United States Government Accountability Office

GAO Report to Congressional Committees

DEFENSE HEALTH 

CARE 

Activities Related to 

Past Drinking Water 

Contamination at 

Marine Corps Base 

Camp Lejeune 

May 2007 

 

GAO-07-276 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

May 2007

DEFENSE HEALTH CARE 

Activities Related to Past Drinking Water 

Contamination at Marine Corps Base 

Camp Lejeune 

Highlights of GAO-07-276, a report to 

congressional committees 

In the early 1980s, volatile organic

compounds (VOCs) were

discovered in some of the water 

systems serving housing areas on

Marine Corps Base Camp Lejeune.

Exposure to certain VOCs may 

cause adverse health effects, 

including cancer. In 1999, the

Department of Health and Human

Services’ (HHS) Agency for Toxic

Substances and Disease Registry 

(ATSDR) began a study to examine 

whether individuals who were

exposed in utero to the 

contaminated drinking water are 

more likely to have developed 

certain childhood cancers or birth 

defects. ATSDR has projected a 

December 2007 completion date for 

the study. 

The National Defense

Authorization Act of Fiscal Year

2005 required GAO to report on

past drinking water contamination 

and related health effects at Camp 

Lejeune. In this report GAO 

describes (1) efforts to identify and

address the past contamination, 

(2) activities resulting from

concerns about possible adverse 

health effects and government

actions related to the past 

contamination, and (3) the design

of the current ATSDR study,

including the study’s population, 

time frame, selected health effects,

and the reasonableness of the

projected completion date. GAO

reviewed documents, interviewed

officials and former residents, and 

contracted with the National

Academy of Sciences to convene 

an expert panel to assess the 

design of the current ATSDR study. 

Efforts to identify and address the past drinking water contamination at 

Camp Lejeune began in the 1980s, when Navy water testing at Camp Lejeune 

detected VOCs in some base water systems. In 1982 and 1983, continued 

testing identified two VOCs—trichloroethylene (TCE), a metal degreaser,

and tetrachloroethylene (PCE), a dry cleaning solvent—in two water 

systems that served base housing areas, Hadnot Point and Tarawa Terrace. 

In 1984 and 1985 a Navy environmental program identified VOCs, such as

TCE and PCE, in some of the individual wells serving the Hadnot Point and 

Tarawa Terrace water systems. Ten wells were subsequently removed from 

service. Department of Defense (DOD) and North Carolina officials 

concluded that on- and off-base sources were likely to have caused the 

contamination. It has not been determined when contamination at Hadnot 

Point began. ATSDR has estimated that well contamination at Tarawa 

Terrace from an off-base dry cleaner began as early as 1957. 

Activities related to concerns about possible adverse health effects began in 

1991, when ATSDR initiated a public health assessment evaluating the 

possible health risks from exposure to the contaminated drinking water. The 

health assessment was followed by two health studies, one of which is 

ongoing. While ATSDR did not always receive requested funding and 

experienced delays in receiving information from DOD for its Camp Lejeunerelated work, ATSDR officials said this has not significantly delayed their 

work. Former residents and employees have filed about 750 claims against 

the federal government. Additionally, three federal inquiries into issues 

related to the contamination have been conducted—one by a Marine Corpschartered panel and two by the Environmental Protection Agency (EPA). 

Members of the expert panel that the National Academy of Sciences 

convened generally agreed that many parameters of ATSDR’s current study 

are appropriate, including the study population, the exposure time frame, 

and the selected health effects. ATSDR’s study is examining whether 

individuals who were exposed in utero to the contaminated drinking water 

at Camp Lejeune between 1968 and 1985 were more likely to have specific 

birth defects or childhood cancers than those not exposed. 

DOD, EPA, and HHS provided technical comments on a draft of this report, 

which GAO incorporated where appropriate. Three members of an ATSDR 

community assistance panel for Camp Lejeune provided oral comments on 

issues such as other VOCs that have been detected at Camp Lejeune, and 

compensation, health benefits, and additional notification for former 

residents. GAO focused its review on TCE and PCE because they were 

identified by ATSDR as the chemicals of primary concern. GAO’s report 

notes that other VOCs were detected. GAO incorporated the panel members’ 

comments where appropriate, but some issues were beyond the scope of 

this report. 

www.gao.gov/cgi-bin/getrpt?GAO-07-276.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Marcia Crosse 

at (202) 512-7119 or crossem@gao.gov. 
Contents 

Letter 1

Results in Brief 6 

Background 9

Efforts to Identify and Address Past Drinking Water Contamination 

at Camp Lejeune Began in the 1980s and Continue with LongTerm Cleanup and Monitoring 20 

Concerns about Possible Adverse Health Effects and Government 

Actions Related to the Past Contamination Have Led to 

Additional Activities 34 

Experts Convened by NAS Generally Agreed That Many 

Parameters of ATSDR’s Current Study Were Appropriate but 

Some Experts Suggested Potential Modifications to the Study 51 

Agency Comments 56 

Appendix I Scope and Methodology 58 

Appendix II Selected Events Related to Past Drinking Water 

Contamination at Camp Lejeune from 1980 

through 1981 62 

Appendix III Selected Events Related to Past Drinking Water 

Contamination at Camp Lejeune from 1982 

through 1983 64 

Appendix IV Selected Volatile Organic Compounds Detected 

in Wells at Hadnot Point and Tarawa Terrace 

Water Systems 66 

Appendix V Selected Events Related to Past Drinking Water 

Contamination at Camp Lejeune from 1984 

through 1985 68 

Page i GAO-07-276 Past Camp Lejeune Water Contamination
Appendix VI Agency for Toxic Substances and Disease 

Registry’s Response to its 2005 Scientific 

Advisory Panel’s Recommendations 71 

Appendix VII Description of Current Agency for Toxic Substances 

and Disease Registry (ATSDR) Health Study 73 

Appendix VIII GAO Contact and Staff Acknowledgments 75 

Tables 

Table 1: EPA Guidance and Regulations for Trichloroethylene 

(TCE) and Tetrachloroethylene (PCE) in Drinking Water 17 

Table 2: Sampling Results from Hadnot Point and Tarawa Terrace 

Water Systems for May 1982 and July 1982 24 

Table 3: Dates Wells Were Removed from Service in 1984 and 1985 

at Hadnot Point and Tarawa Terrace Water Systems, and 

TCE and PCE Levels Detected in Each Well 28 

Table 4: Information about Potential Sites of Contamination for the 

Hadnot Point Water System 31 

Table 5: Funding of ATSDR Activities at Camp Lejeune from Fiscal 

Years 1991 through 2006 40 

Table 6: Potential and Confirmed Cases of Childhood Cancers and 

Birth Defects as of April 2006 74 

Figures 

Figure 1: Conceptual Model of a Camp Lejeune Water System 11 

Figure 2: Selected Water Service Areas at Camp Lejeune Serving 

Base Housing from the 1970s through 1987 12 

Page ii GAO-07-276 Past Camp Lejeune Water Contamination
Abbreviations 

1, 1-DCE 1,1-dichloroethylene 

ATSDR Agency for Toxic Substances and Disease Registry 

CERCLA Comprehensive Environmental Response, 

 Compensation, and Liability Act 

CID Criminal Investigation Division 

DERP Defense Environmental Restoration Program 

DOD Department of Defense 

DOJ Department of Justice 

EPA Environmental Protection Agency 

HHS Department of Health and Human Services 

JAG Judge Advocate General

LANTDIV Naval Facilities Engineering Command, Atlantic 

 Division 

NACIP Navy Assessment and Control of Installation 

 Pollutants 

NAS National Academy of Sciences 

NEHC Navy Environmental Health Center 

OIG Office of Inspector General 

PCE tetrachloroethylene 

SARA Superfund Amendments and Reauthorization Act 

TCE trichloroethylene 

Trans-1,2-DCE trans-1,2-dichloroethylene

TTHMs total trihalomethanes 

USAEHA U.S. Army Environmental Hygiene Agency 

VOC volatile organic compound 

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Page iii GAO-07-276 Past Camp Lejeune Water Contamination
United States Government Accountability Office

Washington, DC 20548 

May 11, 2007

The Honorable Carl Levin 

Chairman 

The Honorable John McCain 

Ranking Member 

Committee on Armed Services 

United States Senate 

The Honorable Daniel Inouye 

Chairman 

The Honorable Ted Stevens 

Ranking Member 

Subcommittee on Defense 

Committee on Appropriations 

United States Senate 

The Honorable Ike Skelton 

Chairman 

The Honorable Duncan Hunter 

Ranking Member 

Committee on Armed Services 

House of Representatives 

The Honorable John P. Murtha 

Chairman 

The Honorable C. W. Bill Young 

Ranking Member 

Subcommittee on Defense 

Committee on Appropriations 

House of Representatives 

In the early 1980s, Department of the Navy water testing at Marine Corps 

Base Camp Lejeune identified contamination in water systems that served 

housing areas on the base.1

 Further water testing revealed that some of the 

individual wells serving two of the water systems were contaminated with 

 1

Water testing was conducted at Camp Lejeune in preparation for meeting future drinking

water regulations and to address concerns about chemicals that had been buried on base. 

Page 1 GAO-07-276 Past Camp Lejeune Water Contamination
volatile organic compounds (VOCs), such as trichloroethylene (TCE), 

which is a metal degreaser and an ingredient in adhesives and paint 

removers, and tetrachloroethylene (PCE), which is a solvent used in the 

textile industry and a dry cleaning solvent. By 1985, 10 wells that were 

determined to be contaminated with VOCs had been removed from 

service.2

 Although it is not known precisely when the wells became 

contaminated, the Department of Health and Human Services’ (HHS) 

Agency for Toxic Substances and Disease Registry (ATSDR), which is 

investigating the issue, has estimated that the contamination may have 

begun as early as the 1950s. According to ATSDR, the VOCs of primary 

concern at Camp Lejeune were TCE and PCE, and the agency notes that 

exposure to these chemicals may cause adverse health effects. For 

example, exposure to low levels of TCE may cause headaches and 

difficulty concentrating.3 Exposure to high levels of both TCE and PCE 

may cause dizziness, headaches, nausea, unconsciousness, cancer, and 

possibly death.4

As required by federal law,5

 ATSDR conducted a public health assessment 

at Camp Lejeune after the Environmental Protection Agency (EPA) 

designated the base as a National Priorities List6

 site in 1989. The health

assessment recommended that studies be conducted to evaluate the risks 

of childhood cancer related to VOC exposure at Camp Lejeune and noted 

that adverse pregnancy outcomes were also of concern.7

 The first study 

based on the health assessment was released in 19988

 and found a 

 2

VOCs had initially been detected in two other wells. Additional test results did not detect

VOCs and these wells were not removed from service. 

3

According to ATSDR, health effects from exposure to low levels of PCE are unknown. 

4

ATSDR did not define “low levels” or “high levels” of TCE or PCE. 

5

Superfund Amendments and Reauthorization Act of 1986, Pub. L. No. 99-499, §110, 100 

stat. 1613, 1642 (codified at 42 U.S.C. § 9604(i). 

6

The National Priorities List is a list of seriously contaminated hazardous waste sites that 

have been identified by EPA’s Superfund Program. Under the Superfund Program, EPA 

may compel parties responsible for contaminated sites to clean them up or reimburse EPA 

for its cleanup costs. Camp Lejeune was designated as a National Priorities List site due to

environmental contamination at various areas on the base. 

7

Agency for Toxic Substances and Disease Registry, Public Health Assessment U.S.

Marine Corps Camp Lejeune Onslow County, North Carolina (Atlanta, Ga: 1997). 

8

U.S. Department of Health and Human Services, Agency for Toxic Substances and Disease 

Registry, Volatile Organic Compounds in Drinking Water and Adverse Pregnancy

Outcomes (Atlanta, Ga: 1998). 

Page 2 GAO-07-276 Past Camp Lejeune Water Contamination
statistically significant association between exposure and some adverse 

pregnancy outcomes. In 1999, ATSDR initiated a second study that 

currently is examining whether individuals who were exposed in utero 

(i.e., as developing fetuses during gestation) and as infants up to 1 year of 

age to the contaminated drinking water at Camp Lejeune between 1968 

and 1985 are more likely to have developed specific childhood cancers or 

birth defects than those who were not exposed. ATSDR has projected a 

December 2007 completion date for the study. In addition to ATSDR’s 

Camp Lejeune-related work, three inquiries into the issues related to the

past drinking water contamination have been conducted, one by a Marine 

Corps-chartered panel, one by EPA’s Office of Inspector General (OIG), 

and one by EPA’s Criminal Investigation Division (CID). 

Former residents of Camp Lejeune have taken legal action against the 

federal government for injuries alleged to have resulted from exposure to

the contaminated water. In addition, some former residents have 

expressed concern over the Marine Corps’ handling of and response to the 

drinking water contamination, noting that even though contaminants were 

detected as early as 1980, the wells that were determined to be 

contaminated were not removed from service until 1985. Some former 

residents have also asserted that there have been delays in the provision of 

funding and information from the Department of Defense (DOD) to 

ATSDR,9

 and have said that DOD and EPA’s responses to their requests for 

drinking water contamination-related documents have sometimes been 

inadequate. Finally, some former residents have raised concerns about 

various aspects of ATSDR’s ongoing study, including whether the study 

population, time frame, and selected health effects are too limited to 

adequately represent those who were potentially affected, and about 

ATSDR’s projected December 2007 study completion date because the 

federal government plans to wait to adjudicate their claims until the study 

is complete. 

The Ronald W. Reagan National Defense Authorization Act of Fiscal Year

2005 directed that we study and report on the past drinking water 

contamination and related adverse health effects at Camp Lejeune, 

including identifying the type, source, and duration of the contamination, 

determining the actions taken to address the contamination, and assessing 

 9

DOD is required by law to provide funding and data as necessary for ATSDR to carry out

certain health-related activities, including public health assessments. 

Page 3 GAO-07-276 Past Camp Lejeune Water Contamination
the current ATSDR health study.10 The act also requires that our study 

consider information and opinions from individuals who lived and worked 

at Camp Lejeune during the period when the drinking water may have 

been contaminated. As discussed with the committees of jurisdiction, in 

this report we examine the history of events related to drinking water 

contamination at Camp Lejeune. Specifically, we (1) examine efforts to 

identify and address the past contamination; (2) describe activities 

resulting from concerns about possible adverse health effects and 

government actions related to the past contamination, such as the current 

ATSDR health study; and, (3) describe an assessment by an independent

panel of experts of the design of the current ATSDR health study, 

including the study’s population, the exposure time frame, selected health

effects being measured, and the reasonableness of the projected

completion date. 

To examine efforts to identify and address the past contamination,11 we 

reviewed more than 1,600 documents related to past and current drinking 

water activities at Camp Lejeune. We focused our review on the past TCE 

and PCE contamination because ATSDR had noted that these chemicals 

were the VOCs of primary concern at Camp Lejeune. However, we also 

reviewed documentation regarding other VOCs detected at Camp Lejeune.

We interviewed current and former officials from various DOD entities, 

including Camp Lejeune, Headquarters Marine Corps, and the Department 

of the Navy, to obtain information about the history of events related to 

the past drinking water contamination at Camp Lejeune, including efforts 

to identify and address the contamination. The current and former officials 

interviewed often provided information based on their memory of events 

that occurred more than 20 years ago. We attempted to corroborate their 

testimonial evidence with documentation whenever possible. The former 

officials we interviewed were responsible for environmental activities at 

Camp Lejeune or the Department of the Navy during the time in which the 

contamination was detected. The current officials we interviewed are 

responsible for environmental activities at Camp Lejeune, Headquarters 

Marine Corps, or the Department of the Navy. Some of these current 

 10Pub. L. No. 108-375, § 317, 118 Stat. 1811, 1844. 

11Throughout this report we use the term “contamination,” which is also used by the law

requiring us to do this work, as well as by EPA and DOD, to describe the drinking water at 

Camp Lejeune in the early 1980s. However, EPA had not yet established maximum 

contaminant levels for the chemicals TCE and PCE during this period. See 40 

C.F.R. §§ 141.2 and 141.12 (1975-1985). 

Page 4 GAO-07-276 Past Camp Lejeune Water Contamination
officials were also responsible for environmental activities during the time 

in which the contamination was detected. We also met with 19 interested 

former residents and individuals who worked on the base during the 

1960s, 1970s, and 1980s, in order to obtain their perspective on historical 

events and to learn about their concerns related to the drinking water 

contamination. A former resident who is active in matters related to the 

past drinking water contamination at Camp Lejeune identified most of the 

interested former residents; others were identified at an ATSDR public 

meeting. Additionally, we examined reports from and interviewed officials 

with EPA and with the North Carolina Department of Environment and 

Natural Resources who were knowledgeable about activities and costs 

related to the cleanup of the suspected sources of contamination. 

To describe activities resulting from concerns about the possible adverse 

health effects and government actions related to past drinking water 

contamination, including efforts to study potential health effects and 

federal inquiries into the response to the contamination, we reviewed 

documents, interviewed agency officials, and attended agency meetings. 

To examine the activities undertaken by ATSDR to study possible adverse 

health effects related to the drinking water contamination, we interviewed 

ATSDR officials and reviewed ATSDR’s Camp Lejeune-related documents 

and publications, including the 1997 public health assessment and the 

ATSDR health study released in 1998. We did not evaluate the 

methodology or findings of the health assessment or health study. We also 

attended the meetings and reviewed the reports of expert review panels 

convened by ATSDR in 2005 regarding improving the study’s water 

modeling efforts and future studies of health effects. We attended the 

February and April 2006 meetings of the ATSDR community assistance 

panel which is made up of seven former residents of Camp Lejeune. We

also reviewed meeting transcripts from the July and September 2006 

meetings. We also interviewed officials with the Department of the Navy

and the U.S. Army Center for Health Promotion and Preventive Medicine, 

which serves as a liaison between DOD and ATSDR. We also interviewed 

officials with the Department of the Navy Judge Advocate General and the 

Department of Justice regarding the status of the legal claims related to 

Camp Lejeune. To describe the three federal inquiries into issues related 

to the drinking water contamination, we reviewed the reports of a Marine 

Corps panel, the EPA OIG, and the EPA CID, and we interviewed EPA 

officials. 

To assess the design of the current ATSDR health study, we contracted 

with the National Academy of Sciences (NAS) to convene a panel of seven

subject area experts for a 1-day meeting on July 29, 2005. The expert panel

Page 5 GAO-07-276 Past Camp Lejeune Water Contamination
was charged with evaluating the study’s population, exposure time frame, 

selected health effects, and completion date. For the assessment of the 

ATSDR study, we relied primarily on information gleaned from the expert 

panel meeting and the panel experts’ subsequent written responses to the 

set of questions that were discussed during the 1-day meeting. Panel 

members were invited as individual experts, not as organizational 

representatives, and were not asked to reach consensus on any topics. 

NAS was not asked to provide advice or produce any report, and the 

comments made during the meeting of the expert panel should not be 

interpreted to represent the views of NAS, of the organizations with which 

the panel members were affiliated, or of all experts regarding health

studies related to drinking water contamination. Not all panel members 

commented individually about each of the questions discussed during the 

1-day meeting. Additionally, some panel members noted that certain 

questions addressed subjects that were outside their areas of expertise. 

We also reviewed study-related documentation furnished by officials from 

ATSDR, Marine Corps, and Navy Environmental Health Center, and 

interviewed officials from those agencies. We conducted our work from

May 2005 through April 2007 in accordance with generally accepted 

government auditing standards. (See app. I for further detail on our scope 

and methodology.) 

Efforts to identify and address past drinking water contamination at Camp 

Lejeune began in the 1980s, when the Navy initiated water testing, and are

continuing with long-term cleanup and monitoring. In 1980, VOCs, 

including TCE, were first detected at Camp Lejeune during an analysis by

a Navy-contracted laboratory that combined treated water from all base 

water systems. During the same year, the Navy began monitoring Camp 

Lejeune’s treated water for total trihalomethanes (TTHMs), contaminants 

that are a byproduct of the water treatment process. The TTHM 

monitoring indicated interference from unidentified chemicals. In 1982 

and 1983, continued TTHM monitoring identified TCE and another VOC, 

PCE, as contaminants in two separate water systems that served base 

housing areas, Hadnot Point and Tarawa Terrace. Sampling results 

indicated that the levels of TCE and PCE found in the water systems 

varied. Former Camp Lejeune environmental officials said that they did 

not take additional steps to address the contamination after TCE and PCE 

were identified. The former officials recalled that they did not act because

at that time they had little knowledge about TCE and PCE, there were no 

drinking water regulations that gave enforceable limits for these 

chemicals, and variation in water testing results raised questions about the 

tests’ validity. Also in 1982, a Navy environmental program began 

Results in Brief 

Page 6 GAO-07-276 Past Camp Lejeune Water Contamination
investigating potentially contaminated sites at many Marine Corps and 

Navy bases, including Camp Lejeune. Testing initiated under that program 

in 1984 and 1985 found that individual wells in the Hadnot Point and 

Tarawa Terrace water systems were contaminated with TCE, PCE, and 

other VOCs. Camp Lejeune officials removed 10 contaminated wells from 

service in 1984 and 1985. Camp Lejeune officials determined that several 

areas on base where hazardous waste and other materials were disposed 

may have been the sources of contamination for the Hadnot Point water 

system, and North Carolina environmental officials determined that an offbase dry cleaner was the likely source of contamination for the Tarawa 

Terrace water system. Efforts are ongoing by ATSDR to determine when 

contamination at Hadnot Point began. In 2006, ATSDR estimated that well 

contamination from the off-base dry cleaner began as early as 1957. In 

1989, EPA placed both Camp Lejeune and the off-base dry cleaner on the 

National Priorities List. Since that time, federal, state, and Camp Lejeune 

officials have partnered to take long-term actions to clean up the sources 

of contamination and to monitor and protect the base’s drinking water. 

Cleanup activities have included the removal of contaminated soils and 

gasoline storage tanks and the treatment of contaminated groundwater 

and soils. 

