United States General Accounting Office

GAO Report to the Honorable Lane Evans,

Ranking Minority Member, Committee

on Veterans Affairs, House of

Representatives

February 1999 GULF WAR

ILLNESSES

Procedural and

Reporting

Improvements Are

Needed in DOD’s

Investigative Processes

GAO/NSIAD-99-59

GAO United States

General Accounting Office

Washington, D.C. 20548

National Security and

International Affairs Division

B-279127 

February 26, 1999

The Honorable Lane Evans

Ranking Minority Member

Committee on Veterans Affairs

House of Representatives

In response to your request, we have reviewed the operations of the Department of Defense’s

Office of the Special Assistant for Gulf War Illnesses. This report focuses on the thoroughness

of this Office’s investigations into and reporting on veterans’ potential exposure to chemical or

biological agents during the Persian Gulf War.

We are sending copies of this report to the Chairmen and Ranking Minority Members of the

House Committee on Appropriations, the House Committee on Government Reform and

Oversight, the Senate Committee on Appropriations, and the Senate Committee on

Governmental Affairs and to the Director, Office of Management and Budget. We will make

copies available to others on request.

If you or your staff have any questions concerning this report, please contact me on

(202) 512-5140. Major contributors to this report are listed in appendix IV.

Sincerely yours,

Mark E. Gebicke

Director, Military Operations

 and Capabilities Issues
Executive Summary

Purpose Many servicemembers who served in the Persian Gulf War have

subsequently experienced health problems such as fatigue, muscle and

joint pain, gastrointestinal complaints, headaches, memory loss, and sleep

disturbances. Whether these health problems are related to these

servicemembers’ exposures to chemical, biological, or environmental

agents during their Gulf War service has been a topic of much controversy.

To ensure that all issues related to Gulf War illnesses were

comprehensively addressed, the Department of Defense (DOD) established

the Office of the Special Assistant for Gulf War Illnesses (OSAGWI) in

November 1996.

To determine whether DOD is diligently addressing issues related to Gulf

War illnesses, the Ranking Minority Member of the House Committee on

Veterans Affairs asked GAO to examine selected OSAGWI operations.

Specifically, GAO’s objectives were to (1) describe DOD’s progress in

establishing an organization to address Gulf War illnesses issues and

(2) evaluate the thoroughness of OSAGWI’s investigations into and reporting

on incidents of veterans’ potential exposure to chemical or biological

warfare agents during the Gulf War.

Background More than 100,000 Gulf War veterans have participated in health

examination programs established by DOD and the Department of Veterans

Affairs (VA). Of those examined, nearly 90 percent have reported a wide

array of health complaints and disabling conditions. Some veterans

suspect that their health problems may be linked to chemical or biological

warfare agents that Iraq may have used during the Gulf War. Other causes,

such as stress, smoke from oil well fires, reactions to pesticides or

vaccines, and exposure to depleted uranium munitions, have also been

suggested as causes of these illnesses. Research to better identify the

causes is ongoing but will not be completed for years.

Following the Gulf War, DOD claimed that chemical weapons were not

present in the Gulf War theater. However, the Central Intelligence Agency

disclosed in 1995 that chemical weapons were found at an ammunition

storage site at Khamisiyah, Iraq. Following an investigation, DOD

acknowledged in July 1997 that U.S. troops might have been exposed to a

chemical warfare agent at Khamisiyah when demolitions were used there

to destroy Iraqi rockets. Other incidents involving potential chemical

warfare agent exposures have been cited by veterans in testimonies before

various congressional committees. Consequently, some have called into

question DOD’s credibility on Gulf War illnesses issues.

Page 2 GAO/NSIAD-99-59 Gulf War Illnesses
Executive Summary

In November 1996, DOD established OSAGWI to restore public confidence in

DOD’s efforts to deal with Gulf War illnesses issues. OSAGWI has focused its

efforts on (1) establishing effective two-way communications with

veterans and veterans groups, (2) investigating and reporting on incidents

of possible chemical warfare agent exposures, and (3) applying lessons

learned from the Gulf War experience to better protect U.S.

servicemembers on a contaminated battlefield.

