
who have been identified since DOD provided its report to Congress in
2003 and ceased its active search for additional individuals, until the
department provides a more substantive analysis that supports its
decision to cease active searches for additional individuals
potentially exposed during Project 112 tests, Congress and veterans may
continue to question the completeness and level of commitment to this
effort. Because DOD has disagreed with our recommendation and has not
adequately addressed our May 2004 recommendation to determine the
feasibility of addressing unresolved issues associated with Project
112, we have added a Matter for Congress to consider directing the
Secretary of Defense to conduct such an analysis.
In response to our recommendations, VA agreed to work with DOD to
modify the guidance about the scope of work for its current effort to
clearly define consistent, reasonable, and acceptable goals and
objectives; and the types and amount of information that will need to
be collected to meet these goals and objectives. VA also agreed to
contact the Internal Revenue Service to determine if a more timely
response can be obtained from them to assist VA in notifying
individuals potentially exposed to chemical or biological substances.
We believe these steps are consistent with the intent of our
recommendations. However, VA disagreed with a part of our
recommendation that it needs to pursue information from the Social
Security Administration since the credit bureau that VA uses to obtain
contact information already receives the same information from the
Social Security Administration. Accordingly, we adjusted our
recommendation to the Secretary of Veterans Affairs so that it did not
refer to the Social Security Administration as another source of
information.
We are sending copies of this report to other interested congressional
committees, the Secretary of Defense, the Secretary of Veterans
Affairs, and the Secretary of Labor. We will also make copies available
to others upon request. In addition, the report will be available at no
charge on the GAO Web site at [hyperlink, http://www.gao.gov].
If you have any questions about this report, please contact me at (202)
512-5431 or dagostinod@gao.gov. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made contributions to this report
are listed in appendix IV.
Signed by:
Davi M. D'Agostino:
Director, Defense Capabilities and Management:
[End of section]
Appendix I: Scope and Methodology:
To assess the Department of Defense's (DOD) efforts since 2003 to
identify servicemembers and civilians who may have been exposed to
chemical or biological substances used during tests conducted under
Project 112, we reviewed and analyzed documents pertaining to Project
112, including DOD's 2003 Report to Congress: Disclosure of Information
on Project 112 to the Department of Veterans Affairs. We interviewed
officials at the Office of the Secretary of Defense, Washington, D.C.,
including the Under Secretary of Defense for Acquisition, Technology,
and Logistics, and the Under Secretary for Personnel and Readiness. We
also interviewed officials at the Office of the Assistant Secretary of
Defense for Health Affairs who were responsible for conducting DOD's
investigation of Project 112 tests and have been designated as the
single point of contact for providing information related to tests and
potential exposures during Project 112. We interviewed officials at the
Institute of Medicine and reviewed their 2007 report on the long-term
health effects of participation in the shipboard hazard and defense
tests of Project 112.[Footnote 30] In addition, we reviewed and
analyzed our prior reports as well as reports of other organizations to
provide a historical and contextual framework for evaluating DOD's
efforts.