Concerns about possible adverse health effects and government actions 

related to the past drinking water contamination have led to additional 

activities, including health studies, claims against the federal government,

and federal inquiries. From 1991 to 1997, ATSDR conducted a public 

health assessment at Camp Lejeune. The assessment recommended that

studies be carried out to evaluate the risks of childhood cancer related to

exposure to the contaminated drinking water. In 1998, an ATSDR study 

found a statistically significant association between exposure to the 

contaminated drinking water at Camp Lejeune and some adverse 

pregnancy outcomes, such as small for gestational age.12 In 1999, ATSDR 

began its current study to determine whether individuals who were 

exposed in utero and as infants up to 1 year of age to the contaminated 

drinking water at Camp Lejeune between 1968 and 1985 were more likely 

to have developed specific birth defects or childhood cancers. Since 

ATSDR began its Camp Lejeune-related work in 1991, the agency has not 

always received requested funding and experienced delays in receiving

 12Small for gestational age means that a fetus or an infant is smaller in size than is expected

for the baby’s gender, race and ethnicity, and length of time from conception until the baby

is delivered. 

Page 7 GAO-07-276 Past Camp Lejeune Water Contamination
information from DOD. For example, for 3 of the 16 fiscal years during 

which ATSDR has conducted its Camp Lejeune-related work (fiscal years 

1998 through 2000), no funding was provided to ATSDR by the Navy or any 

DOD entity. However, ATSDR officials said that these funding and 

information issues had not significantly delayed ATSDR’s work at Camp 

Lejeune. Former Camp Lejeune residents and employees have filed about

750 tort claims against the federal government for injuries alleged to have

resulted from exposure to the contaminated drinking water. Additionally, 

three federal inquiries into issues related to the drinking water 

contamination at Camp Lejeune have been conducted—one in 2004 by a 

Marine Corps-chartered panel, one in 2005 by the EPA OIG, and one from

2003 through 2005 by the EPA CID. The inquiry conducted by the Marine 

Corps-chartered panel found that the Marine Corps acted responsibly and 

found no evidence that the Marine Corps had attempted to cover up 

information that indicated contamination in Camp Lejeune’s drinking 

water. However, the Marine Corps-chartered panel also criticized some 

actions taken by Camp Lejeune and Department of the Navy officials, such

as inadequate communications among these entities about the drinking 

water contamination. The EPA OIG found that some EPA officials’ 

responses to a citizen’s requests regarding Camp Lejeune-related 

documents were inadequate or inappropriate. The EPA CID investigation 

did not find any violations of federal law but criticized some actions taken 

by Marine Corps and Department of the Navy officials, such as a lack of 

diligence by a Navy environmental support entity in providing technical 

expertise to Camp Lejeune’s environmental officials. 

The experts convened by the National Academy of Sciences generally 

agreed that many parameters of ATSDR’s current study are appropriate, 

but some experts suggested potential modifications to the study. 

Regarding the study population, all seven panel experts agreed that 

ATSDR’s study population of individuals who were potentially exposed in 

utero to the contaminated drinking water at Camp Lejeune between 1968 

and 1985 was appropriate, as this population was arguably the most 

vulnerable to the effects of the contamination. Panel experts generally

agreed that the 1968-1985 study time frame was reasonable, based on 

limitations in data availability for the years prior to 1968. However, six of 

the panel experts said that extending the time frame after 1985 to include a 

comparison population of individuals who were not exposed to the 

contamination could help strengthen the ATSDR study. Regarding the 

health effects studied, the five panel experts who discussed health effects 

said that the selected birth defects and childhood cancers were relevant.

Four panel experts said that additional adverse health outcomes not 

included in the study could also be related to this exposure, including 

Page 8 GAO-07-276 Past Camp Lejeune Water Contamination
adverse neurological or behavioral effects and pregnancy loss. Regarding

the proposed completion date, the panel experts had mixed opinions: 

three of the five panel experts who commented said that the projected 

December 2007 date appeared reasonable, while two said that the date

might be optimistic. Four panel experts said that if ATSDR modified its 

study to use a simpler method of analysis, it could expedite completion of 

the study. Panel experts identified some potential modifications to the 

design of the current ATSDR study, such as conducting separate analyses 

for individuals who were born on base and for those who were born off 

base. 

DOD, EPA, and HHS provided technical comments on a draft of this 

report, which we incorporated where appropriate. We provided the seven

former Camp Lejeune residents who are members of the ATSDR 

community assistance panel for Camp Lejeune the opportunity to provide 

comments on our draft—three of the panel members provided both 

technical and general oral comments, and four declined to review the draft 

report. The three panel members commented generally on issues such as 

VOCs other than TCE and PCE that have been detected at Camp Lejeune,

compensation and health benefits for former residents, and additional 

notification for former residents. We incorporated the panel members’ 

technical comments where appropriate, but some issues they discussed 

were beyond the scope of this report. 

Drinking water can come from either groundwater sources, via wells, or 

from surface water sources such as rivers, lakes, and streams. All sources 

of drinking water contain some naturally occurring contaminants. As 

water flows in streams, sits in lakes, and filters thorough layers of soil and 

rock in the ground, it dissolves or absorbs the substances that it touches. 

Some of these contaminants are harmless, but others can pose a threat to 

drinking water, such as improperly disposed-of chemicals, pesticides, and

certain naturally occurring substances. Likewise, drinking water that is not 

properly treated or disinfected, or which travels through an improperly 

maintained water system, may pose a health risk. However, the presence

of contaminants does not necessarily indicate that water poses a health 

risk—all drinking water may reasonably be expected to contain at least 

small amounts of some contaminants. As of July 2006, EPA had set 

standards for approximately 90 contaminants in drinking water that may 

pose a risk to human health. According to EPA, water that contains small 

amounts of these contaminants, as long as they are below EPA’s 

standards, is safe to drink. However, EPA notes that people with severely 

Background 

Page 9 GAO-07-276 Past Camp Lejeune Water Contamination
compromised immune systems and children may be more vulnerable to 

contaminants in drinking water than the general population. 

General Information about 

Camp Lejeune and Its 

Water Systems 

Camp Lejeune began operations in the 1940s. The base covers 

approximately 233 square miles in Onslow County, North Carolina, and

includes training schools for infantry, engineers, service support, and 

medical support, as well as a Naval Hospital and Naval Dental Center. 

Base housing at Camp Lejeune consists of enlisted family housing, officer 

family housing, and bachelor housing, which consists of barracks for 

unmarried service personnel. The base has nine family housing areas, and 

families live in base housing for an average of 2 years. Additionally, 

schools, day care centers, and administrative offices are located on the 

base. Approximately 54,000 people currently live and work at Camp 

Lejeune, including about 43,000 active duty personnel and 11,000 military 

dependents and civilian employees. 

In the 1980s, Camp Lejeune obtained its drinking water from as many as 

eight water systems, which were fed by more than 100 individual wells 

that pumped water from a freshwater aquifer located approximately 180

feet below the ground. Each of Camp Lejeune’s water systems included 

wells, a water treatment plant, reservoirs, elevated storage tanks, and 

distribution lines to provide the treated water to the systems’ respective 

service areas. Drinking water at Camp Lejeune has been created by 

combining and treating groundwater from multiple individual wells that 

are rotated on and off, so that not all wells are providing water to the 

system at any given time. Water is treated in order to remove minerals and 

particles and to protect against microbial contamination. (See fig. 1 for a 

description of how a Camp Lejeune water system operates.) 

Page 10 GAO-07-276 Past Camp Lejeune Water Contamination
Figure 1: Conceptual Model of a Camp Lejeune Water System 

Sources: GAO, Art Explosion, and Marine Corps Base Camp Lejeune.

Untreated water

Treated water

 The drinking water at Camp Lejeune is obtained from groundwater pumped from a freshwater aquifer 

located approximately 180 feet below the ground. Groundwater is pumped through wells located near the 

water treatment plant. In the water treatment plant, the untreated water is mixed and treated through several 

processes: removal of minerals to soften the water, filtration through layers of sand and carbon to remove 

particles, chlorination to protect against microbial contamination, and fluoride addition to help prevent tooth 

decay. After the water is treated, it is stored in ground and elevated storage reservoirs. When needed, 

treated water is pumped from the reservoirs and tanks to facilities such as offices, schools, or houses on the base. 

 

3

5

2

1

4

1

Water

Treatment

Plant

3 School

Office

Wells

2

House

5

4

Reservoir

Note: Water treatment processes may not remove all contaminants present in untreated water. 

From the 1970s through 1987, Hadnot Point, Tarawa Terrace, Holcomb 

Boulevard, and Rifle Range water systems provided drinking water to 

most of Camp Lejeune’s housing areas. (See fig. 2 for the locations of these 

water service areas.) The water treatment plants for the Hadnot Point and

Tarawa Terrace water systems were constructed during the 1940s and 

1950s. The Rifle Range water system was constructed in 1965. The water 

treatment plant for the Holcomb Boulevard water system began operating

at Camp Lejeune in 1972; prior to this time, the Hadnot Point water system 

provided water to the Holcomb Boulevard service area. In the 1980s, each

of these four systems had between 4 and 35 wells that could provide water 

to their respective service areas. In 1987 the Tarawa Terrace water 

Page 11 GAO-07-276 Past Camp Lejeune Water Contamination
treatment plant was shut down and the Holcomb Boulevard water 

distribution system was expanded to include the Tarawa Terrace water 

service area.

Figure 2: Selected Water Service Areas at Camp Lejeune Serving Base Housing

from the 1970s through 1987 

Source: ATSDR.

Boundary of the Camp Lejeune Military Base

Boundaries of Tarawa Terrace, Holcomb Boulevard, Hadnot Point, and Rifle Range water service areas

0 5 KILOMETERS

0 5 MILES

Tarawa Terrace 

Holcomb

Boulevard 

Hadnot 

Point 

Camp Lejeune

Military Base New River 

Atlantic Ocean 

Rifle 

Range

Generally, housing units served by the Tarawa Terrace and Holcomb 

Boulevard water systems consisted of family housing, which included 

single- and multifamily homes and housing in trailer parks. Housing units 

served by the Hadnot Point water system included mainly bachelor 

housing with limited family housing. The housing area served by the Rifle 

Page 12 GAO-07-276 Past Camp Lejeune Water Contamination
Range water system included both family housing and bachelor housing. 

Based on available housing data for the late 1970s and the 1980s,13 the 

estimated annual averages of the number of people living in family housing 

units14 served by these water systems at that time were: 

• 5,814 people in units served by the Tarawa Terrace water system, 

• 6,347 people in units served by the Holcomb Boulevard water system, 

• 71 people in units served by the Hadnot Point water system, and 

• 14 people in units served by the Rifle Range water system. 

In addition to serving housing units, all four water systems provided water 

to base administrative offices. The Tarawa Terrace, Holcomb Boulevard, 

and Hadnot Point water systems also served schools and other 

recreational areas. Additionally, the Hadnot Point water system also 

served an industrial area and the base hospital, and the Rifle Range water

system also served an area used for weapons training. 

The Department of the Navy consists of the Navy and the Marine Corps; 

consequently, certain Navy entities provide support functions for Marine 

Corps bases, such as Camp Lejeune. Two entities provide support for 

environmental issues: 

Department of the Navy 

Environmental Functions 

• The Naval Facilities Engineering Command began providing 

environmental support for bases in the 1970s. The Naval Facilities 

Engineering Command, Atlantic Division (LANTDIV) provides 

environmental support for Navy and Marine Corps bases in the Atlantic 

and mid-Atlantic regions of the United States.15 For example, LANTDIV 

officials work with Camp Lejeune officials to establish environmental 

cleanup priorities and cost estimates and to allocate funding to ensure 

compliance with state and federal environmental regulations. 

 13To determine the estimated annual average of people who lived in family housing units 

served by these four water systems, we used limited housing data from 1977 to 1989 

provided to us by Camp Lejeune officials. Camp Lejeune officials could not provide 

housing data prior to 1977. 

14Camp Lejeune housing officials could not provide occupancy rates for bachelor housing. 

15LANTDIV also manages the planning, design, construction, contingency engineering, real 

estate, and public work support at Navy and Marine Corps facilities in the United States. 

Page 13 GAO-07-276 Past Camp Lejeune Water Contamination
• The Navy Environmental Health Center (NEHC) has provided

environmental and public health consultation services for Navy and 

Marine Corps environmental cleanup sites since 1991. NEHC is also 

designated as the technical liaison between Navy and Marine Corps 

installations and ATSDR, and as a part of this responsibility, reviews and 

comments on all ATSDR reports written for Navy and Marine Corps sites 

prior to publication. Prior to 1991, no agency was designated to provide 

public health consultation services for Navy and Marine Corps sites. 

In 1980, the Department of the Navy established the Navy Assessment and 

Control of Installation Pollutants (NACIP) program to identify, assess, and 

control environmental contamination from past hazardous material 

storage, transfer, processing, and disposal operations. Under the NACIP 

program, initial assessment studies were conducted to determine the 

potential for environmental contamination at Navy and Marines Corps 

bases. If, as a result of the study, contamination was suspected, a followup confirmation study and corrective measures were initiated. In 1986 the 

Navy replaced its NACIP program with the Installation Restoration 

Program. The purpose of the Installation Restoration Program is to reduce, 

in a cost effective manner, the risk to human health and the environment 

from past waste disposal operations and hazardous material spills at Navy 

and Marine Corps bases. Cleanup is done in partnership with EPA, state 

regulatory agencies, and members of the community. 

EPA was established in 1970 to consolidate in one agency a variety of 

federal research, monitoring, standard-setting, and enforcement activities 

to ensure environmental protection. EPA’s primary roles and functions 

include developing and enforcing environmental regulations; conducting 

environmental research; providing financial assistance to states, 

educational institutions, and other nonprofit entities that conduct 

environmental research; and furthering public environmental education. 

Congress passed the Safe Drinking Water Act in 197416 to protect the 

public’s health by regulating the nation’s public drinking water supply. The 

Safe Drinking Water Act, as amended, is the key federal law protecting 

public water supplies from harmful contaminants. For example, the act 

requires that all public water systems conduct routine tests of treated 

water to ensure that the water is safe to drink. Required water testing 

EPA and Environmental 

Laws and Regulations 

Related to Drinking Water 

Contamination and 

Hazardous Waste 

Contamination at Camp 

Lejeune 

 16Pub. L. No. 93-523, 88 Stat. 1660 (codified, as amended, at 42 U.S.C. §§ 300f et seq.). 

Page 14 GAO-07-276 Past Camp Lejeune Water Contamination
frequencies vary and range from weekly testing for some contaminants to 

testing every 3 years for other contaminants. The act also established a 

federal-state arrangement in which states may be delegated primary 

implementation and enforcement authority for the drinking water 

program. For contaminants that are known or anticipated to occur in 

public water systems and that EPA determines may have an adverse 

impact on health, the act requires EPA to set a nonenforceable maximum 

contaminant level goal, at which no known or anticipated adverse health 

effects occur and that allows an adequate margin of safety. Once the 

maximum contaminant level goal is established, EPA sets an enforceable

standard for water as it leaves the treatment plant, the maximum 

contaminant level. A maximum contaminant level is the maximum 

permissible level of a contaminant in water delivered to any user of a 

public water system. The maximum contaminant level must be set as close 

to the goal as is feasible using the best technology or other means 

available, taking costs into consideration. The North Carolina Department 

of Environment and Natural Resources and its predecessors17 have had 

primary responsibility for implementation of the Safe Drinking Water Act 

in North Carolina since 1980. 

In 1979, EPA promulgated final regulations applicable to certain 

community water systems establishing the maximum contaminant levels 

for the control of TTHMs, which are a type of VOC that are formed when 

disinfectants—used to control disease-causing contaminants in drinking 

water—react with naturally occurring organic matter in water. The 

regulations required that water systems that served more than 10,000 

people and which added a disinfectant as part of the drinking water 

treatment process to begin mandatory water testing for TTHMs by 

November 1982 and comply with the maximum contaminant level by

November 1983. TCE and PCE were not among the contaminants included 

in these regulations. 

 17In the 1980s the North Carolina Department of Human Resources administered the Safe

Drinking Water Act and the Department of Natural Resources and Community 

Development was responsible for other environmental functions in the state of North 

Carolina. In 1989, sections of these departments underwent a reorganization and name 

change, becoming the Department of Environment, Health, and Natural Resources. In 1997, 

the department was again reorganized and took on its current name, the Department of 

Environment and Natural Resources. 

Page 15 GAO-07-276 Past Camp Lejeune Water Contamination
In 1979 and 1980 EPA issued nonenforceable guidance establishing 

“suggested no adverse response levels” for TCE and PCE in drinking water 

and in 1980 issued “suggested action guidance” for PCE in drinking 

water.18 Suggested no adverse response levels provided EPA’s estimate of 

the short- and long-term exposure to TCE and PCE in drinking water for 

which no adverse response would be observed and described the known 

information about possible health risks for these chemicals. Suggested 

action guidance recommended remedial actions within certain time 

periods when concentrations of contaminants exceeded specific levels. 

Suggested action guidance was issued for PCE related to drinking water 

contamination from coated asbestos-cement pipes, which were used in 

water distribution lines.

The initial regulation of TCE and PCE under the Safe Drinking Water Act 

began in 1989 and 1992, respectively, when maximum contaminant levels 

became effective for these contaminants. (See table 1 for the suggested no

adverse response levels, suggested action guidance, and maximum 

contaminant level regulations for TCE and PCE.) 

 18Neither issuance was published in The Federal Register. 

Page 16 GAO-07-276 Past Camp Lejeune Water Contamination
Table 1: EPA Guidance and Regulations for Trichloroethylene (TCE) and Tetrachloroethylene (PCE) in Drinking Water 

Nonenforceable guidance Enforceable regulation

Suggested no adverse response levela

for various exposure periods in parts 

per billion (ppb) issued in 1979 (TCE) 

and 1980 (PCE) 

Suggested action guidanceb

 for 

various exposure periods in ppb issued

in 1980 (PCE)

Maximum contaminant 

level in milligrams per 

liter (mg/l) and ppbc

effective in 1989 (TCE) 

and 1992 (PCE)

Chemical 1-Dayd10-DayeLong-termf1-Dayd10-DayeLong-termf

TCE 2,000 200 75 N/AgN/AgN/Ag0.005 mg/l or 5 ppb

PCE 2,300 175 20 2,300 180 40 0.005 mg/l or 5 ppb 

Source: GAO analysis of EPA data. 

a

Suggested no adverse response levels are EPA-issued nonenforceable guidance for community

water systems regarding TCE and PCE in drinking water. 

b

Suggested action guidance is EPA-issued nonenforceable guidance suggesting that remedial action 

be taken when PCE exceeded specific levels. 

c

These are the maximum permissible levels of a contaminant in water that is delivered to a public 

water system. Maximum contaminant levels are not specific to period of exposure. The maximum 

contaminant level for TCE became effective in 1989. See 52. Fed. Reg. 25716 (July 8, 1987). The 

maximum contaminant level for PCE became effective in 1992. See 52. Fed. Reg. 3593 (January 30, 

1991). The maximum contaminant levels were issued in milligrams per liter. EPA also reports these 

contaminant levels in the equivalent ppb. 

d

One-day suggested no adverse response levels and suggested action guidance were the maximum 

levels for one 24-hour period of exposure. 

e

Ten-day suggested no adverse response levels and suggested action guidance were the maximum 

levels each day for 10 days of exposure. 

f

Long-term suggested no adverse response levels and suggested action guidance were the maximum 

levels each day for long-term exposure. Long-term exposure was based on a 70-year exposure. 

g

There was no suggested action guidance for TCE.

The Comprehensive Environmental Response, Compensation, and 

Liability Act (CERCLA) of 198019 established what is known as the 

Superfund program to clean up highly contaminated waste sites and 

address the threats that these sites pose to human health and the 

environment, and assigned responsibility to EPA for administering the 

program.20 CERCLA was amended by the Superfund Amendments and 

 19Pub. L. No. 96-510, 94 Stat. 2767 (codified, as amended, at 42 U.S.C. §§ 9601 et seq.). 

20At privately owned sites, EPA can require that responsible parties either perform the 

cleanup themselves, or reimburse EPA for the costs of Superfund-funded cleanups. Federal 

agencies generally must pay for cleanups and other Superfund activities from their own 

appropriations. 

Page 17 GAO-07-276 Past Camp Lejeune Water Contamination
Reauthorization Act (SARA) of 1986.21 Among other things, SARA requires 

that federal agencies, including DOD, that own or operate facilities on 

EPA’s CERCLA list of seriously contaminated sites, known as the National

Priorities List, enter into an interagency agreement with EPA.22 The 

agreement is to specify what cleanup activities, if any, are required, and to

set priorities for carrying out those activities.23 SARA also established the 

Defense Environmental Restoration Program, through which DOD 

conducts environmental cleanup activities at military installations.24 Under 

the environmental restoration program, DOD’s activities addressing 

hazardous substances, pollutants, or contaminants are required to be 

carried out consistent with the provisions of CERCLA governing 

environmental cleanups at federal facilities.25 Based on environmental 

contamination at various areas on the base, Camp Lejeune was designated

as a National Priorities List site in 1989. EPA, the Department of the Navy,

and the state of North Carolina entered into a Federal Facilities Agreement 

concerning cleanup of Camp Lejeune with an effective date of March 1, 

1991. 

ATSDR’s Assessment of 

the Adverse Health Effects 

of Hazardous Substances 

at DOD Superfund Sites 

ATSDR was created by CERCLA and established within the Public Health 

Service of HHS in April 1983 to carry out Superfund’s health-related 

activities. These activities include conducting health studies, laboratory 

projects, and chemical testing to determine relationships between 

exposure to toxic substances and illness. In 1986, SARA expanded 

ATSDR’s responsibilities to include, among other things, conducting 

public health assessments, toxicological databases, information 

dissemination, and medical education. SARA requires that ATSDR conduct 

a public health assessment at each site proposed for or on the National 

Priorities List, and that ATSDR conduct additional follow-up health studies 

 21Pub. L. No. 99-499, 100 Stat. 1613 (1986) (codified, as amended, at various sections of 

titles 10, 26, 29, and 42 U.S.C.). 