Each OSAGWI investigation into possible exposures of servicemembers to

chemical warfare agents results in a summation document called a case

narrative. The case narrative, a document updated as new evidence

becomes known, contains all important investigative facts and OSAGWI’s

assessment—in terms of “definitely,” “likely,” “indeterminate,” “unlikely,”

or “definitely not”—of the likelihood that servicemembers were exposed

to chemical or biological warfare agents. The standard OSAGWI used for its

assessments was whether all available facts would lead a reasonable

person to conclude that a chemical or biological warfare agent was or was

not present. At the time GAO began its evaluation, OSAGWI had issued eight

case narratives. OSAGWI pursued these cases first because they involved

incidents that were the most prominent and controversial.

GAO evaluated six of these eight investigations. GAO did not review the case

narrative about the alleged exposure at Khamisiyah because it was already

being heavily reviewed by other organizations, such as the Presidential

Advisory Committee on Gulf War Veterans’ Illnesses and the Senate

Committee on Veterans Affairs’ Special Investigation Unit. GAO also did not

review the Possible Chemical Agent on SCUD Missile Sample case

narrative because it appeared to be less controversial than the other case

narratives. In conducting its evaluations, GAO (1) traced each statement in

these reports to its underlying supporting documentation in OSAGWI files,

(2) reviewed OSAGWI documentation associated with the incident to

determine if all relevant information was included in the report,

(3) contacted key sources of information to verify the accuracy and

completeness of the information these sources provided to OSAGWI,

(4) independently sought other sources of information, and (5) contacted

key participants not originally interviewed to determine if relevant

information was available that might affect OSAGWI’s assessment of

possible exposures to chemical warfare agents.

Page 3 GAO/NSIAD-99-59 Gulf War Illnesses
Executive Summary

Results in Brief DOD has made progress in carrying out its mandate to comprehensively

address Gulf War illnesses-related issues. It has assisted veterans through

its outreach program by clearing large backlogs of veterans’ inquiries,

using a toll-free hot line, setting up a Web site, and publishing a newsletter.

In addition, it has assisted veterans in obtaining medical examinations and

other services at DOD and VA facilities. Through the course of its

investigations and other work, OSAGWI has identified needed improvements

in DOD’s equipment, policies, and procedures and has worked with various

DOD agencies to implement changes designed to provide better protection

to U.S. servicemembers on a contaminated battlefield. OSAGWI generally

applied appropriate investigative procedures and techniques in conducting

its work. However, GAO found that three of the six case narratives it

reviewed contained weaknesses such as failures to follow up with

appropriate individuals to confirm key evidence, to identify or ensure the

validity of some evidence, to include some important information, and to

interview some key witnesses. In the remaining three cases, OSAGWI

conducted its investigations without evidence of these weaknesses. In all

six cases, OSAGWI missed an opportunity to perform more complete

investigations because it did not take advantage of potentially valuable

sources of relevant information in DOD and VA clinical databases. GAO does

not know whether the investigatory and reporting weaknesses it found in

its review of these six cases might also exist in the cases that OSAGWI later

investigated.

Despite these weaknesses, GAO agreed with OSAGWI’s conclusions about the

likelihood of the presence of chemical warfare agents in five of the six

cases it reviewed. The one exception involved a potential exposure of U.S.

Marine Corps personnel to a chemical warfare agent during a minefield

breaching operation. OSAGWI concluded that exposure in this case was

“unlikely.” However, GAO found that OSAGWI had overlooked some

information it had in its possession and also did not include all relevant

information in its case narrative. After reviewing the overlooked

information and considering all relevant information OSAGWI had in its files,

GAO believes that OSAGWI should reassess the likelihood of exposure in this

case. There is potential that this case could be more appropriately

assessed as “indeterminate.”

GAO believes that the lack of effective quality assurance policies and

practices in OSAGWI’s investigating and reporting processes contributed to

the weaknesses noted. Although OSAGWI has taken steps to improve its

quality assurance procedures, certain features should be incorporated to

Page 4 GAO/NSIAD-99-59 Gulf War Illnesses
Executive Summary

ensure that all of its investigations are thoroughly conducted and

accurately reported.