To evaluate DOD's current effort to identify servicemember and civilian
exposures that occurred during activities outside of Project 112 tests,
we reviewed and analyzed reports, briefings, and documents and
interviewed officials at the Office of the Secretary of Defense,
Washington, D.C., including the Under Secretary of Defense for
Acquisition, Technology, and Logistics and the Under Secretary of
Defense for Personnel and Readiness. We also interviewed officials at
the Office of the Assistant Secretary of Defense for Health Affairs,
who have been designated as the single point of contact for providing
information related to tests and potential exposures outside of Project
112. In addition, we interviewed officials at the U.S. Army Medical
Research Institute of Infectious Diseases and the U.S. Army Medical
Research and Materiel Command, Fort Dietrich, Maryland; the Department
of Veterans Affairs, Washington, D.C; the Institute of Medicine,
Washington, D.C; the Vietnam Veterans of America, Silver Spring,
Maryland; and DOD's contractor currently conducting research to
identify potential exposures that occurred outside of Project 112. We
also evaluated DOD's methodology for identifying servicemembers and
civilians who may have been exposed to chemical or biological
substances by observing the process the contractor uses to conduct
research at repositories containing documents related to chemical and
biological exposures from tests and other activities, such as the
transportation and storage of chemical and biological substances. We
interviewed officials and observed storage facilities at the three
chemical or biological substance exposure record repositories where the
contractor was currently conducting its work: Edgewood Chemical and
Biological Center Technical Library, Aberdeen Proving Grounds,
Maryland; U.S. Army Research, Development, and Engineering Command
Historical Office, Aberdeen Proving Grounds, Maryland; and U.S. Army
Medical Research Institute of Infectious Diseases Technical Library,
Fort Detrick, Maryland. In addition, we interviewed officials and
observed the records storage area at the U.S. Army Medical Research
Institute of Infectious Diseases Medical Records Office, Fort Detrick,
Maryland, where information about Operation Whitecoat is maintained. We
also reviewed DOD's outreach efforts and the extent to which DOD
coordinated with other agencies that might have useful information,
including the Department of Veterans Affairs (VA), the Department of
Labor, the Institute of Medicine, and the Vietnam Veterans of America.
To evaluate VA's process to notify servicemembers whom DOD has
determined may have been exposed to a chemical or biological substance,
we interviewed VA officials with the Veteran's Benefit Administration,
Veteran's Health Administration, and Office of Planning and Policy, and
gathered data concerning their success in making notifications. In
particular, we documented the number of servicemembers whose names had
been provided to VA by DOD, the extent to which notification letters
were sent, the extent to which veterans were deceased, and the number
of cases where sufficient documentation was not available to obtain
contact information to make notifications.
We assessed the reliability of DOD's and VA's data by interviewing
agency officials knowledgeable about the data and by reviewing existing
information about the data and the systems used to maintain and produce
them. Although we found that there were potential problems with the
quality and reliability of the information, we determined that the data
were sufficient for the purposes of this report.
We conducted this performance audit from June 2007 to February 2008 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
[End of section]
Appendix II: Comments from the Department of Defense:
NUCLEAR AND CHEMICAL AND BIOLOGICAL DEFENSE PROGRAMS:
Assistant To The Secretary Of Defense:
3050 Defense Pentagon:
Washington, DC 20301-3050:
January 24, 2008:
Ms. Davi M. D'Agostino:
Director, Defense Capabilities and Management:
U.S. Government Accountability Office:
441 G Street, N.W.:
Washington, DC 20548:
Dear Ms. D'Agostino:
This is the Department of Defense (DoD) response to the Government
Accounting Office (GAO) draft report, "Chemical And Biological Defense:
DoD and VA Need to Improve Efforts to Identify and Notify Individuals
Potentially Exposed during Chemical and Biological Tests," dated
December 21, 2007 (GAO Code 351052/ GAO-08-366).
The DoD comments to GAO recommendations are contained in enclosure 1.
The DoD concurred with four recommendations, concurred with comment on
one recommendation, and non-concurred with recommendation 1 (pertaining
to GAO's recommendation for full cost-benefit analysis associated with
continuing the search for additional Project 112 participants). In
support of our non-concurrence to recommendation 1, the Office of the
Assistant Secretary of Defense for Health Affairs (OASD(HA)) made a
full accounting of its efforts to Congress in August 2003 stating the
DoD had ceased the active stage of its Project 112 investigation, but
would pursue any new leads that became available as evidenced in the
OASD(HA) information sheet, at enclosure 2. Finally, our technical
comments to the draft report are provided at enclosure 3.
Should you have any questions, please phone or email the point of
contact, COL David Jarrett, 703-697-5116, davidjarrett@osd.mil.