22To determine which sites are eligible for listing on the National Priorities List, EPA uses 

the Hazard Ranking System, a numerical scoring system that assesses the hazards a site 

poses to human health and the environment as its principal determining fact. Once EPA has 

determined that the risks posed by a site make it eligible for the National Priorities List, 

EPA regions then consider many other factors in selecting the sites to submit to EPA

headquarters for proposal to the National Priorities List. 

23See 42 U.S.C. § 9620(e). 

24See 10 U.S.C. §§ 2701-2709. 

25See 10 U.S.C. § 2701(a)(2). 

Page 18 GAO-07-276 Past Camp Lejeune Water Contamination
if needed. Potentially responsible parties, including federal agencies, are 

liable for the costs of any health assessment or health effects study carried 

out by ATSDR.26

SARA requires that ATSDR and DOD enter into a memorandum of 

understanding to set forth the authorities, responsibilities, and procedures 

between DOD and ATSDR for conducting public health activities at DOD 

Superfund sites.27 Based on the memorandum of understanding signed 

between ATSDR and DOD, ATSDR is required to submit an annual plan of 

work to DOD, in which it must describe the public health activities it plans 

to conduct at DOD sites in the following fiscal year, as well as the amount 

of funding required to conduct these activities. After the annual plan of

work has been submitted, DOD has 45 days to respond and negotiate the 

scope of work to be conducted by ATSDR. The memorandum of 

understanding states that DOD must seek sufficient funding through the 

DOD budgetary process to carry out the work agreed upon. 

Possible Adverse Health 

Effects of TCE and PCE 

According to ATSDR’s Toxicological Profile, inhaling small amounts of 

TCE may cause headaches, lung irritation, poor coordination, and 

difficulty concentrating, and inhaling or drinking liquids containing high 

levels of TCE may cause nervous system effects, liver and lung damage,

abnormal heartbeat, coma, or possibly death.28 ATSDR also notes that 

some animal studies suggest that high levels of TCE may cause liver, 

kidney, or lung cancer, and some studies of people exposed over long 

periods to high levels of TCE in drinking water or workplace air have 

shown an increased risk of cancer. ATSDR’s Toxicological Profile notes 

that the National Toxicology Program has determined that TCE is 

reasonably anticipated to be a human carcinogen and the International 

Agency for Research on Cancer has determined that TCE is probably 

carcinogenic to humans. Unlike TCE, the health effects of inhaling or 

drinking liquids containing low levels of PCE are unknown, according to 

ATSDR. However, ATSDR reports that exposure to very high 

 26See 42 U.S.C. § 9607(a)(4)(D). 

27See 10 U.S.C. § 2704(c). 

28ATSDR did not define “small amounts” or “high levels” of TCE. According to ATSDR’s

Toxicological Profiles, when exposure to TCE or PCE occurs many factors determine 

whether an individual will be harmed. These factors include the amount of exposure, 

duration of exposure, and how an individual came in contact with these chemicals (i.e., 

ingestion, inhalation, or contact with the skin). 

Page 19 GAO-07-276 Past Camp Lejeune Water Contamination
concentrations of PCE may cause dizziness, headaches, sleepiness, 

confusion, nausea, difficulty in speaking and walking, unconsciousness, or 

death.29 HHS has determined that PCE may reasonably be anticipated to be

a carcinogen. 

Efforts to identify and address past drinking water contamination at Camp 

Lejeune began in the 1980s, when the Navy initiated water testing at Camp 

Lejeune. In 1980, one water test identified the presence of VOCs and a 

separate test indicated contamination by unidentified chemicals. In 1982 

and 1983, water monitoring for TTHMs by a laboratory contracted by

Camp Lejeune led to the identification of TCE and PCE as the 

contaminants in two water systems at Camp Lejeune. Sampling results 

indicated that the levels of TCE and PCE varied. Former Camp Lejeune 

environmental officials said they did not take additional steps to address 

the contamination after TCE and PCE were identified. The former officials 

recalled that they did not take additional steps because at that time they 

had little knowledge of TCE and PCE, there were no regulations 

establishing enforceable limits for these chemicals in drinking water, and

variations in water testing results raised questions about the tests’ validity. 

In 1984 and 1985, NACIP, a Navy environmental program, identified VOCs, 

including TCE and PCE, in 12 of the wells serving the Hadnot Point and 

Tarawa Terrace water systems. Camp Lejeune officials removed 10 wells 

from service in 1984 and 1985. Additionally, information about the 

contamination was provided to residents. Upon investigating the 

contamination, DOD and North Carolina officials concluded that both onand off-base sources were likely to have caused the contamination in the 

Hadnot Point and Tarawa Terrace water systems. Since 1989, federal, 

state, and Camp Lejeune officials have partnered to take actions to clean 

up the sources of contamination and to monitor and protect the base’s 

drinking water. 

Efforts to Identify and 

Address Past Drinking 

Water Contamination 

at Camp Lejeune 

Began in the 1980s 

and Continue with 

Long-Term Cleanup 

and Monitoring 

Navy Water Testing 

Beginning in 1980 

Identified VOCs in Camp 

Lejeune Water Systems 

The presence of VOCs in Camp Lejeune water systems was first detected 

in October 1980. On October 1, 1980, samples of water were collected from 

all eight water systems at Camp Lejeune by an official from LANTDIV, a 

Navy entity which provided environmental support to Camp Lejeune. The 

water samples were combined into a single sample, and a “priority 

pollutant scan” was conducted in order to detect possible contaminants in 

 29ATSDR did not define “low levels” or “high concentrations” of PCE. 

Page 20 GAO-07-276 Past Camp Lejeune Water Contamination
the water systems. The results of this analysis, conducted by a Navycontracted private laboratory and sent to LANTDIV, identified 11 VOCs, 

including TCE, at their detection limits, that is, the lowest level at which 

the chemicals could be reliably identified by the instruments being used.30

LANTDIV officials we interviewed said they do not remember why this 

testing was conducted. A memorandum written by a Camp Lejeune 

environmental official noted that LANTDIV initiated the testing because 

North Carolina had assumed responsibility in March 1980 for oversight of 

the Safe Drinking Water Act and therefore would have the right to sample 

and test the drinking water at Camp Lejeune for any contaminants 

regulated under the act.

31 The memorandum stated that LANTDIV officials 

were concerned that the state’s testing might discover problems that the 

Navy had not previously identified. The Camp Lejeune memorandum 

characterized the 1980 analysis as indicating “no problems” from the 

pollutants when the samples from eight water systems were tested as one 

combined sample, but also noted that this might not have been true if the 

samples had been analyzed individually. Current and former LANTDIV 

officials told us that they did not recall any actions taken as a result of this 

analysis. 

Separately, in 1980 the Navy began monitoring programs for TTHMs at 

various Navy and Marine Corps bases, including Camp Lejeune, in 

preparation for meeting a future EPA drinking water regulation.32

LANTDIV arranged for an Army laboratory to begin testing the treated 

water from two Camp Lejeune water systems, Hadnot Point and New 

River, in October 1980. At that time, these two water systems were the 

only ones that served more than 10,000 people and therefore would be 

required to meet the future TTHM regulation. From October 1980 to 

 30Additionally, two metals—cadmium and selenium—were identified at levels slightly 

above detection limits. 

31This memorandum was prepared after Camp Lejeune officials received these testing 

results in 1982. 

32According to an August 1980 memorandum, which cited a 1979 amendment to the 

National Interim Primary Drinking Water Regulations, LANTDIV initiated monitoring

programs at various naval facilities, including Camp Lejeune, in order to develop a TTHM 

database prior to the effective dates for the enforcement of the maximum contaminant 

levels. For Camp Lejeune community water systems such as Hadnot Point and New River 

that served 10,000 to 74,999 individuals, the maximum contaminant levels for TTHMs took 

effect in November 1983 and an EPA requirement to begin monitoring TTHM levels in the 

systems began 1 year prior to that date. See 44 Fed. Reg. 68641 (Nov. 29, 1979) (to be

codified at 40 C.F.R. § 141.6). 

Page 21 GAO-07-276 Past Camp Lejeune Water Contamination
September 1981, eight samples were collected from the Hadnot Point 

water system and analyzed for TTHMs. Results from four of the eight 

samples indicated the presence of unidentified chemicals that were 

interfering with the TTHM analyses.33 Reports for each of the four analyses

contained an Army laboratory official’s handwritten notes about the 

unidentified chemicals: two of the notes classified the water as “highly 

contaminated” and notes for the other two analyses recommended 

analyzing the water for organic compounds. 

The exact date when LANTDIV officials began receiving results from 

TTHM testing is not known, and LANTDIV officials told us that they had

no recollection of how or when the results were communicated from the 

Army laboratory. Available Marine Corps documents indicate that Camp 

Lejeune environmental officials34 learned in July 1981 that LANTDIV had 

been receiving the results of TTHM testing and was holding the results 

until all planned testing was complete. Subsequently, Camp Lejeune 

environmental officials requested copies of the TTHM results that 

LANTDIV had received to date, and LANTDIV provided these results in 

August 1981. The next documented correspondence from LANTDIV to 

Camp Lejeune regarding TTHM monitoring occurred in a February 1982 

memorandum in which LANTDIV recommended that TTHM monitoring be 

expanded to all of Camp Lejeune’s water systems and noted that Camp 

Lejeune should contract with a North Carolina state-certified laboratory 

for the testing. 

In early 1981, additional water testing unrelated to the TTHM monitoring 

began at the Rifle Range area within Camp Lejeune for various 

contaminants, including TCE and PCE. A former Camp Lejeune official

recalled that the testing was initiated because of concerns about chemicals 

that had been buried at Rifle Range. In March, April, and May 1981, water 

samples were collected from areas surrounding the chemical dump, 

including a nearby creek; treated water from the Rifle Range water system; 

and untreated water from the individual wells serving the water system. 

These water samples were sent to a Navy-contracted private laboratory for 

 33The results from the other four samples did not note the presence of unidentified 

chemicals. 

34In the early 1980s the environmental staff at Camp Lejeune consisted of three primary 

staff members: a director specializing in natural resources, a supervisory ecologist, and a

chemist. These staff members were responsible for water monitoring and compliance with 

environmental regulations, among other responsibilities. Over time as environmental laws 

have changed, the environmental staff has grown and obtained additional responsibilities. 

Page 22 GAO-07-276 Past Camp Lejeune Water Contamination
analysis, and the results were sent to a LANTDIV official in April and May 

1981. The results for the samples collected from the areas surrounding the 

chemical dump identified VOCs, including TCE and PCE. The results for 

the samples collected from the water system’s treated water and for the 

samples from the untreated water from the individual wells also identified 

VOCs. In July 1981, LANTDIV communicated the results to Camp Lejeune 

officials and noted that one of the VOCs detected was a trihalomethane 

and arrangements had been made to add the Rifle Range water system to 

the base TTHM testing. LANTDIV also recommended that no further 

action be taken until additional data became available from TTHM 

monitoring or the planned NACIP program to identify, assess, and control 

environmental contamination. 

Current and former LANTDIV officials recalled that their agency played a 

limited role in providing information or guidance regarding environmental 

issues at Camp Lejeune, and that this assistance generally would have

been at the request of Camp Lejeune officials. However, former Camp 

Lejeune environmental officials recalled that at that time they had little 

experience in water quality issues and relied on LANTDIV to serve as their

environmental experts. Documents from 1981 indicate that LANTDIV 

officials continuously communicated information about the Rifle Range 

area to Camp Lejeune environmental officials, including providing 

sampling results, discussing the implications of these results, providing 

copies of related regulations and standards, and making recommendations 

for additional action. (See app. II for a more detailed description of 

selected events related to drinking water contamination at Camp Lejeune 

from 1980 through 1981.)

Further Tests Identified 

TCE and PCE in Two 

Camp Lejeune Water 

Systems in 1982 and 1983; 

Camp Lejeune Officials Do 

Not Recall Taking Action 

to Address the 

Contamination at That 

Time

Following LANTDIV’s recommendation to expand TTHM monitoring to all 

base water systems, Camp Lejeune officials contracted with a private 

state-certified laboratory to test samples of treated water from all eight of

their water systems. According to an August 1982 memorandum, in May 

1982 a Camp Lejeune official was informed during a telephone

conversation with a private laboratory official that organic cleaning 

solvents, including TCE, were present in the water samples for TTHM 

monitoring from the Hadnot Point and Tarawa Terrace water systems. In 

July 1982, additional water samples from the two systems were collected

in an effort to investigate the presence of these chemicals. In August 1982 

the contracted laboratory sent a letter to base officials informing them that

TCE and PCE were identified from the May and July samples as the 

contaminants. According to the letter, the testing determined that the 

Hadnot Point water system was contaminated with both TCE and PCE and 

Page 23 GAO-07-276 Past Camp Lejeune Water Contamination
the Tarawa Terrace water system was contaminated with PCE. The letter 

also noted that TCE and PCE “appeared to be at high levels” and were 

“more important from a health standpoint” than the TTHM monitoring. 

Sampling results indicated that the levels of TCE and PCE varied. The 

letter noted that one sample taken in May 1982 from the Hadnot Point 

water system contained TCE at 1,400 parts per billion and two samples 

taken in July 1982 contained TCE at 19 and 21 parts per billion. Four 

samples taken in May 1982 and July 1982 from the Tarawa Terrace water 

system contained levels of PCE that ranged from 76 to 104 parts per 

billion. (See table 2 for the May and July 1982 sampling results.) 

Table 2: Sampling Results from Hadnot Point and Tarawa Terrace Water Systems 

for May 1982 and July 1982 

Concentrations of chemicals in parts per billiona

Housing area SamplesbTCEcPCEd

May samplese

Hadnot Point 1 1,400 15

Tarawa Terrace 2 —f80

July samples

Hadnot Point 3 19 <1

4 21 <1

5 No datag 1.0

Tarawa Terrace 6 —f76

7 —f82

8 —f104

Source: GAO analysis of Headquarters Marine Corps data. 

a

The August 1982 letter from the contracted laboratory in which these sampling results were provided

did not include the detection limit. The detection limit is the lowest level at which the chemicals could 

be reliably identified by the instruments being used. 

b

Camp Lejeune’s samples were identified by nonconsecutive numbers. We renumbered the samples 

to provide consecutive number identifiers. 

c

Trichloroethylene (TCE) is a volatile organic compound typically used as a metal degreaser. 

d

Tetrachloroethylene (PCE) is a volatile organic compound typically used as a dry cleaning solvent. 

e

The May samples were analyzed in July. 

f

The laboratory did not report results for TCE in these samples. 

g

A memorandum by a Camp Lejeune environmental official indicated that this sample was analyzed 

for TCE, but exact quantities were not determined. 

Page 24 GAO-07-276 Past Camp Lejeune Water Contamination
Former Camp Lejeune environmental officials recalled that after the 

private laboratory identified the TCE and PCE in the two water systems, 

they did not take additional steps to address the contamination for three 

reasons. First, they had limited knowledge of these chemicals; second, 

there were no regulations establishing enforceable limits for these 

chemicals in drinking water; and third, they made assumptions about why 

the levels of TCE and PCE varied and about the possible sources of the 

TCE and PCE. The former Camp Lejeune environmental officials told us 

that they were aware of EPA guidance, referred to as “suggested no 

adverse response levels,” for TCE and PCE when these contaminants were 

identified at Camp Lejeune. However, they noted that the levels of these 

contaminants detected at Camp Lejeune generally were below those 

outlined in the guidance. One Camp Lejeune environmental official also 

recalled that at the time they were unsure what the health effects would be 

for the lower amounts detected at the base. Additionally, in an August 

1982 document and during our interviews with current Camp Lejeune

environmental officials, it was noted that EPA had not issued regulations 

under the Safe Drinking Water Act for TCE and PCE when the private 

laboratory identified these chemicals in the drinking water. The former 

Camp Lejeune environmental officials also said that they made 

assumptions about why the levels of TCE and PCE varied in sampling 

results and about the possible sources of the TCE and PCE. Specifically, 

because the levels of TCE and PCE varied, they attributed the higher levels 

to short-term environmental exposures, such as spilled paint inside a 

water treatment plant, or to laboratory or sampling errors. Additionally, in

an August 1982 memorandum, a Camp Lejeune environmental official 

suggested that, based on the sampling results provided by the private 

laboratory, the levels of PCE detected could be the result of using coated

pipes in the untreated water lines at Tarawa Terrace. The former Camp 

Lejeune environmental officials told us that in retrospect, it was likely that 

well rotation in these water systems contributed to the varying sampling 

results because the contaminated wells may not have been providing 

water to the Hadnot Point and Tarawa Terrace systems at any given time. 

However, both they and current Camp Lejeune environmental officials 

said that at that time the base environmental staff did not know that the 

wells serving both systems were rotated. 

After August 1982, the private laboratory continued to communicate with 

Camp Lejeune officials about the contamination of treated water from the 

Hadnot Point and Tarawa Terrace water systems. All eight of Camp 

Lejeune’s water systems were sampled again for TTHMs in November 

1982. In a December 1982 memorandum, a Camp Lejeune environmental 

official noted that during a phone conversation with a chemist from the 

Page 25 GAO-07-276 Past Camp Lejeune Water Contamination
private laboratory the chemist expressed concern that TCE and PCE were 

interfering with Tarawa Terrace and Hadnot Point TTHM samples. The 

chemist said the levels of TCE and PCE were “relatively high” in the 

November 1982 samples, though the specific levels of TCE and PCE were 

not provided to Camp Lejeune officials. The private laboratory report 

providing the November 1982 results said that the samples from Tarawa 

Terrace “show contamination” from PCE and the samples from Hadnot 

Point “show contamination” from both TCE and PCE. All eight of Camp 

Lejeune’s water systems were sampled again for TTHMs in August 1983, 

and the private laboratory report providing these results said that the 

samples from Tarawa Terrace “show contamination” from PCE and the

samples from Hadnot Point “show contamination” from both TCE and 

PCE.35 Former Camp Lejeune environmental officials recalled that they did 

not take any actions related to these findings. (See app. III for a more 

detailed timeline of selected events from 1982 through 1983.)

Discovery of 

Contamination at 

Individual Wells in 1984 

and 1985 Prompted Their 

Removal from Service, and 

Information Was Provided 

to Residents and the Media 

In 1982, Navy officials initiated the NACIP program at Camp Lejeune as 

part of its overall strategy to identify, assess, and control environmental 

contamination at Navy and Marine Corps bases.36 The first step of the 

NACIP program was an initial assessment study, which was designed to 

collect and evaluate evidence that indicated the existence of pollutants 

that may have contaminated a site or that posed a potential health hazard

for people located on or off a military installation. The initial assessment 

study for Camp Lejeune, which was completed in April 1983, determined 

that further investigation was warranted at 22 priority sites with potential 

contamination, including a site near wells that served the Hadnot Point 

water system. 

In July 1984, the base initiated a NACIP confirmation study to investigate

the 22 priority sites. As a part of the confirmation study, a Navy contractor

took water samples from water supply wells located near priority sites 

where groundwater contamination was suspected. Current and former 

Camp Lejeune officials told us that previous water samples usually had 

been collected from treated water at sites such as reservoirs or buildings 

within the water systems rather than being collected directly from 

 35The reports of the November 1982 and August 1983 TTHM analyses did not provide 

further details about the levels of TCE and PCE detected. 

36The NACIP program at Camp Lejeune was unrelated to the prior water testing that

identified TCE and PCE contamination. 

Page 26 GAO-07-276 Past Camp Lejeune Water Contamination
individual wells at Camp Lejeune.37 In November 1984, Camp Lejeune 

officials received sampling results for one Hadnot Point well located near 

a priority site, which showed that TCE and PCE, among other VOCs, were

detected in the well. This well was removed from service, and in 

December 1984, water samples from six Hadnot Point wells that were 

located in the same general area and treated water samples from the 

Hadnot Point water plant were also tested. Results of the analysis of the 

well samples indicated that both TCE and PCE were detected in one well, 

TCE was detected in two additional wells, and other VOCs were detected

in all six wells. Results for the treated water samples also detected TCE 

and PCE. Four of these six wells were removed from service, in addition 

to the original well removed from service. For the two wells that were not

taken out of service, while initial results indicated levels of VOCs, 

including TCE, other test results showed no detectable levels of VOCs. 

Documents we reviewed show that continued monitoring of those two 

wells indicated no detectable levels of TCE. During December 1984, seven

additional samples were taken from the treated water at Hadnot Point 

water plant and revealed no detectable levels of TCE and PCE. According 

to two former Camp Lejeune environmental officials, once the wells had

been taken out of service and the samples from the water plant no longer 

showed detectable levels of TCE or PCE, they believed the water from the 

Hadnot Point water system was no longer contaminated. 

Although the December 1984 testing of water from the Hadnot Point water 

system showed no detectable levels of TCE or PCE, in mid-January 1985

Camp Lejeune environmental staff began collecting water samples from all 

wells on the base. Sampling results were received in February 1985 and 

detected VOCs, including TCE and PCE, in 3 wells serving the Hadnot 

Point water system and 2 wells serving the Tarawa Terrace water system. 

As a result, those 5 wells were removed from service. According to current

Camp Lejeune officials, all 10 wells had been removed from service by 

February 8, 1985.

38 According to memoranda dated March 1985 and May 

1985, 1 of the 2 wells removed from service at Tarawa Terrace was used 

on 1 day in March 1985 and on 3 days in April 1985 for short periods of 

time to meet water needs at the base. See table 3 for the dates that wells 

 37During the water testing conducted at the Rifle Range area, samples were also collected 

from the individual wells serving the Rifle Range water system. 

38Although 1981 sampling results from a well that served the Rifle Range water system 

indicated the presence of VOCs, including TCE, the subsequent 1985 sampling results of

Rifle Range wells performed under NACIP showed no detectable levels of VOCs. 