Principal Findings

DOD Has Made Progress in

Establishing an

Organization to Address

Gulf War Illnesses Issues

DOD established OSAGWI to repair the credibility problems it faced regarding

its past efforts to address Gulf War illnesses issues. It provided OSAGWI

with an operating authority much broader than its predecessor, the

Persian Gulf Illnesses Investigation Team, namely, to coordinate all

aspects of DOD’s programs concerning Gulf War illnesses. Compared with

its predecessor, OSAGWI represents a significant increase in resources

directed toward investigations and outreach efforts. For example, in 1996,

the Persian Gulf Illnesses Investigation Team operated with a staff of 12

persons and a budget of $4.1 million. In contrast, OSAGWI had a staff of 200

persons as of October 9, 1998, and a fiscal year 1998 budget of

$29.4 million. In addition, while the Persian Gulf Illnesses Investigation

Team reported to the Assistant Secretary of Defense for Health Affairs,

OSAGWI reports directly to the Deputy Secretary of Defense.

DOD has made progress in addressing Gulf War illnesses issues. To improve

communications with veterans, OSAGWI has established the means to

receive input from and provide information to veterans. Within its first

year of operation, OSAGWI successfully cleared a backlog of 1,200 veterans’

inquiries through personal telephone calls, and received an additional

1,200 letters and 2,700 E-mail messages. By January 1, 1999, OSAGWI had

received 2,850 letters and 4,906 E-mail messages. OSAGWI officials met with

the public and veterans at 18 town hall meetings and appeared at 41

national veterans conventions. Its Internet site reportedly receives over

60,000 inquiries each week, and over 12,000 individuals receive OSAGWI’s

bimonthly newsletter. OSAGWI also refers veterans to various sources of

medical services. Finally, OSAGWI communicates directly with veterans that

are affected by its investigations. After OSAGWI completes an investigation

and publishes the corresponding case narrative, it sends to each directly

affected veteran a letter that contains a synopsis of the investigation’s

results.

OSAGWI’s mission requires that it advise the Secretary of Defense on

changes needed in military equipment, policies, and procedures in order to

better protect servicemembers during operations on a contaminated

Page 5 GAO/NSIAD-99-59 Gulf War Illnesses
Executive Summary

battlefield. OSAGWI has identified several areas needing improvement on

the basis of its experience in investigating and reporting on possible

chemical, biological, or environmental exposures. OSAGWI is working with

DOD and other executive branch agencies to implement these lessons

learned. For example, OSAGWI was instrumental in prompting the Deputy

Secretary of Defense to issue a requirement that the military services

review their depleted uranium training programs. These programs are

important in addressing potential health problems related to the use of

depleted uranium in armor and ammunition. We did not review the impact

this activity has had on making changes within DOD. However, in

October 1998, OSAGWI established a directorate to focus on ensuring that

lessons learned are implemented.

Investigative and

Reporting Procedures

Have Various Weaknesses

GAO found procedural, investigative, or reporting problems in three of the

six cases it reviewed. These weaknesses were not evident in the other

three cases. Specifically, it found that OSAGWI investigators sometimes

failed to follow up with appropriate individuals to confirm key evidence,

identify or ensure the validity of key evidence, include important

information, and interview key witnesses. Despite these weaknesses, the

preponderance of evidence led GAO to agree with the conclusions in OSAGWI

case narratives concerning the presence of chemical warfare agents in all

but one of the six cases GAO reviewed. This one exception involved a

potential exposure of U.S. Marine Corps personnel during a minefield

breaching operation. OSAGWI concluded that an exposure in this case was

“unlikely.” However, GAO found that this case narrative did not include

some key information contained in OSAGWI files. Specifically, OSAGWI had

information regarding the presence of artillery fire that contradicted one

of its primary determinations—that no artillery fire or chemical mines

were present and therefore no means of chemical warfare agent delivery

existed. Also, OSAGWI did not include information that chemical detection

paper attached to a vehicle used in the operation changed color, indicating

the potential presence of a chemical warfare agent. After reviewing the

overlooked information and considering all relevant information OSAGWI

had in its files, GAO concluded that reassessment is needed and that the

probability of exposure might more appropriately be assessed as

“indeterminate.”