Sincerely,
Signed by:
Arthur T. Hopkins:
Principal Deputy:
Enclosures:
As stated:
GAO Draft Report – Dated December 21, 2007 GAO CODE 351052/GAO-08-366:
"Chemical And Biological Defense: DoD and VA Need to Improve Efforts to
Identify and Notify Individuals Potentially Exposed during Chemical and
Biological Test" dated December 21, 2007 (GAO Code 351052):
Department Of Defense Comments To The Recommendations:
Recommendation I: The GAO recommends that the Secretary of Defense
direct the Office of the Under Secretary of Defense for Personnel and
Readiness to conduct and document an analysis that includes a full
accounting of information known, and the related costs, benefits, and
challenges associated with continuing the search for additional Project
112 participants, and to provide Congress with the results of this
analysis. In developing the analysis, DoD should consult with and
address the identified concerns of the Department of Veterans Affairs
(VA), veterans, and veterans service organizations.
DOD Response: Nonconcur. DoD believes it made a full accounting of its
efforts available to Congress in 2003 (see enclosure 2 detailing DoD's
Project 112 efforts). At that time, DoD informed Congress that it had
ceased the active stage of the investigation, but would pursue any new
leads that became available. DoD does not believe that the cessation of
the effort lends itself to a cost benefit analysis. To date, DoD has
received no credible leads that would allow DoD to continue its
research. Thus, DoD sees no advantage to conducting a cost-benefits
analysis four years after informing Congress of its plans.
DoD does not believe that any degree of replicate searching of records
archives for a program terminated long ago would result in a more
complete documentation of all aspects of the program. DoD believes the
evidence found to date produces an accurate, total picture of Project
112/SHAD (Shipboard Hazard and Defense). DoD currently knows of no
other investigative leads that would meaningfully supplement that
picture.
Most of the new names added to the Project 112 database came from
reexamining existing data already in DoD possession, not from finding
new documentation. Additionally, veterans continue to provide the
Office of the Assistant Secretary of Defense (Health Affairs)
(OASD(HA)) with temporary duty orders, letters of commendation, etc.,
(records that are not permanently archived by the military) that
document their and fellow veterans participation in Project 112. In
these cases, DoD uses this information to give these veterans credit
for participating in Project 112.
Recommendation 2: The GAO recommends that the Secretary of Defense
direct the Office of the Under Secretary of Defense for Acquisition,
Technology, and Logistics in coordination with the Office of the Under
Secretary of Defense for Personnel and Readiness and the Secretary of
Veterans Affairs, modify the guidance about the scope of work for its
current effort, such as the statement of work and concept of operations
plan, to clearly define consistent, reasonable, and acceptable goals
and objectives, and the type and amount of information that will need
to be collected to meet those goals and objectives.
DOD Response: Concur. Office of the Assistant Secretary of Defense
(Health Affairs) (OASD(HA)) and Office of the Under Secretary of
Defense for Acquisition, Technology, and Logistics (OUSD(AT&L))
personnel have already coordinated on updating program goals and
objectives for the identification of individuals who were potentially
exposed during chemical and biological tests outside of Project 112.
The statement of work, implementation plan, and concept of operations
are under revision to ensure consistent guidance and deliverables.
Recommendation 3: The GAO recommends that the Secretary of Defense
direct the Office of the Under Secretary of Defense for Acquisition,
Technology, and Logistics implement effective internal controls and
oversight practices, such as periodic site visits, regular assessments
of the contractor's efforts, and quality assurance reviews of the
information provided by the contractor.
DOD Response: Concur. The Office of the Under Secretary of Defense for
Acquisition, Technology, and Logistics (OUSD(AT&L)) has increased its
oversight of the program and has established an implementation plan
with the Office of the Assistant Secretary of Defense (Health Affairs)
(OASD(HA)) delineating program oversight responsibilities. The
following controls have been ongoing: monthly reporting, quarterly
program reviews, and data reviews with OASD(HA). Per the
recommendation, OUSD(AT&L) will conduct site visits on a quarterly
basis.