Page 27 GAO-07-276 Past Camp Lejeune Water Contamination
were removed from service and for the levels of TCE and PCE which were 

detected in the wells prior to their removal from service in 1984 and 1985.

See app. IV for the levels of other VOCs which were detected in the wells 

prior to their removal from service in 1984 and 1985. 

Table 3: Dates Wells Were Removed from Service in 1984 and 1985 at Hadnot Point 

and Tarawa Terrace Water Systems, and TCE and PCE Levels Detected in Each Well 

Concentrations of chemicals in

parts per billiona

 

Water 

systems Wells

Date removed 

from service TCEb

PCEc

Hadnot Point 602 Nov. 30, 1984 1,600 24

601 Dec. 6, 1984 210 5

608 Dec. 6, 1984 110 ND

634dDec. 14, 1984 ND ND

637dDec. 14, 1984 ND ND

651 Feb. 4, 1985 3,200 386

652 Feb. 8, 1985 9 ND

653 Feb. 8, 1985 5.5 ND

Tarawa TT-26 Feb. 8, 1985 57 1,580

Terrace TT-23e

Feb. 8, 1985 ND 132

Source: GAO analysis of Headquarters Marine Corps data. 

Notes: The detection limit for the instruments used to analyze the samples was 10 parts per billion. 

The detection limit is the lowest level at which the chemicals could be reliably identified by the 

instruments being used. A Marine Corps document providing the sampling results stated that ND

meant “none detected.” 

a

The concentrations provided are those detected prior to each well’s removal from service and are 

one-time sampling results. We did not find documentation that tied the decision to remove the wells 

from service to any particular level of contamination included in related EPA guidance or enforceable 

regulation. DOD sampling also detected other VOCs. (See app. IV). 

b

Trichloroethylene (TCE) is a volatile organic compound typically used as a metal degreaser. 

c

Tetrachloroethylene (PCE) is a volatile organic compound typically used as a dry cleaning solvent. 

d

TCE and PCE were not detected in this well prior to its removal from service. Documents indicate

that this well was taken out of service after detection of “significant levels” of methylene chloride, a 

VOC used in various industrial processes such as paint stripping, paint remover manufacturing, and 

metal cleaning and degreasing. 

e

Tarawa Terrace well TT-23 is also referred to as “TT-new well” in Marine Corps documents. 

Page 28 GAO-07-276 Past Camp Lejeune Water Contamination
In addition, while base officials were waiting for sampling results from 

January 1985 of samples collected from wells serving Hadnot Point, water 

from this system was provided to a third water system for about 2 weeks.

In late January 1985, a fuel line break caused gasoline to leak into the 

Holcomb Boulevard water treatment plant. During the approximately 

2-week period the treatment plant was shut down, water from the Hadnot 

Point system was pumped into the Holcomb Boulevard water lines. 

Former Camp Lejeune environmental officials said that they used water 

from the Hadnot Point water system because it was the only water system 

interconnected with the Holcomb Boulevard water system, and because

they believed the water from the Hadnot Point water system was no longer

contaminated. Prior to restarting the Holcomb Boulevard water system, 

samples of treated water were tested and no gasoline was detected in any 

of these samples. However, the samples were found to contain various 

levels of TCE; these results were attributed to the use of water from the 

Hadnot Point water system. About 5 days after these samples were taken, 

the Holcomb Boulevard water system was restarted because the fuel line 

had been repaired. 

Following the discovery of contamination at individual wells in 1984, 

Camp Lejeune published articles in the base newspaper, provided one 

notification to residents of housing areas served by the Tarawa Terrace 

water system, and created a press release about issues related to drinking 

water at Camp Lejeune. In December 1984 the base newspaper published 

its first story about sampling efforts, detection of VOCs, and removal of 

wells from service in the Hadnot Point water system. At this time, Camp 

Lejeune environmental officials had not begun sampling all other wells on 

the base, including those at the Tarawa Terrace water system. 

Subsequently, in April 1985 the Commanding General of Camp Lejeune 

issued a notice to residents who lived in housing areas served by the 

Tarawa Terrace water system.39 According to the notice: 

“Two of the wells that supply Tarawa Terrace have had to be taken off line because minute 

(trace) amounts of several organic chemicals have been detected in the water. There are no 

definitive State or Federal regulations regarding a safe level of these compounds, but as a

precaution, I have ordered the closure of these wells for all but emergency situations when 

fire protection or domestic supply would be threatened.” 

 39Documents do not indicate how this notice was provided to residents. 

Page 29 GAO-07-276 Past Camp Lejeune Water Contamination
The notice asked residents to reduce water use until early June, when the 

construction of a new water line was to be completed. In May 1985, 

another article in the base newspaper stated the number of wells that had 

been removed from service, stated why the wells were removed from 

service, and noted the potential for water shortage at Tarawa Terrace as a

result. In addition, the Marine Corps provided us with copies of three 

North Carolina newspaper articles published from May 1985 to September 

1985 discussing contamination at Camp Lejeune.40 All three articles 

included information about the drinking water contamination and noted

that 10 wells serving two water treatment systems at Camp Lejeune had 

been removed from service. (See app. V for a more detailed timeline of 

selected documented events from 1984 through 1985.) 

Past Contamination Was 

Estimated to Have 

Originated from Both Onbase and Off-base Sources 

The sources of past contamination for the Hadnot Point water system have 

not been conclusively determined. However, DOD officials have estimated 

that eight contaminated on-base sites in the proximity of the Hadnot Point 

water system may be the sources of contamination for that water system. 

(See table 4.) These eight sites were contaminated by leaking underground 

storage tanks containing fuel, by degreasing solvents, by hazardous 

chemical spills, and by other waste disposal practices.41 Efforts by ATSDR 

are ongoing to conclusively determine the sources of past contamination 

in the Hadnot Point water system, as well as when the contamination 

began. 

 40According to a May 1985 memorandum, Camp Lejeune officials issued a press release 

regarding removal of wells from service at Camp Lejeune in May 1985. However, the 

memorandum did not describe the contents of the press release, and the Marine Corps was

unable to locate a copy of the press release for our review.

41The sources of contamination at these eight sites were identified through the NACIP 

program and the Installation Restoration Program, which replaced NACIP as the Navy and 

Marine Corps environmental program. 

Page 30 GAO-07-276 Past Camp Lejeune Water Contamination
Table 4: Information about Potential Sites of Contamination for the Hadnot Point 

Water System

Sites Uses of the sitea

Open field storage lots Storage, disposal, and handling of potentially

hazardous waste and materials, such as 

cleaning solvents, used batteries, and waste

oils 

Piney Green Road, an area adjacent to 

the open field storage lots 

Storage, disposal, and handling of potentially

hazardous waste and materials, such as 

pesticides, used batteries, and fuel 

Transformer storage lot Pesticide mixing and cleaning and disposal of

oil from electric transformers 

Firefighting training pit Firefighting training exercises in which 

flammable liquids (including used oil, 

solvents, and fuels) were used

An industrial fly ash dump Disposal of waste, including fly ash (which is 

residue resulting from the combustion of 

ground or powdered coal), solvents, water 

treatment sludge, and used paint stripping 

compounds 

An industrial area which includes 75 

buildings and facilities such as

maintenance shops, gas stations, 

administrative offices, commissaries, 

snack bars, warehouses, and storage 

yards 

Mixed uses; due to the industrial nature of the 

site, many spills and leaks of gas-related 

products and solvents occurred 

A service station within the industrial 

area 

Fuel storage; includes four underground 

gasoline storage tanks 

A fuel farm within the industrial area Fuel storage; includes 15 fuel storage tanks,

14 of which are underground 

Sources: Camp Lejeune Site Management Plan, Fiscal Year 2006, EPA Superfund Record of Decision for Camp Lejeune 1993 and 

1994, and interviews with current Camp Lejeune officials. 

a

Some sites may have multiple uses. The only uses of the sites that were included were those that 

may be related to the contamination. 

For the Tarawa Terrace water system, North Carolina officials determined 

that an off-base source was the likely cause of the drinking water 

contamination. After the Marine Corps requested assistance in identifying

the source of the contamination, North Carolina state officials conducted 

an investigation from April 1985 through September 1985 to determine 

whether two off-base dry cleaning facilities located near the two 

contaminated wells were the sources of the PCE contamination at Tarawa 

Terrace. The state officials concluded that the contamination likely came 

from dry cleaning solvent that had been released into a leaking septic tank

at one of the cleaners—ABC One Hour Cleaners—which built its septic 

Page 31 GAO-07-276 Past Camp Lejeune Water Contamination
system and began operation in 1954. Both the dry cleaning facility and its 

septic tank were located off base but adjacent to a supply well for the 

Tarawa Terrace water system. Based on the environmental contamination 

at this site, ABC One Hour Cleaners was designated as a National 

Priorities List site in 1989. As part of its current health study, ATSDR has 

estimated that beginning as early as 1957 individuals were exposed to PCE 

in treated drinking water at levels equal to or greater than what became 

effective in 1992 as EPA’s maximum contaminant level of 5 parts per 

billion. 

Cleanup and Monitoring 

Activities Are Under Way 

to Address the 

Contamination 

Since 1989, officials from Camp Lejeune, North Carolina, and federal 

agencies, including EPA, have taken actions to clean up the suspected 

sources of the contamination in the Hadnot Point and Tarawa Terrace 

water systems. Because the contamination is thought to have come from 

both on- and off-base sources, and because those sources are part of two 

separate National Priorities List sites—Camp Lejeune and ABC One Hour 

Cleaners—cleanup activities for the suspected sources of contamination 

are being managed separately. 

Following Camp Lejeune’s listing as a National Priorities List site in 

October 1989 and the signing of a Federal Facilities Agreement in 

February 1991, on-base cleanup activities have been managed by a 

partnership of DOD, EPA, and North Carolina environmental officials. 

Cleanup of the eight sites suspected to be possible sources of 

contamination for the Hadnot Point water system has included the 

removal of contaminated soils and gasoline storage tanks and the 

treatment of contaminated groundwater and soils. The cleanup activities 

at four of the eight sites were completed by 2006. The estimated 

completion date for cleanup activities of contaminated groundwater and 

soils at three of the other four sites is 2025. There is no estimated 

completion date for the fourth site. Funding for the cleanup of the on-base 

sites has come from Department of the Navy Environmental Restoration 

Program funds, and Navy officials estimated that about $70 million would 

be needed to complete the cleanup of all eight sites. 

Efforts to clean up the suspected source of contamination that affected 

the Tarawa Terrace water system began after ABC One Hour Cleaners was 

listed as a National Priorities List site in 1989. Cleanup activities at the site, 

which have been designed to address both the contaminated groundwater 

and soil, have been managed by EPA, with support from North Carolina 

officials. While treatment of some of the areas with contaminated soil has 

been completed, the EPA official who serves as project manager for the 

Page 32 GAO-07-276 Past Camp Lejeune Water Contamination
ABC One Hour Cleaners site could not provide an estimated completion 

date for cleanup of either the soil or the groundwater. Funding for the 

cleanup of this site comes primarily from the Superfund, though a portion

of the funds has been provided by ABC One Hour Cleaners and North 

Carolina. The total estimated cost for the cleanup of this site is about 

$4.3 million. According to a North Carolina official, North Carolina will 

assume authority for cleanup at the site in August 2013. 

Currently, Camp Lejeune uses various methods to monitor and protect the 

base’s drinking water. In drinking water reports published in 2004 and 

available on the Camp Lejeune Web site, base officials stated that their 

efforts to monitor the drinking water supply had met or exceeded all

required testing standards. For example, Camp Lejeune reported that “in 

accordance with Safe Drinking Water Act sampling requirements” it had 

regularly tested its treated drinking water for more than 80 different EPAregulated contaminants and additional unregulated contaminants. The 

reports noted that testing of treated water for VOCs had been conducted

on a monthly basis—exceeding the requirement to test every 3 years—“in 

order to show that there should be no concern about current VOC 

contamination.” The Camp Lejeune reports stated that the base had 

sampled the wells at least annually for VOCs. Additionally, the Water 

Quality Program at Camp Lejeune produces annual reports about each

drinking water system on the base in order to inform water consumers 

about the quality of their water. The 2004 reports also stated that Camp 

Lejeune officials have undertaken numerous efforts to protect the drinking 

water supply, including restricting land uses near well fields,42 locating 

well fields in undeveloped areas, constructing wells in a manner that 

minimizes the potential for contamination, and using new technologies to

prevent groundwater contamination. Examples of some of these new 

technologies included a computer-based monitoring system for 

underground storage tanks that immediately alerts personnel when a leak 

occurs, and the installation of bullet traps at firing areas, which prevent

lead and copper bullets from contaminating the groundwater and soil. 

 42Well fields are areas containing one or more wells that produce usable amounts of water. 

Page 33 GAO-07-276 Past Camp Lejeune Water Contamination
Concerns about possible adverse health effects and government actions 

related to the past drinking water contamination have led to additional 

activities, including health studies, claims against the federal government,

and federal inquiries. Activities resulting from concerns about possible 

adverse health effects began in 1991, when ATSDR initiated a public health

assessment that evaluated the possible health risks from past exposure to 

the contaminated drinking water at Camp Lejeune. The health assessment 

was followed by two studies, one of which was ongoing as of April 2007. 

Since ATSDR began its work, the agency did not always receive requested 

funding and experienced delays in receiving information from DOD 

entities. However, ATSDR officials said that the agency’s Camp Lejeunerelated work was not significantly delayed by DOD. As of January 2007, 

about 750 claims had been filed by former Camp Lejeune residents and 

employees against the federal government for injuries alleged to have

resulted from past exposure to the contaminated drinking water at Camp 

Lejeune. Additionally, three federal inquiries into issues related to the 

drinking water contamination at Camp Lejeune have been conducted, one 

by a Marine Corps-chartered panel, one by the EPA OIG, and one by the 

EPA CID. The inquiry conducted by the Marine Corps-chartered panel

found that the Marine Corps acted responsibly and found no evidence that 

the Marine Corps had attempted to cover up information that indicated

contamination in Camp Lejeune’s drinking water. However, the Marine 

Corps-chartered panel also criticized some actions taken by Camp Lejeune 

and Department of the Navy officials, such as inadequate communications 

among these entities about the drinking water contamination. The EPA 

OIG found that some EPA officials’ responses to a citizen’s requests 

regarding Camp Lejeune-related documents were inadequate or 

inappropriate. The EPA CID investigation did not find any violations of 

federal law but criticized some actions taken by Marine Corps and 

Department of the Navy officials, such as a lack of diligence by a Navy

environmental support entity in providing technical expertise to Camp 

Lejeune’s environmental officials. 

Concerns about 

Possible Adverse 

Health Effects and 

Government Actions 

Related to the Past 

Contamination Have 

Led to Additional 

Activities 

Page 34 GAO-07-276 Past Camp Lejeune Water Contamination
Beginning in 1991, ATSDR has undertaken several activities to study the 

possible adverse health effects related to the past drinking water 

contamination at Camp Lejeune, including a public health assessment and 

two studies. From 1991 to 1997, ATSDR conducted a public health 

assessment at Camp Lejeune that was required by law because of the 

base’s listing on the National Priorities List. The health assessment 

evaluated several ways in which people on base had been exposed to 

hazardous substances, including exposure to the VOC-contaminated 

drinking water.43 ATSDR concluded that (1) cancerous and noncancerous 

health effects were unlikely in adults exposed to VOC-contaminated 

drinking water, (2) the likelihood of either noncancerous or cancerous 

health effects in children could not be determined because of insufficient 

scientific information, and (3) there was evidence that suggested that, 

because of their developing systems, individuals who were exposed in 

utero were potentially more sensitive to the effects of VOCs than 

individuals who were exposed as adults or children.44 In its 1997 report, 

ATSDR recommended that a study be carried out to evaluate the risks of 

childhood cancer in those who were exposed in utero to the contaminated 

drinking water and also noted that adverse pregnancy outcomes were of 

concern. ATSDR officials said that the health assessment did not 

recommend a study of adverse pregnancy outcomes because such a study 

was already under way. 

ATSDR Has Undertaken 

Several Activities to Study 

Possible Adverse Health 

Effects Related to the 

Drinking Water 

Contamination at Camp 

Lejeune 

In 1995, while the health assessment was being conducted, ATSDR 

initiated a study to determine whether there was an association between 

exposure to VOCs in drinking water and specific adverse pregnancy 

outcomes among women who had lived at Camp Lejeune from 1968 

through 1985.45 The study, released in 1998, originally concluded that there 

was a statistically significant elevated risk for several poor pregnancy 

outcomes, including (1) small for gestational age among male infants born 

 43While conducting the health assessment, ATSDR also considered two other types of past

exposures at Camp Lejeune as possibly a public health hazard: lead in tap water and 

pesticides in soil at a former day care facility. 

44Agency for Toxic Substances and Disease Registry, Public Health Assessment U.S.

Marine Corps Camp Lejeune Onslow County, North Carolina (Atlanta, Ga.: 1997). 

45Although there was no evidence of an increased rate of adverse pregnancy outcomes at

Camp Lejeune at that time, the 1998 study report states that the agency believed it was 

prudent to research this topic because fetuses tend to be more sensitive to toxic chemical 

exposures and many pregnant women had resided in housing areas supplied with 

contaminated water. In addition to small for gestational age, other adverse pregnancy 

outcomes evaluated in the study included pre-term birth and mean birth weight. 

Page 35 GAO-07-276 Past Camp Lejeune Water Contamination
to mothers living at Hadnot Point, (2) small for gestational age for infants 

born to mothers over 35 years old living at Tarawa Terrace, and (3) small 

for gestational age for infants born to mothers with two or more prior fetal

losses living at Tarawa Terrace.46 However, ATSDR officials said they are 

reanalyzing the findings of this study because of an error in the original 

assessment of exposure to VOCs in drinking water. While the study 

originally assessed births from 1968 to 1972 in the Holcomb Boulevard 

service area as being unexposed to VOCs, these births were exposed to 

contaminants from the Hadnot Point water system. An ATSDR official said

the reanalysis may alter the study’s results. 

In 1999, ATSDR initiated its current study examining whether certain birth

defects and childhood cancers are associated with exposure to TCE or 

PCE at Camp Lejeune. The study examines whether individuals born 

during 1968 through 1985 to mothers who were exposed to the 

contaminated drinking water at any time while they were pregnant and

living at Camp Lejeune were more likely than those who were not exposed 

to have neural tube defects, oral cleft defects, or childhood hematopoietic

cancers.47 The current study began with a survey to identify potential cases 

of the selected birth defects and childhood cancers. The study is also using 

water modeling48 to help ATSDR determine the potential sources of past 

contamination and estimate when the water became contaminated and

which housing units received the contaminated water. The water modeling 

data will help ATSDR identify which pregnant women may have been 

exposed to the contaminated water, and will also help ATSDR estimate the 

amount of TCE and PCE that may have been in the drinking water. ATSDR 

officials said that the study is expected to be completed by December 

2007. 

ATSDR also has hosted two expert panel meetings related to the past 

drinking water contamination at Camp Lejeune. In February 2005, ATSDR 

hosted an expert scientific advisory panel to explore opportunities for 

conducting additional health studies of people who were potentially 

 46U.S. Department of Health and Human Services, Agency for Toxic Substances and 

Disease Registry, Volatile Organic Compounds in Drinking Water and Adverse 

Pregnancy Outcomes (Atlanta, Ga.: 1998). 

47Childhood hematopoietic cancers include childhood leukemia and non-Hodgkin’s

lymphoma. 

48Water modeling is a scientific method that is used to help estimate past water system 

conditions. 

Page 36 GAO-07-276 Past Camp Lejeune Water Contamination
exposed to contaminated drinking water at Camp Lejeune. The agency 

noted that it convened this panel in response to continuing public concern 

about health effects from past exposure to contaminated drinking water. 

ATSDR received nine recommendations from its scientific advisory panel 

in a final report released in June 2005, which include a recommendation to 

create an advisory panel to oversee future studies and a recommendation 

that funding for future studies should come from appropriations to 

ATSDR, not from DOD’s budget.49 In an August 2005 published response, 

ATSDR agreed with all but three of the scientific advisory panel’s 

recommendations.50 (See app. VI for ATSDR’s panel recommendations and 

ATSDR’s response.) 

ATSDR has taken steps to accomplish three of the recommended 

activities. In February 2006, ATSDR created a community assistance panel 

to respond to the two recommendations urging a closer partnership with 

former Camp Lejeune residents and development of an advisory panel to 

oversee health studies related to VOC exposures at Camp Lejeune.51 As of 

January 2007, the community assistance panel had held four meetings. The 

panel includes seven former Camp Lejeune residents. Also participating in

CAP meetings are one representative from DOD, two independent 

scientific experts, and ATSDR staff. ATSDR officials said the community 

assistance panel is comparable with other panels that ATSDR had set up 

for community participation at National Priorities List sites similar to 

Camp Lejeune. In response to a recommendation to conduct feasibility or 

pilot studies before beginning full-scale health studies, ATSDR had begun 

conducting a feasibility assessment to determine the availability and 

sufficiency of data needed to conduct several additional health studies 

related to past drinking water contamination. At the February 2006 

 49U.S. Department of Health and Human Services, Agency for Toxic Substances and 

Disease Registry, Report of the Camp Lejeune Scientific Advisory Panel (Atlanta, Ga.: 

2005). 

50Agency for Toxic Substances and Disease Registry, ATSDR Response to the Report of the 

Camp Lejeune Scientific Advisory Panel Held February 17-18, 2005 (Atlanta, Ga.: 2005). 

51In 1992, ATSDR announced that it was developing community assistance panels at 

selected Superfund sites in order to enhance effective communication of environmental

health concerns to ATSDR by the public and provide a means for community participation

in ATSDR activities. ATSDR noted that among the factors that influence its decision to 

establish a community assistance panel at a particular site are the degree of community 

interest, whether there are varying viewpoints regarding the health issues, and a

willingness on the part of the public to actively participate in the process. 57 Fed. Reg. 

27779 (June 22, 1992). 