The other two of the three cases in which GAO found investigative or

reporting weaknesses involved (1) a possible exposure of a

servicemember to a mustard agent and (2) a possible exposure of

servicemembers to chemical agents in Al Jubayl, Saudi Arabia. In the case

Page 6 GAO/NSIAD-99-59 Gulf War Illnesses
Executive Summary

involving the potential exposure of a servicemember to a mustard agent

during an inspection of an Iraqi bunker complex, OSAGWI did not follow up

adequately to confirm whether an in-theater urinalysis test was

administered. GAO found insufficient evidence to support the existence of

such a test. Moreover, OSAGWI did not establish whether clothing tested for

chemical warfare agent in this case actually belonged to the individual

allegedly exposed. Finally, OSAGWI reached its conclusion without

interviewing some key witnesses. Despite these weaknesses, the evidence

in this case supported OSAGWI’s conclusion that exposure to a chemical

warfare agent was “likely.” In the case involving potential exposure to

chemical agents in Al Jubayl, Saudi Arabia, GAO found that the available

evidence generally supported OSAGWI’s conclusions. However, OSAGWI did

not include important information that would have made the case

narrative more complete. Had OSAGWI included this information, it would

have avoided any appearance that it had not completely reported what

was known from the investigation. Specifically, OSAGWI did not report that

many of the individuals associated with this case had reported unusually

high levels of health problems since their service during the Persian Gulf

War. Without this information, a reader could conclude that there was

little basis for concern about exposure to hazardous substances in this

case. The case report also failed to mention that health problems affecting

many individuals associated with this incident were among the first Gulf

War illnesses-related incidents reported and the subject of several major

DOD investigations and studies.

For all six cases, GAO found that OSAGWI had not taken advantage of DOD

and VA clinical databases that contain information on the health of

thousands of Gulf War veterans who may have symptoms of the types

commonly associated with Gulf War illnesses. Use of these databases is

identified in OSAGWI’s methodology for conducting investigations, and they

were used by OSAGWI in some other investigations. Their use might have

provided leads regarding whether more investigative effort was needed in

cases where exposure to chemical warfare agents or other environmental

hazards might have occurred.

During its review of the case narratives, GAO noted weaknesses in OSAGWI’s

internal quality assurance practices that contributed to some of the

problems it found. In responding to GAO’s findings, OSAGWI officials said

that subsequent to the publication of these cases, they implemented

internal review and quality assurance procedures that should prevent such

shortcomings in future reports. This internal review mechanism has been

evolving since July 1997. It remains to be seen whether these procedures

Page 7 GAO/NSIAD-99-59 Gulf War Illnesses
Executive Summary

will effectively provide the quality assurances necessary for OSAGWI to

thoroughly investigate potential chemical, biological, and environmental

exposures and to maintain credibility with veterans.

Recommendations To ensure that OSAGWI’s case narratives contain all the facts that have

surfaced to date, GAO recommends that the Secretary of Defense direct the

Special Assistant for Gulf War Illnesses to

• revise the Marine Minefield Breaching, the Exposure to Mustard agent,

and the Al Jubayl case narratives to reflect the new and/or unreported

information identified by GAO and

• determine whether OSAGWI’s conclusion in the Marine Minefield Breaching

case that exposure to chemical warfare agent was “unlikely” should be

changed to “indeterminate” in light of the additional information known

about this case.

To enhance the thoroughness of OSAGWI’s investigative and reporting

practices, GAO recommends that the Secretary of Defense direct the

Special Assistant for Gulf War Illnesses to

• use the DOD and VA Gulf War clinical databases to assist in designing the

nature and scope of all OSAGWI investigations and

• ensure that OSAGWI’s internal review procedures provide that (1) those

reviewing an investigation and related report are independent of the team

investigating the incident and (2) steps are in place that will lead the

reviewers to thoroughly check that all relevant information obtained by

the investigation teams has been included in the case narrative reports, all

conclusions have been fully substantiated by the facts, and all logical leads

have been pursued.

More detailed recommendations are found on pages 44 and 45.

Agency Comments

and GAO’s Evaluation

GAO asked DOD and VA to comment on a draft of this report.

DOD generally concurred with the report. In response to GAO’s findings and

recommendations, DOD agreed to revise OSAGWI’s reports to include new or

unreported data identified by GAO’s efforts and to use this information in

reassessing case narrative findings. DOD also stated that follow-up

investigations were either planned or under way regarding the Marine

Minefield Breaching, Reported Mustard Agent Exposure, and Al Jubayl

Page 8 GAO/NSIAD-99-59 Gulf War Illnesses
Executive Summary

case narratives. While DOD agreed to update the Marine Minefield

Breaching narrative, it also noted that there were still inconsistencies

regarding the presence of artillery fire. DOD said that as part of its

follow-up investigation, it would objectively consider all information and

detail more completely the artillery issue and its relevance to whatever

final assessment is made.