Recommendation 4: The GAO recommends that the Secretary of Defense
direct the Office of the Under Secretary of Defense for Acquisition,
Technology, and Logistics to coordinate and communicate with other
entities that previously identified exposed individuals to leverage
existing information, including institutional knowledge and documents.
DOD Response: Concur. As part of the revised statement of work, a
quarterly analysis/search will be conducted to determine if other
organizations are conducting similar work. The Office of the Under
Secretary of Defense for Acquisition, Technology, and Logistics
(OUSD(AT&L)) will coordinate and leverage all available information
including institutional knowledge and documents.
Recommendation 5: The GAO recommends that the Secretary of Defense
direct the Office of the Under Secretary of Defense for Acquisition,
Technology, and Logistics make its efforts transparent with regular
updates to Congress, the public, and veterans' service organizations.
DOD Response: Concur with comment. The draft report mentions using the
existing DoD website to update veterans on the current search efforts
for non-Project 112 exposed personnel. The Office of the Assistant
Secretary of Defense (Health Affairs) (OASD(HA)) intends to add
information on its current efforts to the Office of Force Health
Protection & Readiness (FHP&R) website ([hyperlink,
http://fhp:osd.mil/]) to update the public and make efforts more
transparent. Similarly, OASD (HA) will update Veteran's Service
Organizations (VSO) on these efforts during regularly scheduled
meetings with VSO representatives.
Recommendation 6: The GAO recommends that the Secretary of Defense
direct the Office of the Under Secretary of Defense for Personnel and
Readiness to take appropriate action to address the factors--such as
competing priorities and database management weaknesses-affecting DOD's
ability to forward the names of potentially exposed individuals to the
Secretary of Veterans Affairs in a timely and effective manner.
DOD Response: Concur. Office of the Assistant Secretary of Defense
(Health Affairs) (OASD (HA)) personnel and the Department of Veterans
Affairs (VA) have discussed short term and long term improvements
necessary for improving the transfer of information to the VA in a
timely and effective manner. OASD(HA) and VA are in the process of
formalizing data transfer agreements.
[End of section]
Appendix III: Comments from the Department of Veterans Affairs:
THE SECRETARY OF VETERANS AFFAIRS:
WASHINGTON:
January 29, 2008:
Ms. Davi M. D'Agostino:
Director, Defense Capabilities and Management:
U.S. Government Accountability Office:
441 G Street, NW:
Washington, DC 20548:
Dear Ms. D'Agostino:
The Department of Veterans Affairs (VA) has reviewed the Government
Accountability Office's (GAO) draft report, Chemical And Biological
Defense: DOD and VA Need to Improve Efforts to Identify and Notify
Individuals Potentially Exposed during Chemical and Biological Tests
(GAO-08-366). VA agrees with GAO's conclusions and concurs in part with
GAO's recommendations that are addressed to VA.
The Department of Defense and VA need to improve efforts to identify
and notify individuals potentially exposed during chemical and
biological tests. The enclosure specifically addresses GAO's
recommendation and provides additional discussion and comments to the
draft report. VA appreciates the opportunity to comment on your draft
report.
Sincerely,
Signed by:
James B. Peake, M.D.:
Enclosure:
Department of Veterans Affairs (VA) Comments to Government
Accountability Office (GAO) Draft Report Chemical And Biological
Defense: DOD and VA Need to Improve Efforts to Identify and Notify
Individuals Potentially Exposed during Chemical and Biological Tests
(GAO-08-366):
To ensure that all veterans who have been identified as having been
potentially exposed to chemical or biological substances have been
notified, GAO recommends that the Secretary of Veterans Affairs take
the following action:
* Increase its use of available resources, such as the Social Security
Administration (SSA) and Internal Revenue Service (IRS), to implement a
more efficient and effective process for obtaining contact information
for living veterans.
Concur in part ” VA will contact IRS to determine if a more timely
response can be obtained from them. We do not agree that additional
inquiry capability with SSA will yield additional information since
ChoicePoint already uses the same data from SSA that we would be
requesting.