Page 37 GAO-07-276 Past Camp Lejeune Water Contamination
community assistance panel meeting, the panel members and ATSDR 

officials agreed that ATSDR should move forward with the initial stages of 

planning a mortality study and an adult cancer incidence study of those 

potentially exposed to contaminated water at Camp Lejeune so long as 

necessary data are available. ATSDR officials said that they had identified

databases such as the National Death Index,52 which contains death 

records, and state cancer registries53 that could be used to assist ATSDR 

with conducting these studies. An ATSDR official said that mortality and 

cancer incidence studies would potentially be easier to carry out than 

some other health studies because of the existence of these databases. 

Since the February 2006 community assistance panel meeting, ATSDR 

officials have begun reviewing additional databases at the Defense 

Manpower Data Center and Naval Health Research Center to determine if 

those databases could be linked to both the National Death Index and 

state cancer registries, and to Camp Lejeune family housing records.54 If 

the feasibility assessment shows that these databases can be used, ATSDR 

will likely proceed with the two studies, officials said. Additionally, 

ATSDR officials said they plan to computerize the family housing records 

at Camp Lejeune that were still in paper format. Officials noted that the 

fully computerized family housing records might be used as the basis for 

defining a registry of potentially affected residents, as recommended by 

the scientific advisory panel, if the feasibility assessment indicates that it 

is possible to obtain social security numbers and dates of birth for each 

potential member of the registry. 

 52The National Death Index is a central computerized index of death record information on 

file in state vital statistics offices. Working with these state offices, the National Center for 

Health Statistics established the index as a resource to aid epidemiologists and other health

and medical investigators with mortality ascertainment activities. 

53Cancer registries collect data about the occurrence of cancer, the types of cancer that 

occur, the cancer’s location in the body, the extent of disease at the time of diagnosis, and 

the kinds of treatment patients receive. Cancer data are reported to a central statewide 

registry from various medical facilities including hospitals, physicians’ offices, therapeutic 

radiation facilities, freestanding surgical centers, and pathology laboratories.

54The Defense Manpower Data Center maintains the largest archive of personnel, 

manpower, training, and financial data in DOD. The personnel data holdings are broad in

scope and extend back to the early 1970s to cover all military services and all phases of the 

military personnel life cycle. The Naval Health Research Center is a laboratory that 

supports fleet operational readiness through research, development, test, and evaluation on

the biomedical and psychological aspects of the Navy and Marine Corps. 

Page 38 GAO-07-276 Past Camp Lejeune Water Contamination
In March 2005, ATSDR hosted a separate expert peer review panel to 

evaluate the agency’s water modeling and data-gathering efforts at Camp 

Lejeune. In a report published in October 2005, the expert peer review 

panel on water modeling made two primary recommendations urging the 

agency to make additional effort and expend more resources on more 

rigorous record searches to improve the information for the historical 

reconstruction of events.55 ATSDR agreed and had hired new staff and 

consultants to begin record searches at Camp Lejeune; however, ATSDR 

officials did not proceed with their record search after they learned that 

the Marine Corps had separately hired a private contractor to conduct 

such a search. The Marine Corps’ private contractor completed its 

document search in August 2006, which yielded more than 6,000 

documents. An ATSDR official told us that during a preliminary review of 

the documents in July 2006, ATSDR determined that the documents were 

“extremely useful” for its water modeling activities. The remaining three 

recommendations of the expert peer review panel on water modeling were

technical comments related to modeling activities, such as a 

recommendation to use simplified models that required less effort and 

resources. ATSDR officials said that they agreed with these technical 

recommendations and had subsequently used them to refine their 

modeling procedures. 

Although ATSDR Did Not 

Always Receive Requested 

Funding and Experienced 

Delays in Receiving 

Information from DOD, 

Officials Said Their Work 

Has Not Been Significantly 

Delayed 

Since ATSDR began its Camp Lejeune-related work in 1991, the agency did 

not always receive requested funding and experienced delays in receiving

information from DOD entities. Although concerns have been raised by 

former Camp Lejeune residents, ATSDR officials said these issues have 

not significantly delayed its work and that such situations are normal 

during the course of a study. 

 55U.S. Department of Health and Human Services, Agency for Toxic Substances and 

Disease Registry, Expert Peer Review Panel Evaluating ATSDR’s Water-Modeling 

Activities in Support of the Current Study of Childhood Birth Defects and Cancer at U.S.

Marine Corps Base Camp Lejeune, North Carolina (Atlanta, Ga.: 2005). 

Page 39 GAO-07-276 Past Camp Lejeune Water Contamination
ATSDR received funding from DOD for 13 of the 16 fiscal years during 

which it has conducted its Camp Lejeune-related work, and ATSDR 

provided its own funding for Camp Lejeune-related work during the other 

3 years. Under federal law and in accordance with a memorandum of 

understanding between DOD and ATSDR, DOD is responsible for funding 

public health assessments and any follow-up public health activities such

as health studies or toxicological profiles related to DOD sites as agreed to 

in an annual plan of work. While ATSDR conducted the health assessment 

at Camp Lejeune, from fiscal year 1991 to fiscal year 1996 funding was 

provided by DOD as part of an annual payment for all ATSDR activities at

DOD sites. These annual payments were provided from Defense 

Environmental Restoration Program funds. In fiscal year 1997, the 

individual military services assumed responsibility for making these 

payments. Therefore, for fiscal year 1997, funding for ATSDR’s Camp 

Lejeune-related work came directly from the Navy (see Table 5). 

Funding of ATSDR’s Camp 

Lejeune Work 

Table 5: Funding of ATSDR Activities at Camp Lejeune from Fiscal Years 1991 

through 2006 

Fiscal year Total amountaFunding source

1991 95,018 Defense Environmental Restoration Program (DERP)b

1992 33,868 DERP

1993 97,000 DERP

1994 230,795 DERP

1995 434,328 DERP

1996 141,405 DERP

1997 109,045 Navy Environmental Restoration Programc

1998 731,247 ATSDR

1999 390,000 ATSDR

2000 935,312 ATSDR

2001 1,241,003 Navy Environmental Restoration Program 

2002 1,021,437 Navy Environmental Restoration Program 

2003 567,389 Marine Corps Operations & Maintenanced

2004 1,723,000 Marine Corps Operations & Maintenance 

2005 1,549,000 Marine Corps Operations & Maintenance 

2006 1,376,263eMarine Corps Operations & Maintenance, Navy 

Environmental Restoration Program 

Sources: ATSDR and DOD. 

a

Expenditure amounts, in dollars, as reported by ATSDR and DOD.

Page 40 GAO-07-276 Past Camp Lejeune Water Contamination
b

The DERP was established by the Superfund Amendments and Reauthorization Act of 1986. 

Through the DERP, DOD conducts environmental cleanup activities at military installations. The 

Office of the Secretary of Defense provides oversight for the DERP. Each of the military departments

is responsible for implementing DERP requirements. 

c

Beginning in fiscal year 1997, the individual military services assumed responsibility for making 

payments to ATSDR. The Department of the Navy conducts DERP-related activies through the Navy 

Environmental Restoration Program. 

d

Marine Corps Operation & Maintenance appropriations provide the funding for various Marine Corps 

missions, functions, activities, and facilities.

e

In fiscal year 2006, the Marine Corps provided $1,269,263 to support ATSDR’s current study, and 

the Navy Environmental Restoration Program provided an additional $107,000, as submitted in a 

supplemental request by ATSDR to conduct community assistance panel meetings and a feasibility

assessment to determine whether additional health studies could be conducted for the Camp Lejeune 

site. 

From fiscal year 1998 through fiscal year 2000, no funding was provided to 

ATSDR by the Navy or any DOD entity for its Camp Lejeune-related work 

because the agencies could not reach agreement about the funding for 

Camp Lejeune. In June 1997, ATSDR proposed conducting a study of 

childhood leukemia and birth defects associated with TCE and PCE 

exposure at Camp Lejeune during fiscal years 1998 and 1999 at an 

estimated cost of almost $1.8 million. In a July 1997 letter to the Navy, an 

ATSDR official noted that during a June meeting the Navy appeared to be

reluctant to fund the proposed study; however, the official noted that DOD 

was liable for the costs of the study under federal law. In an October 1997 

letter responding to ATSDR, a senior Navy official stated that the Navy did 

not believe it should be required to fund ATSDR’s proposed study because 

the cause of the contamination was an off-base source, ABC One Hour 

Cleaners. The Navy official said that it was more appropriate for ATSDR to 

seek funding for the study from the responsible party that caused the 

contamination.56 However, ATSDR officials told us that while they 

expected that the study would focus primarily on contamination from the 

dry cleaner, the study was also expected to include people who were 

exposed to on-base sources of contamination. An ATSDR official reported 

that the agency submitted its funding proposals for the Camp Lejeune 

study to DOD in each of the annual plans of work from fiscal year 1998 to

fiscal year 2000, but that during that time period the agency received no 

DOD funding and funded its Camp Lejeune-related work from general 

ATSDR funding. 

 56Additionally, the EPA CID concluded that funding for the current study was apparently 

delayed because of opposition characterized as a professional difference of opinion as to 

the scientific value of the study by a midlevel manager at the Navy Environmental Health 

Center. 

Page 41 GAO-07-276 Past Camp Lejeune Water Contamination
In fiscal year 2001 the Navy resumed funding of ATSDR’s Camp Lejeunerelated work. We could not determine why the Navy decided to resume 

funding of ATSDR’s work at that time. Beginning in fiscal year 2003,

funding for ATSDR’s Camp Lejeune-related work has been provided by the 

Marine Corps. According to a DOD official, the Marine Corps has 

committed to funding the current ATSDR study. The DOD official also 

noted that per a supplemental budget request from ATSDR for fiscal year 

2006, the Marine Corps agreed to fund community assistance panel 

meetings and portions of a feasibility assessment for future studies that 

will include computerization of Camp Lejeune housing records. 

ATSDR has experienced some difficulties obtaining information from 

Camp Lejeune and DOD officials. For example, while conducting its public 

health assessment in September 1994, ATSDR sent a letter to the 

Department of the Navy noting that ATSDR had had difficulties getting 

documents needed for the public health assessment from Camp Lejeune,

such as Remedial Investigation57 documents for Camp Lejeune. The letter 

also noted that ATSDR had sent several requests for information and 

Camp Lejeune’s responses had been in most cases inadequate and no 

supporting documentation had been forwarded. ATSDR also had difficulty 

in obtaining access to DOD records while preparing to conduct its survey,

the first phase of the current ATSDR health study. In October 1998, ATSDR 

requested assistance from the Defense Manpower Data Center, which 

maintains archives of DOD data, in locating residents of Camp Lejeune 

who gave birth between 1968 and 1985 on or off base. An official at the 

Defense Manpower Data Center initially did not provide the requested 

information because he believed that doing so could constitute a violation 

of the Privacy Act.58 Between February and April 1999, Headquarters 

Marine Corps facilitated discussion between ATSDR and relevant DOD 

entities about these Privacy Act concerns and some information was 

subsequently provided to ATSDR by DOD. In April 2001, Headquarters 

Marine Corps sent a letter to the Defense Privacy Office suggesting that 

the Defense Manpower Data Center had only provided a limited amount of

Provision of Information to 

ATSDR by DOD 

 57A Remedial Investigation is performed at a site after it is listed on the National Priorities 

List. The Remedial Investigation serves as a mechanism for collecting data. Data collected 

during the Remedial Investigation influence the development of remedial alternatives for

the site. 

58The Privacy Act of 1974 provides safeguards for individuals against invasions of privacy 

as a result of the collection of personal information by the federal government. Pub. L. 

No. 93-579, § 3, 88 Stat. 1896, 1897 (codified as amended at 5 U.S.C. § 552a). 

Page 42 GAO-07-276 Past Camp Lejeune Water Contamination
information to ATSDR.59 However, in a July 2001 reply to Headquarters 

Marine Corps, the Defense Privacy Office noted that it believed that 

relevant data had been provided to ATSDR by the Defense Manpower Data 

Center in 1999 and 2001.

In December 2005, ATSDR officials told us that they had recently learned

of a substantial number of additional documents that had not been 

previously provided to them by Camp Lejeune officials. ATSDR then sent a 

letter to Headquarters Marine Corps seeking assistance in resolving 

outstanding issues related to delays in the provision of information and 

data to ATSDR. In an attachment to the letter, ATSDR provided a list of 

data and information needed from the Marine Corps in order to complete 

water modeling activities for its current study. In a January 2006 response,

a Headquarters Marine Corps official noted that a comprehensive review 

was conducted of responses to ATSDR’s requests for information and that 

the Marine Corps believed it had made a full and timely disclosure of all 

known and available requested documents. The official also noted that 

while ATSDR had requested that the Marine Corps identify and provide 

documents that were relevant or useful to ATSDR’s study, the Marine 

Corps did not always have the subject matter expertise to determine the 

relevance of documents. The official noted that the Marine Corps would 

attempt to comply with this request; however, the official also noted that 

ATSDR was the agency with the expertise necessary to determine the 

relevance of documents. 

Despite difficulties, ATSDR officials said the agency’s Camp Lejeunerelated work had not been significantly delayed or hindered by DOD. 

Officials said that while funding and access to records were probably 

slowed down and made more expensive by DOD officials’ actions, their 

actions did not significantly impede ATSDR’s health study efforts. The 

ATSDR officials also stated that while issues such as limitations in access 

to DOD data had to be addressed, such situations are normal during the 

course of a study. The officials stated that ATSDR’s progress on the study 

has been reasonable in light of the complexity of the project. Nonetheless, 

as some former residents have learned that ATSDR has not always 

received requested funding and information from DOD entities, they have 

Effect on ATSDR’s Work 

 59The Defense Privacy Office is responsible for implementation of DOD’s Privacy Program,

which regulates how and when DOD collects, maintains, uses, or disseminates personal 

information on individuals. 

Page 43 GAO-07-276 Past Camp Lejeune Water Contamination
raised questions about DOD’s commitment to supporting ATSDR’s work.60

For example, when some former residents learned during a community 

assistance panel meeting that it took about 4 months for DOD to respond 

to a supplemental budget request from ATSDR for fiscal year 2006, they 

questioned DOD entities’ commitment to ATSDR’s Camp Lejeune-related 

work. However, DOD and ATSDR officials described this delay in 

responding as typical during the funding process. 

Some Former Residents 

and Employees Have Filed 

Claims against the Federal 

Government 

Some former residents have filed tort claims and lawsuits against the 

federal government related to the past drinking water contamination.61 As 

of January 2007, about 750 former residents and former employees of 

Camp Lejeune have filed tort claims with the Department of the Navy 

related to the past drinking water contamination. According to an official 

with the U.S. Navy Judge Advocate General (JAG)—which is handling the

claims on behalf of the Department of the Navy—the agency is currently 

maintaining a database of all claims filed. The official said that JAG is 

awaiting completion of the current ATSDR health study before deciding

whether to settle or deny the pending claims in order to base its response 

on as much objective scientific and medical information as possible.62

As of February 2007, two of these claims had resulted in the filing of 

lawsuits in Federal District Courts in Texas and Mississippi.63 Among other 

things, both lawsuits seek damages for various physical ailments and 

emotional distress alleged to have resulted from the government’s 

 60The Marine Corps has issued multiple public statements indicating support for ATSDR’s 

work at Camp Lejeune. 

61The Federal Tort Claims Act provides a system for making claims against the federal 

government for, among other things, personal injury, property damage, or wrongful death

allegedly caused by the negligence of its employees. Act of Aug. 2, 1946, ch. 753, 60 Stat. 

842 (codified, as amended, to various sections of 28 U.S.C.). An individual must file a valid 

claim with the federal agency alleged to have caused the harm before filing a lawsuit 

against the federal government for negligence. 28 U.S.C. § 2675. 

62DOD officials noted that other considerations may lead to an earlier adjudication of some 

claims. 

63Snyder et al. v. U.S., Civ. No. 627 (S.D. Miss. filed July 27, 2004); Gros et al. v. U.S., Civ. 

No. 4665 (S. D. Tex. filed Dec. 13, 2004). The Federal Tort Claims Act requires that a claim 

must be presented in writing within 2 years after the claim accrues and that after a claim 

has been filed the agency has 6 months to make a decision. If the claim is denied or if no 

decision has been made after 6 months, the individual can then file a lawsuit against the 

federal government. 28 U.S.C. § 2675. The lawsuits were filed in the districts where the 

individuals resided at the time.

Page 44 GAO-07-276 Past Camp Lejeune Water Contamination
negligence in protecting the water supply at Camp Lejeune. In the first 

lawsuit, a former servicemember’s son alleged that he suffered a 

congenital heart defect as a result of his mother’s exposure (while 

pregnant with him) as well as his subsequent direct exposure to 

contaminated water at Camp Lejeune during the early 1970s.64 The 

outcome of the lawsuit was still pending as of February 2007. In the 

second lawsuit, a former servicemember and his family alleged injuries as 

a result of their past exposure to TCE and PCE while living at Camp 

Lejeune. The claims of the former service member and his wife were 

dismissed because his alleged injuries occurred while he was on active

duty in the Marine Corps.65 An appeal of the claims of the former service 

member and his family members remained pending in February 2007.66

Several Federal Inquiries 

Have Examined Events 

Related to the Drinking 

Water Contamination 

Three federal inquiries into issues related to the drinking water 

contamination at Camp Lejeune have been conducted, each of which cited 

concerns by former residents as one of the reasons for conducting its 

inquiry. These include one by a Marine Corps-chartered panel, one by 

EPA’s OIG, and one by EPA’s CID. 

In March 2004 the Commandant of the Marine Corps created a fact-finding

panel charged with conducting a review of the facts surrounding the 

decisions made following the 1980 discovery of VOCs in drinking water at 

Camp Lejeune.67 The panel focused its review on the 1980 to 1985 time 

period. The panel released a report in October 2004 which found that the 

Marine Corps acted responsibly and found no evidence that the Marine 

Marine Corps-Chartered Panel 

Review 

 64Plaintiffs’ Complaint, Snyder et al. (Civ. No. 627). 

65Order Granting Defendant’s Motion to Dismiss, Gros et al. (Civ. No. 4665). The Supreme

Court has held that under the Federal Tort Claims Act the federal government is not liable 

for injuries to members of the armed forces sustained while on active duty and resulting 

from the negligence of others in the armed forces. Feres v. U.S., 340 U.S. 135, 146 (1950). 

The claims of the former service member and his wife were dismissed on the grounds that

the husband’s alleged exposure to contaminated water occurred while he was on active

duty in the military. Subsequently, in March 2006, the District Court entered a final 

judgment for the government on all individual claims alleged by the former service 

member’s family members in this case. Final Judgment in Favor of Defendant, Gros et al. 

(Civ. No. 4665). 

66Gros et al. v. U.S., No. 06-20354 (5th Cir. filed May 8, 2006). 

67Members of the panel consisted of a former member of Congress; an adviser on water

management, treatment, and protection issues; a retired assistant commandant of the

Marine Corps; a former acting Secretary of the Navy; and a former branch chief of EPA. 

Page 45 GAO-07-276 Past Camp Lejeune Water Contamination
Corps had attempted to cover up information that indicated contamination 

in Camp Lejeune’s drinking water.68 Additionally, the panel concluded that

Camp Lejeune provided residents with drinking water at a level of quality 

consistent with general utility practices at the time. However, the panel

noted that while Camp Lejeune made every effort to comply with existing 

regulations, it did not anticipate or independently evaluate health risks 

associated with chemicals such as TCE or PCE that were not yet 

regulated, and for which there was developing concern about possible 

adverse health effects. The panel noted that this “compliance-based 

approach to regulations,” combined with factors including inadequate 

funding, staffing, and training of Camp Lejeune’s Environmental Division, 

contributed to a lack of understanding about the potential significance of

the contamination. Additionally, the panel identified other factors that 

appeared to have hindered Camp Lejeune personnel from quickly 

recognizing the significance of VOC contamination, including the absence 

of regulatory standards, no records of resident complaints about water 

quality, sampling errors, and inconsistent sampling results. 

The panel also made several other findings critical of Camp Lejeune and 

the Department of the Navy, noting that: 

• LANTDIV, as a technical advisory organization, was “not aggressive” in 

providing Camp Lejeune with the technical expertise to help base officials 

understand the significance of the contamination and how it could have 

been addressed; 

• communications both internally among Camp Lejeune officials, and 

between Camp Lejeune and LANTDIV, were inadequate; and

• communications to Camp Lejeune residents regarding drinking water 

contamination were not detailed enough to completely characterize the 

contamination found at the time of the well closures. 

In January 2005 EPA’s OIG completed an internal report describing a 

preliminary review of five complaints reported by three citizens regarding

issues indirectly or directly related to the drinking water contamination at 

Camp Lejeune. The complaints were as follows: 

EPA’s OIG Inquiry

 68Drinking Water Fact-Finding Panel for Camp Lejeune, Report to the Commandant United 

States Marine Corps (October 2004). 

Page 46 GAO-07-276 Past Camp Lejeune Water Contamination
1. EPA inadequately responded to a Freedom of Information Act69

request, 

2. EPA inappropriately responded to a Freedom of Information Act fee 

waiver request,70

3. EPA did not adequately perform oversight of Camp Lejeune based on 

its responsibilities listed in the Safe Drinking Water Act, 

4. EPA did not devote adequate resources to the review that was being 

conducted by its Criminal Investigation Division, and 

5. the 1998 study conducted by ATSDR was inadequate. 

The OIG conducted a preliminary review of these complaints to determine 

whether the complaints merited a full-scale audit of EPA activities. 

Regarding the first two complaints, the OIG determined that EPA’s 

response to a Freedom of Information Act request for documents related 

to Camp Lejeune contamination was inadequate and that its denial of an 

associated fee waiver request was inappropriate and insensitive. The third 

complaint was closed because the OIG concluded that EPA had little 

oversight responsibility for the Safe Drinking Water Act until 1996, 

significantly later than the contamination occurred at Camp Lejeune. The 

OIG found no merit with the fourth complaint, noting that although only 

one agent was assigned to the case, that agent had access to other agents

and resources when needed. OIG officials said the fifth complaint was 

closed in part because they knew we would also be reviewing this 

concern, and also because complaints regarding ATSDR’s study are not 

related to any actions by EPA and are therefore outside the scope of an 

EPA review. Based on this preliminary review, a full audit of EPA officials’ 

actions was not initiated.