DOD and VA both disagreed with GAO’s recommendation that OSAGWI

incorporate the use of DOD and VA clinical databases into its evaluations.

Their disagreement was based on their concern that these databases might

be inappropriately used to establish a causal relationship between an

event and the medical findings of the registries. However, DOD agreed that

the databases needed to be examined and analyzed for what they can

contribute to understanding the illnesses of Gulf War veterans.

GAO continues to believe that the VA and DOD databases could provide

relevant information to investigators about whether individuals that were

at or near a site under investigation are reporting health problems. This

information could then be combined with other information to help guide

the nature and scope of OSAGWI investigations. GAO agrees that information

for these databases cannot be used to establish a causal association as

described by DOD and VA and did not intend that this information should be

used for such purposes.

DOD agreed that independent reviewers are critical to a thorough and

acceptable report on its investigations. DOD commented that this was the

reason it established its current multilevel review process. This is now

being supplemented by the President’s Special Oversight Board, which is

examining OSAGWI cases in detail.

DOD and VA general comments are addressed in more detail in chapter 3.

DOD and VA comments in their entirety and our evaluation of them are

included in appendixes I and II, respectively.

Page 9 GAO/NSIAD-99-59 Gulf War Illnesses
Contents

Executive Summary 2

Chapter 1 

Introduction

12

Establishment of the Persian Gulf Illnesses Investigation Team 12

OSAGWI’s Mission and Implementation Strategy 14

Objective, Scope, and Methodology 15

Chapter 2 

OSAGWI Has Made

Progress in

Addressing Issues

Related to Gulf War

Illnesses

18

DOD Increases Emphasis on Determining Cause of Gulf War

Veterans’ Health Problems

18

OSAGWI Has Improved Communications With Veterans 19

OSAGWI Has Identified Chemical and Biological Warfare Force

Protection Issues Requiring Attention

20

Chapter 3 

Some Case Narratives

Have Investigative

and Reporting

Weaknesses

22

OSAGWI’s Investigations and Reporting Procedures Have Various

Weaknesses

22

OSAGWI Did Not Use DOD and VA Medical Databases in

Conducting Its Investigations for Cases We Reviewed

39

Three Case Narratives Appear to Have Been Appropriately

Investigated

41

OSAGWI Has Made Changes to Improve Its Investigative and

Reporting Processes

42

Conclusions 43

Recommendations 44

Agency Comments and Our Evaluation 45

Appendixes Appendix I: Comments From the Department of Defense 48

Appendix II: Comments From the Department of Veterans Affairs 60

Appendix III: OSAGWI Reports and Active Investigations 64

Appendix IV: Major Contributors to This Report 66

Table Table I.1: OSAGWI Published Case Narratives, Information

Papers, and Environmental Exposure Reports

64

Page 10 GAO/NSIAD-99-59 Gulf War Illnesses
Contents

Abbreviations

ASP Ammunition Supply Point

CCEP Comprehensive Clinical Evaluation Program

DOD Department of Defense

EPMU Environmental and Preventive Medicine Unit

NMCB Naval Mobile Construction Battalion

OSAGWI Office of the Special Assistant for Gulf War Illnesses

VA Department of Veterans Affairs

Page 11 GAO/NSIAD-99-59 Gulf War Illnesses
Chapter 1 

Introduction

Many Persian Gulf War veterans have complained of illnesses since the

war’s end in 1991. Over 100,000 of the approximately 700,000 Gulf War

veterans have participated in health examination programs established by

the Department of Defense (DOD) and the Department of Veterans Affairs

(VA). Many of those examined reported health complaints, including

fatigue, muscle and joint pain, gastrointestinal problems, headaches,

depression, neurologic and neurocognitive impairments, memory loss,

shortness of breath, and sleep disturbances. Many veterans claim that their

medical symptoms, some of them debilitating in nature, were not present

before their service in the Persian Gulf War. Some veterans suspect that

their health problems may be linked to chemical or biological warfare

agents that Iraq may have used during the Gulf War.

Various organizations have researched the causes of Gulf War

illnesses—the source of much controversy over the past 7 years. By the

end of 1996, DOD and the VA together had funded 82 research projects

related to Gulf War illnesses. Despite these efforts, it remains unclear why

some Gulf War veterans became ill following their service in the Persian

Gulf War. It also remains unclear whether the rates of reported illnesses

for veterans that deployed to the Gulf are higher overall than the rates for

those that did not deploy or than the rates for the civilian or military

population as a whole. Also unexplained are differences in the frequency

of symptoms reported by reserve units and active duty units and any

correlations between the location of units and the occurrence of particular

illnesses. Research designed to answer these and many other Gulf War

illnesses-related questions will not be completed for years. Of the 151

current federally sponsored research projects, less than 25 percent have

been completed, and many are not scheduled for completion until after

2000.