In coordination with the Office of the Under Secretary of Defense for
Personnel and Readiness and the Secretary of Veterans Affairs, modify
the guidance about the scope of work for its current effort, such as
the statement of work and concept of operations plan, to clearly define
consistent, reasonable, and acceptable goals and objectives, and the
type and amount of information that will need to be collected to meet
these goals and objectives.
Concur – VA looks forward to working with DoD on this recommendation.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Davi M. D'Agostino, (202) 512-5431 or dagostinod@gao.gov:
Acknowledgments:
In addition to the contact named above, Robert L. Repasky (Assistant
Director), Tommy Baril, Renee S. Brown, Brian D. Pegram, Steven
Putansu, Terry L. Richardson, and Karen Thornton made key contributions
to this report.
[End of section]
Related GAO Products:
Agent Orange: Limited Information Is Available on the Number of
Civilians Exposed in Vietnam and Their Workers' Compensation Claims.
GAO-05-371. Washington, D.C.: April 22, 2005.
Chemical And Biological Defense: DOD Needs to Continue to Collect and
Provide Information on Tests and Potentially Exposed Personnel. GAO-04-
410. Washington, D.C.: May 14, 2004.
Human Experimentation: An Overview on Cold War Era Programs. GAO/T-
NSIAD-94-266. Washington, D.C.: September 28, 1994.
Veterans Disability: Information From Military May Help VA Assess
Claims Related to Secret Tests. GAO/NSIAD-93-89. Washington, D.C.:
February 18, 1993.
[End of section]
Footnotes:
[1] In this report the term "substance" is synonymous with the term
"agent." Both terms are used to mean chemical and biological agents,
simulants (a substitute for a more toxic agent), tracers, vaccines, and
medical and "non-harmful" substances.
[2] GAO, Chemical and Biological Defense: DOD Needs to Continue to
Collect and Provide Information on Tests and Potentially Exposed
Personnel, GAO-04-410 (Washington, D.C.: May 14, 2004); Human
Experimentation: An Overview on Cold War Era Programs, GAO/ T-NSIAD-94-
266 (Washington, D.C.: Sept. 28, 1994); Veterans Disability:
Information from Military May Help VA Assess Claims Related to Secret
Tests, GAO/NSIAD-93-89 (Washington, D.C.: Feb. 18, 1993); Department of
Veterans Affairs, Chemical Warfare Agent Experiments Among U.S. Service
Members (Washington, D.C.: Updated August 2006); Institute of Medicine,
Veterans at Risk: The Health Effects of Mustard Gas and Lewisite
(Washington, D.C.: 2003).
[3] Senate Committee on Veterans Affairs, Is Military Research
Hazardous to Veterans' Health? Lessons Spanning Half a Century, 103rd
Cong., 2d sess., 1994, Committee Print 103-97.
[4] Institute of Medicine, Veterans at Risk: The Health Effects of
Mustard Gas and Lewisite.
[5] Mustard agents and lewisite are chemical warfare agents known as
vesicants because of their ability to form vesicles, or blisters, on
exposed skin.
[6] Pub. L. No. 107-314, § 709 (2002), hereafter referred to as the
Defense Authorization Act for FY 2003.
[7] A team from the Office of the Deputy Assistant Secretary of Defense
for Force Health Protection & Readiness within OASD (HA) led the
investigation.
[8] DOD, 2003 Report to Congress Disclosure of Information on Project
112 to the Department of Veterans Affairs (Washington D.C.: 2003).
[9] GAO-04-410.
[10] As defined in the Federal Acquisition Regulation, a "task order"
is issued against an indefinite delivery services contract, also
referred to as an umbrella contract, which does not procure or specify
a firm quantity of services (other than a minimum or maximum quantity).
In this case the umbrella contract is for operations of the DOD
Chemical, Biological, Radiological and Nuclear Defense Information
Analysis Center. This umbrella contract is being administered by a
contracting officer's representative with the Air Combat Command.