 69The Freedom of Information Act generally ensures public access to federal agency 

records. Upon written request, federal government agencies are required to disclose those 

records, unless they can be lawfully withheld from disclosure under specific exemptions in 

the act. 5 U.S.C. § 552.

70The Freedom of Information Act also provides that documents shall be furnished at no or 

reduced charge under specified circumstances. 

Page 47 GAO-07-276 Past Camp Lejeune Water Contamination
A criminal investigation conducted by EPA and reviewed by the 

Department of Justice (DOJ) did not find any violations of federal law, but 

criticized some of the actions taken by Marine Corps and Navy officials.71

From 2003 through 2005, EPA’s CID conducted an investigation of 

allegations made by former residents that federal law was violated by the 

individuals and entities addressing the drinking water contamination at 

Camp Lejeune, including officials from the Marine Corps, Navy, and 

ATSDR. With regard to the Navy and Marine Corps, the CID investigated

five principal allegations of violation of federal law: 

EPA’s Criminal Investigation 

1. violation of the Safe Drinking Water Act, 

2. conspiracy to violate the Safe Drinking Water Act, 

3. conspiracy to conceal records and prevent persons from talking with a 

federal agency conducting a congressionally mandated health study, 

4. conspiracy to conceal Freedom of Information Act records from the 

public, and 

5. providing material false statements to a federal law enforcement 

officer. 

The CID concluded that in the absence of enforceable regulatory 

standards for both TCE and PCE between 1980 and 1985, there was no 

violation of the Safe Drinking Water Act at that time, and drinking water 

provided by Camp Lejeune during that time appeared to have met all state

and federal regulatory requirements. A CID investigator told us that he 

looked for evidence of conspiracy from the 1980s, when the events 

occurred, through 2004. With regard to allegations that Marine Corps or 

Navy officials conspired to violate the Safe Drinking Water Act or to 

conceal records, the CID’s report noted that investigators were unable to

substantiate that a conspiracy by military or civilian employees of either 

entity existed. Regarding allegations that false statements were provided 

to a federal law enforcement officer, investigators noted that while they 

were concerned that LANTDIV officials were not completely forthcoming 

 71According to EPA, as part of the agency’s responsibility for ensuring compliance with 

environmental laws, the CID investigates allegations that environmental laws have been

violated and refers the cases that pose risks to human health and the environment for 

criminal prosecution. 

Page 48 GAO-07-276 Past Camp Lejeune Water Contamination
during their interviews, there was never any direct evidence that LANTDIV 

officials were aware of the contamination prior to 1984. 

With regard to ATSDR, the CID investigated two principal allegations 

made by former residents of Camp Lejeune: 

1. destruction of a federal agency’s records, and 

2. conspiracy to improperly administer a congressionally mandated 

health study. 

Regarding an alleged order by an ATSDR official to destroy records related 

to the Camp Lejeune health study, CID investigators found that the records 

in question were never destroyed. Concerning allegations that ATSDR 

failed to properly address the drinking water contamination at Camp 

Lejeune because of influence from the Navy, the CID found no evidence 

that ATSDR’s scientific work was influenced by regular meetings between 

ATSDR and Navy officials. 

Although the CID found no evidence that federal law had been violated, 

because of the unique history and complexity of the case and an 

evaluation of statements from persons they interviewed, investigators 

noted that the case warranted a review by DOJ. Additionally, several of the 

allegations from the public had also been forwarded by DOJ to the CID for 

investigation. Following the CID’s referral of this case to DOJ for its 

review, DOJ discussed its findings at an August 2005 meeting with former 

residents and officials from the Navy and Marine Corps.72 DOJ concluded

that it would not seek criminal prosecution, saying that the government’s 

investigation had concluded that no federal criminal law was broken nor 

was there an attempt to conceal evidence regarding a violation of any law. 

In addition to investigating whether federal law had been violated, the CID 

also investigated additional questions that were relevant to the case but

were determined not to be violations of federal law. The CID noted that 

some of these matters appeared to have contributed to confusion, 

suspicion, and concern by retired Marines. Additionally, the CID 

commented on and criticized certain actions taken by Navy and Marine 

Corps officials. For example: 

 72The former residents at this meeting were those who helped initiate this investigation. 

Page 49 GAO-07-276 Past Camp Lejeune Water Contamination
• The CID concluded that as a technical advisory agency to Camp Lejeune,

LANTDIV was not diligent in providing technical expertise to the base’s 

environmental officials and noted that LANTDIV officials appeared to have

been better suited by virtue of their training and expertise to recognize 

and address VOC contamination and the possible effects on public health 

than the environmental officials at Camp Lejeune. 

• The CID commented that former Camp Lejeune environmental officials 

failed to properly investigate the contamination and determine the 

contamination was coming from individual wells. Until 1984, the Camp 

Lejeune environmental officials never sampled individual water wells and 

the CID noted that this was arguably their most significant lapse in 

judgment. 

• Because of questions raised by Congress and former residents, the CID 

also investigated the provision of DOD funding for ATSDR’s work. The 

CID concluded that funding for the current study was apparently delayed 

because of opposition characterized as a professional difference of 

opinion as to the scientific value of the study by a midlevel manager at the 

Navy Environmental Health Center, and that coupled with this opposition 

was confusion within the Navy hierarchy regarding what entity was 

responsible for the contaminated wells. 

• Regarding the provision of records and data to ATSDR by the Marine 

Corps, the CID found no instances when data or records were 

intentionally withheld or false data were provided by Marine Corps 

officials to ATSDR. The CID noted the Marine Corps appeared not to have 

recognized the complexity and degree of attention this issue required in 

1997 and that prior to 1997, the Marine Corps admitted that it failed to 

adequately address concerns and data requests from the public and 

ATSDR. 

Page 50 GAO-07-276 Past Camp Lejeune Water Contamination
The seven members of an expert panel convened by the National Academy 

of Sciences (NAS) at our request generally agreed that specific parameters

of ATSDR’s current study were appropriate, including the study 

population, the exposure time frame, and the selected health effects. The 

expert panel members had mixed opinions on ATSDR’s projected 

completion date. Some panel experts suggested modifying the study to use 

a simpler method of analysis, with alternative ways to define exposure 

categories, in order to complete the study sooner. Some panel experts also 

identified other potential modifications to the study, such as conducting 

separate analyses for those who were born on the base and those born off 

the base. (See app. VII for a more detailed description of ATSDR’s study.) 

The seven panel experts concurred that ATSDR logically limited its study 

population to those individuals who were in utero while their mothers 

were pregnant and lived at Camp Lejeune during the 1968 through 1985 

time frame, and who may have been exposed to the contaminated drinking

water.73 The current study follows recommendations from the agency’s 

1997 public health assessment of Camp Lejeune, which noted that studies 

of cancer among those who were exposed in utero should be conducted to 

further the understanding of the health effects in this susceptible 

population. Panel experts said that ideally a study would attempt to 

include all individuals who were potentially exposed, but that limited 

resources and data availability were practical reasons for limiting the 

study population. Additionally, panel experts agreed that those exposed 

while in utero were an appropriate study population because they could be

considered at higher risk of adverse health outcomes than others, such as

those exposed as children or adults. In addition, two panel experts said 

that studying only those who lived on base was reasonable because they 

likely had a higher risk of inhalation exposure to VOCs such as TCE and 

Experts Convened by 

NAS Generally Agreed 

That Many 

Parameters of 

ATSDR’s Current 

Study Were 

Appropriate but Some 

Experts Suggested 

Potential 

Modifications to the 

Study 

Experts Agreed That Study 

Population of Individuals 

Who Were Potentially 

Exposed in Utero Was 

Appropriate and Studying 

Children and Adults Could 

Also Be Reasonable 

 73ATSDR’s current study population of those individuals who were in utero includes

individuals whom ATSDR determined were exposed during specific time periods of the

mother’s pregnancy or after their birth to contaminated drinking water because they lived 

in an area that was served by the Hadnot Point or Tarawa Terrace water systems, and those 

that ATSDR determined through its study analysis were not exposed because they did not

live in those areas or were not exposed during specific time periods. 

Page 51 GAO-07-276 Past Camp Lejeune Water Contamination
PCE, which may be more potent than ingestion exposure.74 Thus, pregnant

women who lived in areas of base housing with contaminated water and 

conducted activities during which they could inhale water vapor—such as 

bathing, showering, or washing dishes or clothing—likely faced greater 

exposure than those who did not live on base but worked on base in areas 

served by the contaminated drinking water. 

While supporting the decision to limit the study population to individuals 

who were in utero, the panel experts did not discount the possibility that 

children and adults who lived or worked on base may also be at risk for 

adverse health effects because of their potential exposure to contaminated

drinking water. For example, four panel experts pointed out that exposed 

children and adults might have an elevated risk for neurological effects, 

and one of the four experts said exposed adults might have an elevated 

risk for certain cancers. Similarly, the ATSDR scientific advisory panel 

convened in February 2005 identified at least four groups of individuals at 

Camp Lejeune who might be at higher risk for adverse health effects 

because they could have been exposed to the contaminated drinking 

water. In addition to individuals who were in utero, these groups included 

children who lived on base, adults who lived on base, and adults who lived 

off base but worked on base, because they too spent time at Camp Lejeune 

and were potentially exposed to the contaminated drinking water. 

The seven panel experts agreed that the 1968 through 1985 study time 

frame was reasonable, based on limitations in data availability. This time 

frame was adopted from ATSDR’s 1998 study of adverse pregnancy 

outcomes, which limited the study population to include those potentially

exposed between 1968 and 1985. According to ATSDR’s study protocol, 

these years were chosen because 1968 was the first year that birth 

certificates were computerized in North Carolina and 1985 was when the 

affected water wells were removed from service. Four of the panel experts 

said they did not see any benefit in using an earlier start date than 1968 

because collecting birth records before 1968 could require a significant 

amount of resources to collect data. In addition, while the initial exposure 

to contaminated drinking water may have occurred as early as the 1950s, 

Experts Agreed That the 

Study Time Frame of 1968 

through 1985 Was 

Reasonable, but Could Be 

Extended Beyond 1985 

 74According to ATSDR, inhalation of TCE and PCE that have evaporated from drinking 

water is likely to result in higher exposures than ingestion. Additionally, a 1991 EPA 

guidance on estimating exposure to VOCs during showering noted that scientific studies

found that this exposure is approximately equivalent to exposure from ingesting two liters

of the contaminated water per day. 

Page 52 GAO-07-276 Past Camp Lejeune Water Contamination
at the time the ATSDR study time frame was selected officials were unable 

to determine precisely when the contamination began. Four of the panel 

experts commented that exposure was likely highest in the latter part of 

the study time frame—presumably as a result of a higher accumulated 

level of contamination over time—thus making the uncertainty of when 

the contamination began less significant and supporting ATSDR’s decision 

to study the later time frame. 

Six of the panel experts said that extending the time frame past 1985 could 

help strengthen ATSDR’s study by adding an additional unexposed 

population for comparison. Having an additional comparison population 

could help researchers reinforce any conclusions about whether TCE or 

PCE are associated with adverse health outcomes, panel experts said. For 

example, if the study found some association between adverse health 

outcomes and the pre-1985 exposed population, but no association with an 

additional unexposed comparison group, it would support any finding that 

TCE or PCE exposure was associated with adverse health outcomes, since 

the exposure ended in 1985. Two of the expert panel members said that if 

adverse health effects continued to be found in a comparison population 

after 1985, that finding could mean that exposure to the contaminated 

drinking water was not associated with the adverse health effects. 

However, one of the six experts also noted that extending the study time 

frame would be cost effective only if a significant association between 

TCE or PCE exposure and adverse health outcomes was first found among 

those exposed before 1985. 

Page 53 GAO-07-276 Past Camp Lejeune Water Contamination
The five panel experts who discussed health effects said that those 

selected for the study were valid for individuals who were potentially 

exposed in utero at Camp Lejeune.75 Based on previous ATSDR work and 

existing literature, the health effects chosen for the study were neural tube 

defects, oral cleft defects, and childhood hematopoietic cancers, including

leukemia and non-Hodgkin’s lymphoma.76 Two panel experts said that 

ATSDR had limited its study to health effects that are rare and that 

generally occur at higher levels of exposure to VOCs such as TCE and PCE 

than are expected to have occurred at Camp Lejeune. They said that this 

may result in ATSDR not identifying enough individuals with these health 

effects to determine meaningful results in the study.77

Four panel experts added that other adverse health outcomes not included 

in the study could also be related to exposure to drinking water 

contaminated with TCE or PCE, including adverse neurological or 

behavioral effects, or pregnancy loss. However, three of these four panel 

experts said that studying adverse neurological or behavioral health 

effects would likely be difficult because of limited access to needed 

records, such as school records for children, or because there might be 

few databases for researchers to use to study these effects in adults. 

ATSDR has projected a December 2007 completion date for the study, 

which would include activities such as identifying and enrolling study 

participants, conducting a parental interview, confirming each reported 

diagnosis, modeling the water system to quantify the amount and extent of 

each individual’s exposure, analyzing the data, and drafting a final report. 

Panel experts had mixed opinions regarding ATSDR’s completion date. Of

the five panel experts who commented on the proposed completion date,

Experts Said Health 

Effects Selected for the 

Study Were Valid, Though 

Other Neurological and 

Behavioral Health Effects 

May Also Occur 

Experts Had Mixed 

Opinions on ATSDR’s 

Projected Completion Date 

and Some Said a Simpler 

Analysis Could Provide 

Earlier Results 

 75The two panel experts who did not discuss health effects said that this discussion was

outside their areas of expertise. One expert is a professor of geochemistry and the second

is an environmental engineer. 

76An ATSDR document setting out frequently asked questions about its health study states 

that the agency chose to study these birth defects and cancers based on the results of 

previous studies; two previous studies suggested that the chemicals in the drinking water 

at Camp Lejeune might cause these birth defects, while three studies suggested that these 

chemicals in drinking water might cause childhood leukemia. Additionally, ATSDR’s study

protocol noted that ATSDR’s study could add to the body of scientific knowledge. 

77ATSDR’s public health assessment noted that the exposure levels experienced at Camp 

Lejeune were expected to be relatively low and experienced over a relatively short

duration. 

Page 54 GAO-07-276 Past Camp Lejeune Water Contamination
three said that the date appeared reasonable, and two others said that 

based on the complexity of the water modeling the projected completion 

date might be optimistic.78

While none of the panel experts said that ATSDR’s projected completion 

date should be earlier, several said that one way to provide analytical

results sooner would be to conduct the study without using the water 

modeling analysis. Three of the experts explained that water modeling 

would be useful if it improved the classification of the study participants 

as either exposed or unexposed to contaminated water or provided more 

accurate estimates of individual exposure levels, as ATSDR intends. 

ATSDR officials said that a precise and accurate exposure assessment 

would enhance the scientific credibility of a study and strengthen the 

study’s ability to identify any important exposure effects. But all of the 

panel experts raised concerns about the limited historical record of the 

amount of PCE or TCE concentration identified at individual Camp 

Lejeune wells. They said that with limited historical data there would be 

minimal potential for water modeling to provide accurate information 

about the level of concentration of the contamination and thus about each 

individual’s total amount of exposure. As an alternative to estimating the 

extent of each study individual’s exposure using the water modeling 

results, four panel experts suggested ATSDR could use simpler categories 

of whether and to what extent individuals were exposed to water 

contamination. These four experts said that analyzing the data on birth 

defects and childhood cancers by using the same exposure categories that

were used in the 1998 ATSDR study could yield an effective study sooner 

than December 2007. The current ATSDR study expects to use more 

categories of exposure than were used in the 1998 study, based on data

from its water modeling activities and from information gathered on the 

mothers’ usage and consumption of the contaminated water. 

 78One of the panel experts did not discuss the completion date of the study. A second

expert said he did not have sufficient data to make a determination on whether the 

projected completion date was reasonable. 

Page 55 GAO-07-276 Past Camp Lejeune Water Contamination
Panel experts identified several other possibilities for modifying the design

of the ATSDR study. Four panel experts suggested conducting separate 

analyses for study individuals born in the county where Camp Lejeune is 

located, and for individuals who were born outside the county but whose 

mothers were pregnant with them while living in base housing.79 Word of 

mouth among current and former residents and media campaigns were the 

primary methods used to identify and recruit those individuals born 

outside the county as study participants. According to three panel experts, 

the methods used to identify these study participants raise the possibility 

of selection bias for that group. Specifically, the experts suggested that 

eligible study individuals born out of county, or their parents, who had 

concerns about potential exposure to TCE or PCE or about existing health

problems may have been more likely to sign up for the study than those 

who did not have these concerns. Selection bias could result in a mistaken 

estimate of an exposure’s effect on the risk of disease.80

As another potential study modification, two panel experts suggested 

conducting separate analyses for those with childhood leukemias and nonHodgkin’s lymphoma, which they said ATSDR had inappropriately 

combined into one category of hematopoietic cancers. ATSDR study 

investigators had combined these health outcomes into one category 

following advice from the ATSDR scientific advisory panel at its meeting 

in February 2005. Before the February meeting, ATSDR study investigators 

had dropped plans to separately analyze childhood non-Hodgkin’s 

lymphoma because they were unable to confirm a large enough number of 

individuals with this type of cancer to further study this health outcome. 

DOD, EPA, and HHS provided technical comments on a draft of this 

report, which we incorporated where appropriate. We provided the seven

former Camp Lejeune residents who are members of the ATSDR 

community assistance panel for Camp Lejeune the opportunity to provide 

comments on our draft—three of the panel members provided technical 

and general oral comments, and four declined to review the draft report. 

Experts Identified 

Additional Potential 

Modifications to the 

ATSDR Study 

Agency Comments 

 79The current study includes only those individuals whose mothers were pregnant with 

them and living on base at any time from 1968 through 1985 and who were born in Onslow

County, where Camp Lejeune is located. Additionally, the study identified individuals 

whose mothers were pregnant with them while living on base during this time, but who 

gave birth outside Onslow County. 

80Leon Gordis, Epidemiology, 1st ed. (Philadelphia, Pa.: W.B. Saunders Company, 1996), 

183. 

Page 56 GAO-07-276 Past Camp Lejeune Water Contamination
Two of the panel members said that the report should address 

contaminants other than TCE and PCE with potential adverse health 

effects, such as benzene, that were identified at Camp Lejeune. Our report 

focused on TCE and PCE because ATSDR’s health studies have focused on

these chemicals and their associated health effects and ATSDR has 

identified TCE and PCE as the chemicals of primary concern at Camp 

Lejeune. However, in response to technical comments from ATSDR and 

the panel members’ comments, we have added the sampling results for all 

other VOCs detected in wells that were taken out of service at Camp 

Lejeune during 1984 and 1985. Additionally, the three members expressed 

the belief that the Marine Corps had not fully disclosed information related 

to the past drinking water contamination and two of the members 

expressed disappointment that our report was not more critical of the 

Marine Corps. We believe that we have accurately described efforts to 

identify and address the past contamination and described activities 

resulting from concerns about possible adverse health effects and 

government actions related to the past contamination. Finally, the three 

members raised various other issues, such as compensation and health

benefits for former residents and their families and the need for additional 

notification to be provided to former residents regarding the past drinking 

water contamination; however, these issues were beyond the scope of this 

report. 

We are sending copies of this report to the Secretary of Defense, the 

Administrator of EPA, the Secretary of Health and Human Services, 

appropriate congressional committees, and other interested parties. We 

will also make copies available to others upon request. In addition, the 

report is available at no charge on the GAO Web site at 

http://www.gao.gov. If you or your staff have questions about this report, 

please contact me at (202) 512-7119. 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 major contributions are listed in 

appendix VIII. 

Marcia Crosse 

Director, Health Care 

Page 57 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix I: Scope and Methodology Appendix I: Scope and Methodology 

To examine efforts to identify and address the past drinking water 

contamination at Camp Lejeune, we obtained and reviewed more than 

1,600 documents related to past and current drinking water activities at 

Camp Lejeune. We focused our review on the past trichloroethylene (TCE) 

and tetrachloroethylene (PCE) contamination at Camp Lejeune because 

the Agency for Toxic Substances and Disease Registry (ATSDR) had noted 

that these chemicals were the VOCs of primary concern. However, we also 

reviewed documentation regarding other volatile organic compounds 

(VOCs) detected at Camp Lejeune. The documents we reviewed were 

obtained from Headquarters Marine Corps and had been collected and 

organized by a contractor for the Commandant of the Marine Corps’ 

Drinking Water Fact-Finding Panel for Camp Lejeune. Documents related 

to past and current drinking water activities were also obtained during a

visit to Camp Lejeune. The authors of the documents we collected 

included officials with Camp Lejeune, Headquarters Marine Corps, the 

Department of the Navy, other federal agencies such as the Environmental 

Protection Agency (EPA), the state of North Carolina, and private 

laboratories. The types of documents that were collected included results 

of laboratory analyses of drinking water samples, e-mails, memorandums, 

letters, reports, site maps, federal and state regulations, press releases, 

and newspaper articles.

Additionally, we reviewed a list of more than 6,000 historical documents 

collected by a contractor hired by Headquarters Marine Corps; this list was 

compiled by the contractor and included detailed descriptions and dates 

of the historical documents. We requested and reviewed more than 100 

documents from this list that we thought might be relevant to the past 

drinking water contamination. 

We interviewed 39 current and former officials from various Department 

of Defense (DOD) entities, including Camp Lejeune, Headquarters Marine

Corps, and the Department of the Navy, who were involved in activities 

related to or knowledgeable about historical environmental activities at 

Camp Lejeune. The former officials we interviewed were responsible for 

environmental activities at Camp Lejeune or the Department of the Navy

during the time in which the contamination was detected. The current 

officials we interviewed are responsible for environmental activities at 

Camp Lejeune, Headquarters Marine Corps, or the Department of the 

Navy. Some of these current officials were also responsible for 

environmental activities during the time in which the contamination was 

detected. The current and former officials interviewed often provided 

information based on their memory of events which occurred more than 

20 years ago. We attempted to corroborate their testimonial evidence with 

Page 58 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix I: Scope and Methodology 

documentation whenever possible. We also met with 19 interested former 

residents and individuals who worked on the base during the 1960s, 1970s, 

and 1980s in order to obtain their perspective on historical events. A 

former resident who is active in matters related to the past drinking water 

contamination at Camp Lejeune identified most of the interested former 

residents; others were identified at an ATSDR public meeting. We also 

interviewed current Camp Lejeune housing officials in order to obtain 

estimated historical occupancy rates, including the limitations of the 

occupancy data that were provided. Additionally, we examined reports 

from and interviewed current officials from Camp Lejeune, EPA, and the 

North Carolina Department of Environment and Natural Resources who 

were involved with or knowledgeable about past and current activities and 

costs related to the cleanup of the suspected sources of contamination. 

Finally, we obtained and analyzed information from ATSDR and EPA on 

drinking water contaminated with TCE and PCE, the possible adverse 

health effects related to exposure to these chemicals, and relevant federal 

regulations for TCE and PCE. 

To describe activities resulting from concerns about the possible adverse 

health effects and government actions related to past drinking water 

contamination, including efforts to study potential health effects and 

federal inquiries into the response to the contamination, we reviewed 

documents, interviewed agency officials, and attended agency meetings. 

To examine the activities undertaken by ATSDR to study potential health

effects related to the drinking water contamination at Camp Lejeune, we 

reviewed the agency’s 1997 Public Health Assessment that evaluated the 

risks of adverse health effects from exposure to the contaminated drinking

water, as well as released documents regarding ATSDR’s 1998 health study 

of the association between exposure to TCE and PCE in drinking water at 

Camp Lejeune and a variety of adverse pregnancy outcomes. We did not 

evaluate the methodology or findings of the public health assessment or 

health study. For ATSDR’s current study, we examined the study protocol, 

a progress report, and other documents describing ATSDR’s current study 

examining whether birth defects and childhood cancers are associated 

with exposure to TCE or PCE at Camp Lejeune. We interviewed ATSDR 

officials involved with the Public Health Assessment, the 1998 study, and 

the current study, and also attended ATSDR expert panel meetings 

convened to evaluate and provide recommendations regarding the 

agency’s work related to Camp Lejeune. In order to examine the sources 

of and issues surrounding funding for ATSDR’s Camp Lejeune-related 

work, we obtained documents from and interviewed officials with ATSDR, 

the Department of the Navy, and the U.S. Army Center for Health 

Promotion and Preventive Medicine, which currently executes the 

Page 59 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix I: Scope and Methodology 

memorandum of understanding between DOD and ATSDR and negotiates 

an annual plan of work with ATSDR. We examined documentation and 

interviewed DOD, ATSDR, and EPA officials about efforts to address the 

concerns of the former Camp Lejeune residents. To examine the 

recommendations of additional review panels convened by ATSDR in 2005 

regarding improving the study’s water modeling efforts and future studies 

of health effects, we attended two panel meetings and obtained and 

reviewed the final reports of both panels, which included ATSDR’s 

response to the panels’ recommendations. To determine the actions taken

by ATSDR to address the panel recommendations, we interviewed 

relevant ATSDR officials and observed and subsequently reviewed 

transcripts of meetings of the Camp Lejeune community assistance panel 

held in 2006, where ATSDR officials reported on their activities. In order 

to describe the lawsuits and tort claims filed against the federal 

government for injuries alleged to have resulted from exposure to the 

contaminated drinking water at Camp Lejeune, we interviewed officials 

with the Department of the Navy’s Judge Advocate General and the 

Department of Justice. To describe three federal inquiries into issues 

related to the drinking water contamination at Camp Lejeune, we reviewed 

the reports and statements of the Drinking Water Fact-Finding Panel for 

Camp Lejeune, the EPA Office of Inspector General, the EPA Criminal 

Investigation Division, and the Department of Justice. We also interviewed 

officials from the EPA Office of Inspector General and the EPA Criminal 

Investigation Division about their examinations of allegations made by 

former residents. We did not evaluate the methodology used by the 

officials who conducted these three inquiries. 

When the source of evidence we cited is from an interview, we identified

the respondent’s agency and noted whether the individual was a current or 

former official. Whenever possible, we reviewed documents to verify 

testimonial evidence from DOD and ATSDR officials. When this was not 

possible, we attempted to corroborate testimonial evidence by

interviewing multiple individuals about the information we obtained. 

To assess the design of the current study by ATSDR on the possible health

effects associated with the contaminated drinking water at Camp Lejeune, 

including the study population, time frame, health effects, and completion 

date, we contracted with the National Academy of Sciences (NAS) to 

convene a 1-day meeting of scientific experts in the areas of drinking 

water contamination, hydrologic modeling, and reproductive health. We 

identified for NAS the categories of expertise preferred at the meeting and 

expressed a preference that each participant have no conflict of interest 

with ATSDR, DOD, or EPA. NAS identified participants according to the 

Page 60 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix I: Scope and Methodology 

preferred categories. Once we concurred with the proposed participants,

NAS contacted the potential participants to determine interest and 

availability to participate in the meeting. In total, seven experts and one 

moderator participated in the meeting. The experts and the moderator had 

combined research expertise in environmental engineering; reproductive, 

environmental, and occupational epidemiology; statistics and modeling; 

public health investigations, risk assessment, and decision analysis; 

geochemistry; and water and wastewater treatment and water modeling. 

We observed the meeting, which took place in July 2005, and subsequently 

reviewed the written transcript of the meeting. The experts’ discussion 

during the meeting was guided by a set of questions we prepared regarding

the ATSDR study population, time frame, health effects, and completion 

date. Participants were invited as individual experts, not as organizational 

representatives, and were not asked to reach consensus on any topics. 

NAS was not asked to provide advice or produce any report, and the 

comments made during the meeting of the expert panel should not be 

interpreted to represent the views of NAS or of all experts regarding 

health studies related to drinking water contamination. As we requested,

each of the experts also provided written responses to the set of questions 

that were discussed during the meeting. During the meeting and in their 

written responses, not all panel members commented individually about 

each of the questions discussed during the 1-day meeting. Additionally, 

some panel members noted that certain questions addressed subjects that

were outside their areas of expertise. In addition to convening and 

attending the expert panel meeting, we also reviewed ATSDR documents 

related to the current study, including the study protocol and progress 

reports, and interviewed ATSDR officials involved in the study’s 

epidemiologic and water modeling activities. 

We conducted our work from May 2005 through April 2007 in accordance 

with generally accepted government auditing standards. 

Page 61 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix II: Selected Events Related to Past 

Drinking Water Contamination at Camp 

Lejeune from 1980 through 1981 

Date Event

October 1, 1980 An official with the Naval Facilities Engineering Command, Atlantic Division (LANTDIV), 

collected samples from all eight water systems at Camp Lejeune to be combined into a single 

sample and analyzed in order to detect any potential contaminants in the water systems. 

October 21 and October 24, 1980 At the direction of LANTDIV, Camp Lejeune collected separate samples to be analyzed for total 

trihalomethanes (TTHMs)a

 at two base water systems, Hadnot Point and New River. LANTDIV 

arranged for the U.S. Army Environmental Hygiene Agency (USAEHA) laboratory to conduct 

the testing. 

October 31, 1980 A LANTDIV-contracted private laboratory reported results from the samples collected on

October 1, 1980, from all eight water systems at Camp Lejeune. The results, sent to LANTDIV, 

indicated that 11 volatile organic compounds (VOCs) were detected, including trichloroethylene 

(TCE).b

 All VOCs detected in this analysis were identified at their detection limits, which were 

the lowest level at which the chemicals could be reliably identified by the instruments being

used. 

October 31, 1980 A reportc from USAEHA of the results of the analysis of samples collected on October 21, 1980, 

contained a USAEHA official’s handwritten notes which indicated unidentified chlorinated 

hydrocarbons were interfering with the testing for TTHMs at the Hadnot Point water system. 

January 22, 1981 Handwritten notes from a USAEHA official on a USAEHA report indicated that continued 

interference with the TTHM analysis of samples collected on December 29, 1980, for the 

Hadnot Point water system, and recommended conducting analyses for chlorinated organics. 

February 9, 1981 Handwritten notes from a USAEHA official on a USAEHA report indicated continued 

interference with the TTHM analysis of samples collected on January 30, 1980, for the Hadnot 

Point water system, and recommended conducting analyses for chlorinated organics. 

March 9, 1981 Handwritten notes from a USAEHA official on a USAEHA report indicated that water samples 

collected on March 9, 1981, for analysis for TTHMs at the Hadnot Point water system were 

“highly contaminated” with other chlorinated hydrocarbons. 

April 7, 1981 According to the private laboratory report sent to LANTDIV, an analysis of water samples 

collected on March 30, 1981, from areas surrounding the Camp Lejeune Rifle Range chemical 

dump detected VOCs. However, TCE and tetrachloroethylene (PCE)d

 were not among the 

VOCs detected in these samples. 

April 16, 1981 According to the private laboratory report sent to LANTDIV, an analysis of water samples 

collected on April 10, 1981, was conducted from the untreated water in the wells that served the 

Rifle Range water system, from treated water from the Rifle Range water system, and from 

areas surrounding the Rifle Range chemical dump. VOCs, including TCE and PCE, were

detected in water samples from the areas surrounding the chemical dump. VOCs, including

TCE, were also detected in the well samples. TCE was detected at 1.8 parts per billione

 in one 

of the well samples. 

May 8, 1981 The Commander of LANTDIV wrote a memorandum to the Commanding General of Camp 

Lejeune that recommended resampling the Rifle Range area because of variation in the results 

from the April 7 and April 16 analysis reports. LANTDIV noted that three contaminants were

detected in the treated and untreated water in the Rifle Range water system. Two of these 

contaminants, methylene chloridef

 and TCE, were not regulated and the third chemical, a 

TTHM, was detected at levels within the new regulatory standards. The LANTDIV official noted 

that no imminent threat to human health was presented by consumption of water from the Rifle 

Range water system. 

Appendix II: Selected Events Related to Past 

Drinking Water Contamination at Camp 

Lejeune from 1980 through 1981 

Page 62 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix II: Selected Events Related to Past 

Drinking Water Contamination at Camp 

Lejeune from 1980 through 1981 

Date Event

May 29, 1981 According to the private laboratory report sent to LANTDIV, an analysis of water samples 

collected on May 20, 1981, from treated water in the Rifle Range water system and from areas 

surrounding the Rifle Range chemical dump detected VOCs in the treated water at the Rifle 

Range water system and also detected VOCs, including TCE, in areas surrounding the Rifle 

Range chemical dump. 

July 31, 1981 The Commander of LANTDIV wrote a memorandum to the Commanding General of Camp 

Lejeune that described the analyses of the additional water samples taken from the Rifle Range 

area. The official noted that of the organic contaminants detected at the Rifle Range area, only 

one, a TTHM, had an established regulation with a maximum contaminant levelg

 though it did 

not apply to the Rifle Range water system because this system did not serve more than 10,000 

people. The official noted that LANTDIV would add the Rifle Range water system to the TTHM 

testing that had been initiated in 1980. Additionally, he suggested no further action be taken 

until the Navy Assessment and Control of Installation Pollutants programh

 and TTHM analysis 

provided additional data. According to a handwritten note at the end of the memorandum, an 

environmental official at Camp Lejeune recommended arranging a meeting with the state in 

order to share these results. 

August 26, 1981 The Commander of LANTDIV wrote a memorandum to the Commanding General of Camp 

Lejeune noting that in accordance with Camp Lejeune’s request, it was providing the summary 

of TTHM regulations and copies of the TTHM testing reports for the two water systems that met 

the requirement to be tested. 

Source: GAO analysis of Headquarters Marine Corps documents. 

Note: We use the term “contamination,” which is also used by the law requiring us to do this work, as 

well as by EPA and DOD, to describe the drinking water at Camp Lejeune in the early 1980s.

However, EPA had not yet established maximum contaminant levels for the chemicals TCE and PCE 

during this period. See 40 C.F.R. §§ 141.2 and 141.12 (1975-1985).

a

TTHMs are a type of volatile organic compound and are formed when disinfectants—used to control

disease-causing contaminants in drinking water—react with naturally occurring organic matter in 

water. 

b

Many volatile organic compounds (VOCs) are human-made chemicals such as industrial solvents or

components of fuels, paint thinners, and dry cleaning agents. TCE is a VOC typically used as a metal 

degreaser. 

c

Generally, the USAEHA reports did not indicate to whom they were sent. 

d

PCE is a VOC typically used as a dry cleaning solvent. 

e

Parts per billion are units commonly used to express contamination ratios of the amount of a 

contaminant in water, land, or air.

f

Methylene chloride is a VOC used in various industrial processes including paint stripping, paint 

remover manufacturing, and metal cleaning and degreasing. 

g

Maximum contaminant levels are the maximum permissible level of a contaminant in water delivered 

to a public water system. 

h

The Navy Assessment and Control of Installation Pollutants program was established in 1980 to 

identify, assess, and control environmental contamination from past hazardous materials storage, 

transfer, processing, and disposal operations. 

Page 63 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix III: Selected Events Related to Past 

Drinking Water Contamination at Camp 

Lejeune from 1982 through 1983 

Date Event

April 19, 1982 Camp Lejeune environmental officials began collecting monthly samples for monitoring of total 

trihalomethanes (TTHMs)a

 at all eight base water systems. 

May 6, 1982 A private laboratory contracted by Camp Lejeune to conduct the TTHM analysis informed Camp 

Lejeune by telephone that synthetic organic cleaning solvents, including trichloroethylene (TCE),b

were detected in the samples that were collected from April 19 to April 22, 1982, from the Tarawa 

Terrace and Hadnot Point water systems. Grainger Laboratory stated that TCE interference with the 

analysis of the Hadnot Point samples prevented the detection of a precise reading for TTHMs. 

May 27 and May 28, 1982 Camp Lejeune environmental officials took a second set of monthly water samples at the base water 

systems because of problems with the collection of earlier samples taken from May 17 through 

May 24, 1982. 

June 9, 1982 The private laboratory report of the results of the analysis of monthly samples collected May 27 and 

May 28, 1982, noted that an unknown compound was interfering with the testing for TTHMs at the 

Hadnot Point water system. 

July 13, 1982 The private laboratory report of the results of the analysis of monthly samples collected June 24 and 

June 25, 1982, did not specifically note interference with the testing for TTHMs at the Hadnot Point 

water system, but, as in previous reports, noted that there was some uncertainty in the 

measurements for this water system. 

July 28, 1982 Camp Lejeune environmental officials collected samples, which were in addition to the monthly 

samples, from the Hadnot Point and Tarawa Terrace water systems. An internal Camp Lejeune 

memorandum noted that the additional sampling was conducted because the private laboratory 

identified interference by TCE and another synthetic organic cleaning solvent while analyzing earlier 

samples from the Hadnot Point and Tarawa Terrace water systems for TTHMs. 

August 10, 1982 The private laboratory sent a letter to Camp Lejeune officials stating that the contaminants interfering

with the TTHM monitoring at the Tarawa Terrace and Hadnot Point water systems were TCE and 

tetrachloroethylene (PCE).c The laboratory noted that these chemicals appeared to be at high levels 

and were thus more important from a health standpoint than the TTHM levels. The laboratory further 

noted that the levels of PCE detected in the Tarawa Terrace water system had been relatively stable 

over the time period examined, while levels of TCE and PCE detected in the Hadnot Point water 

system had varied, and the most recent Hadnot Point readings had been at significantly lower levels 

than the levels detected in May. 

August 18, 1982 Camp Lejeune officials decided to reduce monitoring for TTHMs from monthly to quarterly for six of 

the eight water systems, including Tarawa Terrace and Hadnot Point, beginning in September 1982. 

Officials noted in a memorandum that federal and state regulations required only quarterly sampling.d

August 19, 1982 A Camp Lejeune environmental official sent a memorandum to her supervisor that discussed the 

TTHM sampling and interference at the Tarawa Terrace and Hadnot Point water systems. She 

explained that the additional samples had been collected on July 28, 1982, to identify the source of 

the interference in the earlier TTHM testing; TCE and PCE were identified as the interfering 

chemicals. The official detailed the possible adverse health effects from both TCE and PCE, but 

further explained that TCE and PCE were not regulated under the Safe Drinking Water Act. However, 

she noted that the EPA had issued “suggested no adverse response levels”e

 and “suggested action 

guidance,”f

 which provided some guidance on unregulated contaminants. The official explained that 

levels of TCE and PCE detected in the Hadnot Point water system were presently within the limits 

suggested by the suggested no adverse response levels, but she offered no explanation for the 

higher level detected in samples taken in May 1982 and analyzed in July 1982. She also noted that it 

was possible that the levels of PCE detected in the Tarawa Terrace water system were the result of 

the use of asbestos-coated pipe in the water lines carrying untreated water. 

Appendix III: Selected Events Related to Past 

Drinking Water Contamination at Camp 

Lejeune from 1982 through 1983 

Page 64 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix III: Selected Events Related to Past 

Drinking Water Contamination at Camp 

Lejeune from 1982 through 1983 

Date Event

December 9, 1982 The private laboratory report of the results of the analysis of samples collected in November from all 

eight water systems for quarterly TTHM testing was provided to Camp Lejeune officials. This report 

stated that all samples from Tarawa Terrace indicated contamination from PCE and all samples from 

Hadnot Point indicated contamination from TCE and PCE. 

December 21, 1982 An environmental official at Camp Lejeune wrote a memorandum to her supervisor about the TTHM 

analysis from November 1982. She noted that during a telephone conversation with a chemist at the 

private laboratory, the chemist had expressed concerns over the solvents that interfered with the 

Tarawa Terrace and Hadnot Point samples, particularly those from Hadnot Point. According to the 

memorandum, the chemist told the Camp Lejeune official that while the levels of TCE and PCE had 

dropped for a period of time, the November samples showed levels of TCE and PCE that were 

relatively high again. 

September 16, 1983 The private laboratory report of the results of the analysis of samples collected on August 25 and 

August 26, 1983, from all eight water systems for TTHM testing was provided to Camp Lejeune 

officials. The report stated that all samples from Tarawa Terrace exhibited contamination from PCE 

and all samples from Hadnot Point exhibited contamination from both TCE and PCE. 

Source: GAO analysis of Headquarters Marine Corps documents. 

Note: We use the term “contamination,” which is also used by the law requiring us to do this work, as 

well as by EPA and DOD, to describe the drinking water at Camp Lejeune in the early 1980s.

However, EPA had not yet established maximum contaminant levels for the chemicals TCE and PCE 

during this period. See 40 C.F.R. §§ 141.2 and 141.12 (1975-1985).

a

TTHMs are a type of volatile organic compound and are formed when disinfectants—used to control

disease-causing contaminants in drinking water—react with naturally occurring organic matter in 

water. 

b

Trichloroethylene (TCE) is a volatile organic compound typically used as a metal degreaser. 

c

Tetrachloroethylene (PCE) is a volatile organic compound typically used as a dry cleaning solvent. 

d

Amendments in 1979 to the National Interim Primary Drinking Water Regulations required that water 

systems serving more than 10,000 people and adding a disinfectant as part of the drinking water 

treatment process to begin mandatory water testing for TTHMs by November 1982 and comply with 

the maximum contaminant level by November 1983. Only two water systems at Camp Lejeune, 

Hadnot Point and New River, served more than 10,000 people when TTHM testing was initiated at 

Camp Lejeune. 

e

EPA’s suggested no adverse response levels were nonenforceable guidance for community water 

systems regarding TCE and PCE in drinking water issued in 1979 and 1980. 

f

EPA’s suggested action guidance was a nonenforceable guidance suggesting that remedial action be

taken when PCE exceeded specific levels. 

Page 65 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix IV: Selected Volatile Organic 

Compounds Detected in Wells at Hadnot Point Appendix IV and Tarawa Terrace Water Systems : Selected Volatile Organic 

Compounds Detected in Wells at Hadnot 

Point and Tarawa Terrace Water Systems 

Concentrations of chemicals in parts per billiona

Water systems Wells 

Date removed 

from service Benzeneb

Trans-1,2-DCEc1,1-DCEd

Methylene 

chloridee

Toluenef

Vinyl 

chlorideg

Hadnot Point 602 Nov. 30, 1984 120 630 2.4 — 5.4 18

601 Dec. 6, 1984 ND 88 ND ND ND ND

608 Dec. 6, 1984 3.7 5.4 ND ND ND ND

634 Dec. 14, 1984 ND 2.3 — 130 — ND

637 Dec. 14, 1984 ND ND — 270 — —

651 Feb. 4, 1985 — 3,400 187 — — 655

652 Feb. 8, 1985 — ND ND — — ND

653 Feb. 8, 1985 — ND ND — — ND

Tarawa Terrace TT-26 Feb. 8, 1985 ND 92 — — — 27

TT-23h

Feb. 8, 1985 ND 11 — — — ND

Source: GAO analysis of Headquarters Marine Corps data. 

Notes: The detection limit for the instruments used to analyze the samples was 10 parts per billion. 

The detection limit is the lowest level at which the chemicals could be reliably identified by the 

instruments being used. A Marine Corps document providing the sampling results stated that ND

meant “none detected.” Where no concentration or ND is provided, the laboratory did not report 

results for these samples. 

a

The concentrations provided are those detected prior to each well’s removal from service in 1984 

and 1985 and are one-time sampling results. We did not find documentation that tied the decision to 

remove the wells from service to any particular level of contamination included in related 

Environmental Protection Agency (EPA) guidance or enforceable regulation. 

b

Benzene is a widely used chemical formed from both natural processes and human activities. Some

industries use benzene to make other chemicals which are used to make plastics, resins, and nylon 

and synthetic fibers. Benzene is also a natural part of crude oil, gasoline, and cigarette smoke. 