[11] GAO-04-410.
[12] GAO-04-410.
[13] Institute of Medicine, Veterans at Risk: The Health Effects of
Mustard Gas and Lewisite.
[14] GAO/NSIAD-93-89.
[15] DOD, Phase II Final Report on Chemical Weapons Exposure Study Task
Force (CWEST) Event Database (Arlington, Va.: August 1995) and DOD,
Phase III Chemical Weapons Exposure Study Task Force (CWEST) Event
Database (Arlington, Va.: June 1996).
[16] Is Military Research Hazardous to Veterans' Health? Lessons
Spanning Half a Century.
[17] GAO-04-410.
[18] Office of Management and Budget, Guidelines and Discount Rates for
Benefit-Cost Analysis of Federal Programs, Circular A-94 (Washington,
D.C.: Oct. 29, 1992).
[19] GAO, Surface Transportation: Many Factors Affect Investment
Decisions, GAO-04-744 (Washington, D.C.: June 30, 2004).
[20] Institute of Medicine, Long-Term Health Effects of Participation
in Project SHAD (Shipboard Hazard and Defense) (Washington, D.C.:
2007).
[21] GAO-04-410. Our research for the 2004 report resulted in the
identification of 167 additional potentially exposed individuals,
including 39 servicemembers and 128 civilians.
[22] The current effort has identified an array of substances to which
individuals have been potentially exposed, which include medicinal
substances (e.g., Benadryl), chemical or biological agents (e.g., LSD),
biological simulants (e.g., bacillus globigii), vaccines (e.g., rubella
virus vaccine), and "non-harmful" substances (e.g., caffeine).
[23] The identity of the substance to which an individual was
potentially exposed is the most pertinent information because any
potential benefits that the veteran could receive would be based on the
veteran's ability to link a current ailment to that particular
substance, regardless of the details about the amount of the
individual's exposure.
[24] GAO, A Call For Stewardship: Enhancing the Federal Government's
Ability to Address Key Fiscal and Other 21st Century Challenges, GAO-08-
93SP (Washington, D.C.: December 2007); High-Risk Series: Department of
Defense Contract Management, GAO-07-310 (Washington, D.C.: January
2007); Contract Management: Opportunities to Improve Surveillance on
Department of Defense Service Contracts, GAO-05-274 (Washington, D.C.:
Mar. 17, 2005).
[25] OASD (HA) officials told us that they were unable to precisely
identify the number of individuals in the database who were either
potentially exposed in a nontest event or not exposed to any chemical
or biological substance for multiple reasons, such as the information
that they collected did not clearly identify whether the individuals
were exposed to any substances. Since DOD assigns an exposure to an
individual when the information is not clear, it is possible that some
of the people recorded as exposed in the database were in fact not
exposed.
[26] This number includes the total number of servicemembers who were
identified as having been potentially exposed during chemical and
biological tests conducted or sponsored by DOD, including tests
conducted as part of DOD's Project 112 program and tests conducted
outside of Project 112.
[27] While DOD had provided 20,710 names to VA, the VA office that is
responsible for notifying veterans has identified 3,390 of these
veterans as deceased and consequently did not send notification letters
to them. In addition, VA officials stated that they are unable to
obtain contact information for the 1,051 veterans missing a numeric
identifier. Of the remaining 16,269 names, some of these individuals
could be deceased or impossible to locate due to various factors, such
as missing social security numbers.
[28] GAO-04-410.
[29] GAO, Agent Orange: Limited Information Is Available on the Number
of Civilians Exposed in Vietnam and Their Workers' Compensation Claims,
GAO-05-371 (Washington, D.C.: Apr. 22, 2005). The report identified
compensation programs that are available to restore lost wages and pay
medical expenses of those who are disabled by an occupational-related
illness.
[30] Institute of Medicine, Long-Term Health Effects of Participation
in Project SHAD (Shipboard Hazard and Defense) (Washington, D.C.:
2007).
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