Breathing benzene can cause drowsiness, dizziness, and unconsciousness; long-term benzene 

exposure causes effects on the bone marrow and can cause anemia and leukemia. The Department 

of Health and Human Services (HHS) has determined that benzene is a known carcinogen. 

c

Trans-1,2-dichloroethylene (Trans-1,2-DCE) is an odorless organic liquid used as a solvent for 

waxes and resins; in the extraction of rubber; as a refrigerant; in the manufacture of pharmaceuticals 

and artificial pearls; in the extraction of oils and fats from fish and meat; and in making other organics.

EPA has found trans-1,2-DCE to potentially cause central nervous system depression when people 

are exposed to it at levels above 100 parts per billion for relatively short periods of time. Trans-1,2-

DCE has the potential to cause liver, circulatory, and nervous system damage from long-term 

exposure at levels above 100 parts per billion. 

d

1,1-dichloroethylene (1,1-DCE) is an organic liquid with a mild, sweet, chloroform-like odor. Virtually 

all of it is used in making adhesives, synthetic fibers, refrigerants, food packaging, and coating resins. 

EPA has found 1,1-DCE to potentially cause liver damage when people are exposed to it at levels

above 7 parts per billion for relatively short periods of time. 1,1-DCE has the potential to cause liver 

and kidney damage, as well as toxicity to the developing fetus, and cancer from a lifetime exposure at

levels above 7 parts per billion. 

Page 66 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix IV: Selected Volatile Organic 

Compounds Detected in Wells at Hadnot Point 

and Tarawa Terrace Water Systems 

e

Methylene chloride is a VOC used in various industrial processes, including paint stripping, paint 

remover manufacturing, and metal cleaning and degreasing. Breathing in large amounts of methylene 

chloride can damage the central nervous system. Contact of eyes or skin with methylene chloride can 

result in burns. HHS has determined that methylene chloride can be reasonably anticipated to be a 

cancer-causing chemical. 

f

Toluene is a clear, colorless liquid which occurs naturally in crude oil and in the tolu tree. It is also 

produced in the process of making gasoline and other fuels from crude oil and making coke from 

coal. Toluene may affect the nervous system. Low to moderate levels can cause tiredness, confusion, 

weakness, drunken-type actions, memory loss, nausea, loss of appetite, and hearing and color vision 

loss. Inhaling high levels of toluene in a short time can result in feelings of light-headedness, 

dizziness, or sleepiness. It can also cause unconsciousness, and even death. High levels of toluene 

may affect kidneys. Studies in humans and animals generally indicate that toluene does not cause 

cancer. 

g

Vinyl chloride is a colorless gas. It is a manufactured substance that does not occur naturally. It can 

be formed when other substances such as trichloroethane, trichloroethylene, and tetrachloroethylene 

are broken down. Breathing high levels of vinyl chloride for short periods of time can cause dizziness, 

sleepiness, unconsciousness, and at extremely high levels can cause death. Breathing vinyl chloride 

for long periods of time can result in permanent liver damage, immune reactions, nerve damage, and

liver cancer. HHS has determined that vinyl chloride is a known carcinogen. 

h

Well TT-23 is also referred to as “TT-new well” in Marine Corps documents. 

Page 67 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix V: Selected Events Related to Past 

Drinking Water Contamination at Camp 

Lejeune from 1984 through 1985 

Date Event

July 1984 Camp Lejeune initiated the Navy Assessment and Control of Installation Pollutants 

(NACIP)a

 confirmation study. The purpose of the confirmation study was to further 

investigate potential contamination at 22 priority sites at Camp Lejeune that were 

identified in an initial assessment study. As part of the confirmation study, sampling began

at any well in the vicinity of a priority site where groundwater contamination was 

suspected. Prior water samples at Camp Lejeune had usually been drawn at the water 

treatment plants or in the distribution system—not from individual wells. 

November 30, 1984 Camp Lejeune officials received results from the confirmation study sampling which 

detected trichloroethylene (TCE) and tetrachloroethylene (PCE), among other volatile 

organic compoundsb (VOC), at a well serving the Hadnot Point water system, one of eight

water systems at Camp Lejeune. This well was removed from service. 

December 4, 1984 Water samples were collected from six Hadnot Point wells and from the untreated and 

treated water at the Hadnot Point water treatment plant. These wells were sampled 

because of their proximity to the contaminated well that was removed from service on 

November 30, 1984. 

December 6, 1984 Camp Lejeune officials received results of the analysis of samples collected on 

December 4, 1984, that indicated three additional wells and the untreated and treated 

water from the Hadnot Point water system had levels of TCE and PCE, among other 

VOCs. In one of the wells, TCE was detected at 210 parts per billion (ppb)

c

 and PCE was 

detected at 5 ppb. In the second well, TCE was detected at 110 ppb. In the third well, TCE

was detected at 4.6 ppb. The first two wells were removed from service.d

 

December 10, 1984 A Camp Lejeune official contacted a North Carolina state environmental official by 

telephone to discuss suspected contamination found in wells, untreated water, and 

treated water from the Hadnot Point water system. The Camp Lejeune official explained 

Camp Lejeune anticipated that a resampling program would be initiated, and indicated 

that some form of information might be released to the public. 

December 10, 1984 Samples were again collected from the same seven Hadnot Point wells and the treated 

water at the Hadnot Point water treatment plant. 

December 13, 1984 through 

December 19, 1984 

Separately, daily samples were collected from the untreated water at the Hadnot Point 

water treatment plant. 

December 13, 1984 The base newspaper published its first article about water testing, VOC contamination, 

and corrective actions taken by base officials, including removing wells from service. The 

article did not identify TCE or PCE as the VOC contaminants. 

December 14, 1984 Camp Lejeune officials received results of the analysis of samples collected on 

December 10, 1984, that indicated two additional wells in the Hadnot Point water system 

had significant levels of a VOC, methylene chloride,e

 while a third well also indicated 

levels of methylene chloride. TCE and PCE were not detected in these wells. Two of 

these three wells were removed from service.f 

December 21, 1984 Camp Lejeune officials received the results of the analysis of samples that were collected

from December 13 to December 19, 1984, at the Hadnot Point water treatment plant. TCE 

and PCE were not detected in these samples.

January 8, 1985 The director of the NACIP program at Camp Lejeune received a reportg reviewing the 

December 1984 sampling of wells, untreated water, and treated water at the Hadnot Point 

water system. In the report, sampling of all the wells and the water treatment plants at 

Camp Lejeune was proposed. 

Appendix V: Selected Events Related to Past 

Drinking Water Contamination at Camp 

Lejeune from 1984 through 1985 

Page 68 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix V: Selected Events Related to Past 

Drinking Water Contamination at Camp 

Lejeune from 1984 through 1985 

Date Event

January 16, 1985 Samples were collected at all wells serving the Hadnot Point and Holcomb Boulevard 

water systems to be tested for VOCs. 

January 23, 1985 Samples were collected at all wells serving four other water systems, including Tarawa 

Terrace, to be tested for VOCs. 

January 27, 1985 A fuel line from Holcomb Boulevard water treatment plant leaked fuel into the water 

system. The Holcomb Boulevard water treatment plant was subsequently shut down and 

water from the Hadnot Point water system was pumped into the Holcomb Boulevard water

lines. 

January 31, 1985 Samples were collected at various locations within the Hadnot Point and Holcomb 

Boulevard water systems for analysis required by North Carolina prior to restarting the 

Holcomb Boulevard water treatment plant. 

February 4, 1985 Camp Lejeune officials received results of the analysis of the samples collected on 

January 16, 1985, that indicated one additional well in the Hadnot Point water system had 

significant levels of TCE and PCE, among other VOCs. TCE was detected at 3,200 ppb 

and PCE was detected at 386 ppb. This well was removed from service. 

The results also noted that trace amounts of TCE were detected in two other Hadnot Point 

wells. In one well, TCE was detected at 9 ppb and in the other well TCE was detected at 

5.5 ppb. 

February 4, 1985 Camp Lejeune officials received results of the analysis of the samples collected on 

January 31, 1985, from various locations within the Hadnot Point and Holcomb Boulevard

water systems. No gasoline was detected in samples from Holcomb Boulevard. However,

various levels of TCE were detected in all of the samples; TCE was detected at levels 

ranging from 24 ppb to 1,148 ppb. 

February 4, 1985 The Holcomb Boulevard water treatment plant was restarted. 

February 7, 1985 Camp Lejeune officials received results of the analysis of the samples collected on 

January 23, 1985, that indicated that two wells in the Tarawa Terrace water system had 

levels of TCE and PCE. In one well, TCE was detected at 57 ppb and PCE was detected 

at 158 ppb. In the other well, TCE was detected at 5.8 ppb and PCE was detected at 132

ppb. 

February 8, 1985 The two wells in the Tarawa Terrace water system that were found to be contaminated 

with TCE and PCE on February 7, 1985, were removed from service. Additionally, the two 

wells in the Hadnot Point water system that were found to be contaminated with trace 

levels of TCE and PCE on February 4, 1985, were removed from service. 

March 12, 1985 According to an internal Camp Lejeune memorandum, one of the wells removed from 

service on February 8, 1985, was restarted on March 11, 1985, after samples were taken. 

After 24 hours of operation, additional samples were taken and the well was removed 

from service. 

April 30, 1985 The Commanding General of Camp Lejeune issued a notice to the residents of Tarawa 

Terrace housing area regarding problems with the water supply. According to the notice,

two of the wells that supplied water to the Tarawa Terrace water system were taken off 

line because “minute (trace)” amounts of several organic chemicals were detected in the 

water. The notice stated that there were no regulations regarding safe levels of the 

organic chemicals found in these wells, but as a precaution the Commanding General had 

ordered the wells to be removed from service in all but emergency situations. Additionally, 

the notice provided ways for residents to reduce water usage because of concerns that a 

water shortage might result following the removal of these wells from service. 

Page 69 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix V: Selected Events Related to Past 

Drinking Water Contamination at Camp 

Lejeune from 1984 through 1985 

Date Event

May 9, 1985 An article was published in the base newspaper explaining that 10 wells that served the 

Tarawa Terrace and Hadnot Point water systems were removed from service because of 

contamination. The article also noted the potential for water shortages in the Tarawa 

Terrace water system and included information about how to conserve water. 

May 10, 1985 An article was published in a North Carolina newspaper providing similar information as 

that included in the May 9, 1985, base newspaper article regarding the contamination in

the Tarawa Terrace and Hadnot Point water systems. 

May 11, 1985 An article was published in a second North Carolina newspaper providing similar 

information as that included in the May 9, 1985, base newspaper article regarding the 

contamination in the Tarawa Terrace and Hadnot Point water systems. 

May 31, 1985 Camp Lejeune officials sent a memorandum to Headquarters Marine Corps and LANTDIV 

noting that all 10 contaminated wells remained out of service, although 1 of the 

contaminated wells at Tarawa Terrace had been used on April 22, 23, and 29 to maintain

water production. 

September 15, 1985 An article was published in a third North Carolina newspaper that provided similar 

information as that included in the May 9, 1985, base newspaper article regarding the 

contamination in the Tarawa Terrace and Hadnot Point water systems. 

Source: GAO analysis of Headquarters Marine Corps documents. 

Note: We use the term “contamination,” which is also used by the law requiring us to do this work, as 

well as by the Environmental Protection Agency (EPA) and the Department of Defense (DOD), to 

describe the drinking water at Camp Lejeune in the early 1980s. However, EPA had not yet 

established maximum contaminant levels for the chemicals TCE and PCE during this period. See 40 

C.F.R. §§ 141.2 and 141.12 (1975-1985). 

a

As part of the Navy Assessment and Control of Installations Pollutants (NACIP) program, initial 

assessment studies were conducted to determine the potential for environmental contamination and if 

potential contamination was identified, a follow-up confirmation study was initiated. 

b

Many volatile organic compounds (VOCs) are human-made chemicals such as industrial solvents or

components of fuels, paint thinners, and dry cleaning agents. TCE is a VOC typically used as a metal 

degreaser. PCE is a VOC typically used as a dry cleaning solvent. 

c

Parts per billion are units commonly used to express contamination ratios of the amount of a 

contaminant in water, land, or air.

d

The Marine Corps were not able to provide documents that indicated why one of these three wells 

was not removed from service. 

e

Methylene chloride is a VOC used in various industrial processes including paint stripping, paint 

remover manufacturing, and metal cleaning and degreasing 

f

The Marine Corps were not able to provide documents that indicated why one of these three wells 

was not removed from service. 

g

The report did not indicate from whom it was sent. 

Page 70 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix VI: Agency for Toxic Substances 

and Disease Registry’s Response to its 2005 

Scientific Advisory Panel’s Recommendations 

Scientific advisory panel’s recommendations regarding 

future health studies of past drinking water contamination 

at Camp Lejeune

Agency for Toxic Substances and Disease Registry’s 

(ATSDR) response 

1. Create an advisory panel to oversee health studies related to

Volatile Organic Chemical (VOC) exposures at Camp Lejeune. 

Agreed. ATSDR will create a community assistance panel (CAP) 

comparable to other panels it has set up for community 

participation at National Priorities List sites. ATSDR 

recommended that its Camp Lejeune CAP be comprised of five 

or more community members and one or two scientific advisers, 

along with ex officio members from the Navy. 

2. Conduct future studies in full partnership with the potentially

exposed community. 

Agreed. ATSDR said it considered interaction with the community 

an important aspect of its on-site work and planned to continue to 

work closely with organized community advocacy groups. It 

agreed to be responsive to recommendations from the CAP. 

3. Establish a registry to identify groups of potentially exposed

individuals to study, including exposed and unexposed 

individuals who had lived and/or worked at Camp Lejeune 

during the period of interest, which would serve as the 

population base for further studies. 

Agreed. In order to identify various distinct groups of individuals 

with potential exposure, ATSDR said that efforts or activities 

should be conducted to determine if potential databases exist that 

would identify these groups, such as children who lived on base 

and adults who lived or worked on base. However, the agency 

said that it believed that it had already identified as completely as 

possible those who may have been exposed while in utero for the 

years 1968-1985. 

4. Conduct various types of feasibility or pilot studies—to 

determine whether study individuals can be identified and 

tracked and what types of medical records are available—

before embarking on full-scale studies of the impact on health 

of exposures at Camp Lejeune. 

Agreed. ATSDR will conduct a feasibility assessment to 

determine the number of adults and children that could be

identified through available data sources. 

5. Study additional health outcomes, such as mortality and cancer 

incidence. Also, conduct feasibility studies of other adverse

health outcomes, such as autoimmune diseases; spontaneous 

abortion; neurological effects; organ failure; adult heart disease; 

reproductive outcomes of male and female children who were 

born (or were in utero) at Camp Lejeune; birth defects beyond 

those considered by ATSDR; and ocular problems. 

Agreed. ATSDR agreed that mortality and cancer incidence 

should receive the highest priority and are the outcomes most 

feasible to study. The agency said that decisions concerning

study period, study population, and study outcomes should be

made in consultation with the CAP, and said that ATSDR would 

defer decisions about additional health studies until feasibility 

studies were completed and reviewed by the CAP. 

6. Conduct future research activities in parallel with the current

study and without awaiting completion of current ATSDR 

activities. 

Agreed. The agency said that its highest priority is to complete 

the current study. Development of a CAP and further research 

activities would likely require additional staffing and resources, 

which ATSDR said it would request from the Department of 

Defense (DOD). 

7. Amend the 1997 public health assessment to include the 

possibility that adult cancers and other adverse health 

outcomes may be related to VOC exposures. Additionally, 

in the period since release of the original public health 

assessment, much additional information on exposures at 

Camp Lejeune and their potential risks has been developed,

and this additional material should be incorporated into an 

amended document. 

Did not agree. ATSDR said revisions to the assessment would be

needed only if new information changed the assessment’s 

conclusions or recommendations. ATSDR noted that its 

assessment acknowledged that the science was inconclusive and 

did not rule out the possibility of cancerous health effects from 

low-dose exposure to VOCs. 

8. Notify all persons potentially affected by exposure to VOCs in 

the drinking water at Camp Lejeune. 

Did not respond directly. ATSDR indicated that it would work with 

the CAP to determine effective ways to disseminate information 

about its current study and any future health studies. 

Appendix VI: Agency for Toxic Substances 

and Disease Registry’s Response to its 2005 

Scientific Advisory Panel’s Recommendations 

Page 71 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix VI: Agency for Toxic Substances 

and Disease Registry’s Response to its 2005 

Scientific Advisory Panel’s Recommendations 

Scientific advisory panel’s recommendations regarding 

future health studies of past drinking water contamination 

at Camp Lejeune

Agency for Toxic Substances and Disease Registry’s 

(ATSDR) response 

9. Obtain future funding for Camp Lejeune health studies through 

direct congressional appropriation, not through DOD’s budget, 

to avoid even the appearance of a conflict of interest. 

Did not agree. ATSDR said it recognized that the affected 

community had some distrust of ATSDR and DOD, and said that 

the CAP was intended to help mitigate this distrust. However, 

ATSDR suggested that DOD is the most likely funding source for 

these research activities because no other funds are available 

outside those budgeted to complete the current study. 

Sources: U.S. Department of Health and Human Services, Agency for Toxic Substances and Disease Registry, Report of the Camp

Lejeune Scientific Advisory Panel (Atlanta, Ga.: 2005). Agency for Toxic Substances and Disease Registry, ATSDR Response to the 

Report of the Camp Lejeune Scientific Advisory Panel Held February 17-18, 2005 (Atlanta, Ga.: 2005). 

Page 72 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix VII: Description of Current Agency

for Toxic Substances and Disease Registry Appendix VII: Description of Current Agency (ATSDR) Health Study 

for Toxic Substances and Disease Registry 

(ATSDR) Health Study 

ATSDR is conducting a study of the potential health effects of exposure 

while in utero and as infants up to 1 year of age to trichloroethylene (TCE) 

and tetrachloroethylene (PCE)—two volatile organic chemicals found in 

drinking water at Marine Corps Base Camp Lejeune in the 1980s. ATSDR’s 

study will analyze whether exposure to the TCE or PCE-contaminated 

drinking water at Camp Lejeune before birth is associated with increased

risks of specific birth defects or childhood cancers. These birth defects 

include (1) neural tube defects, (2) oral cleft defects, and (3) childhood 

leukemias and non-Hodgkin’s lymphoma, which have been combined into 

one category of hematopoietic cancers. 

ATSDR’s efforts to conduct this study began in 1999 with a telephone 

survey conducted with parents of 12,598 individuals born to women who 

were pregnant with them while living in on-base housing at Camp Lejeune 

any time from 1968 through 1985. Parents were asked if their child had a 

birth defect or developed a childhood cancer, along with other questions 

such as those to confirm residency on base during the specific time period

and questions regarding water usage. A total of 106 potential cases of the 

childhood cancers or birth defects were reported by the interviewed 

parents.1

 ATSDR reviewed health records in order to verify the reported 

health problems and had confirmed 57 cases of the childhood cancers or 

birth defects as of June 2006. (See table 6.) The study population includes 

the 57 individuals with confirmed health problems and 548 comparison 

individuals chosen randomly from among the remaining individuals 

identified in the survey. 

 1

There were 103 potential cases reported during the survey; 3 additional potential cases 

were reported to ATSDR after the survey was closed. 

Page 73 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix VII: Description of Current Agency

for Toxic Substances and Disease Registry 

(ATSDR) Health Study 

Table 6: Potential and Confirmed Cases of Childhood Cancers and Birth Defects as of April 2006 

Health condition 

Reported cases of 

health conditions

Confirmed cases 

with diagnosis of

health condition

Cases not yet 

confirmed 

Cases confirmed

as without health 

condition, refused to 

participate, or ineligible

Neural tube defects 35 17 2 16

Oral clefts 42 24 4 14

Childhood cancers 29 16 2 11

Total 106 57 8 41

Source: ATSDR. 

As part of this study, ATSDR officials are also conducting computer 

modeling of the drinking water system at Camp Lejeune from 1968 through 

1985 in order to determine which pregnant women were probably exposed 

to the contaminated drinking water and to estimate their levels of 

exposure. ATSDR’s drinking water distribution system model is based on 

current and historical information for the base water system as well as 

historical information on the sources of the contamination. The results of 

the model are intended to establish whether the mothers of the individuals 

with the birth defects or childhood cancers were more likely to have been 

exposed during their pregnancy to the drinking water contaminants than 

were the mothers of the comparison individuals. ATSDR officials said they

did not expect to finalize exposure categories for the current study until 

February or March 2007, after most water modeling activities were 

completed, but noted that they would use the water modeling results to 

assign multiple exposure levels to each study participant. Additionally, 

data gathered from the survey about the mothers’ drinking water and other 

home water use activities, such as dishwashing, clothes washing, and

bathing, will be combined with the estimated exposures levels to create 

another exposure measure. ATSDR officials also said the current study 

will analyze results for individuals who were exposed to TCE separately 

from those exposed to PCE and will analyze cancer and each type of birth 

defect separately. The study is expected to be completed by December 

2007. 

Page 74 GAO-07-276 Past Camp Lejeune Water Contamination
Appendix VIII: 

A

GAO Contact and Staff 

cknowledgments 

Page 75 GAO-07-276 

Appendix VIII: GAO Contact and Staff 

Acknowledgments 

GAO Contact Marcia Crosse (202) 512-7119 or crossem@gao.gov

In addition to the contact named above, Bonnie Anderson, Assistant 

Director; Karen Doran, Assistant Director; George Bogart; Helen 

Desaulniers; Cathleen Hamann; Danielle Organek; Roseanne Price; 

Christina Ritchie; and Stuart Ryba made key contributions to this report. 

Past Camp Lejeune Water Contamination

Acknowledgments 

(290456) 
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To Report Fraud,

Waste, and Abuse in 

Federal Programs 

Congressional 

Relations 

Public Affairs 

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