Establishment of the

Persian Gulf Illnesses

Investigation Team

Prompted by the continuing controversy over Gulf War illnesses, President

Clinton, in 1995, ordered DOD and other federal agencies to reexamine

whether possible exposure to chemical or biological agents occurred

during the Gulf War. In March 1995, the Deputy Secretary of Defense

established the Persian Gulf Illnesses Investigation Team within the Office

of the Assistant Secretary of Defense for Health Affairs to explore this

question. The Investigation Team was established as DOD began to lose

credibility among veterans and veterans’ groups in its efforts to determine

the causes of Gulf War illnesses and to support the problems experienced

by veterans. The 12-member team included intelligence officers, an Army

Chemical Corps officer, a pilot, a chemist, a physician, and a criminal

Page 12 GAO/NSIAD-99-59 Gulf War Illnesses
Chapter 1 

Introduction

investigator. Beginning in 1991, senior Defense officials had taken the

position, in testimony before the Congress and in press interviews, that

Iraq did not use chemical or biological weapons during the Persian Gulf

War and that no U.S. forces were exposed to chemical or biological agents.

DOD officials maintained this position as late as 1994. This position came

under attack because both U.S. and foreign detection teams had reported

that chemical warfare agents were present on the battlefield. In 1995 and

1996, Central Intelligence Agency and U.N. reports established that during

the Gulf War, Iraq had stored rockets filled with sarin, a deadly chemical

warfare agent, at an ammunition storage site located at Khamisiyah, Iraq,

about 60 miles from Kuwait’s border. In June 1996, DOD announced that

U.S. troops at Khamisiyah in March 1991 were likely to have destroyed a

bunker of rockets containing chemical agents. By July 1997, DOD

acknowledged that U.S. troops near Khamisiyah may have unknowingly

been exposed to low levels of sarin when they used demolitions to destroy

these rockets.

In the midst of this controversy, DOD became dissatisfied with the results

of the Investigation Team’s efforts. The Investigation Team did not have

the resources needed to accomplish its mission. For example, it was

unable to follow up on more than 1,200 toll-free calls received on DOD’s hot

line with Gulf War veterans. In addition, its operation was criticized in the

December 1996 report by the Presidential Advisory Committee on Gulf

War Veterans’ Illnesses.1

 The report cited, for example, the Investigation

Team’s failure to take advantage of its unique access to classified and

routine military records to fully investigate and help answer the public’s

questions about veterans’ possible exposure to chemical and biological

warfare agents.

A DOD team asked by the Deputy Secretary of Defense to evaluate DOD’s

responses to Gulf War illnesses concluded that DOD’s work in this area

needed a broader focus, a strategy for systematically examining the

various theories concerning the nature and causes of Gulf War illnesses,

and a method of effectively communicating DOD’s findings to U.S. veterans

and the public. On November 12, 1996, the Deputy Secretary of Defense

established the Office of the Special Assistant for Gulf War Illnesses

(OSAGWI).

1

Final Report, Presidential Advisory Committee on Gulf War Veterans’ Illnesses, December 31, 1996,

pp. 44-45.

Page 13 GAO/NSIAD-99-59 Gulf War Illnesses
Chapter 1 

Introduction

OSAGWI’s Mission

and Implementation

Strategy

The goal of restoring public confidence in DOD shaped the mission and

organizational focus of OSAGWI. OSAGWI’s mission was broadly defined as

ensuring that (1) veterans of the Gulf War are appropriately cared for,

(2) DOD is doing everything possible to understand and explain Gulf War

illnesses, and (3) DOD puts into place all required military doctrine and

personnel and medical policies and procedures to minimize any future

problems from exposure to chemical and biological warfare agents and

other environmental hazards.

Although OSAGWI’s mission statement charges it with ensuring that veterans

are appropriately cared for, specific responsibility for providing health

care to servicemembers still on active duty and for conducting the health

research program continues to reside with the Office of the Assistant

Secretary of Defense for Health Affairs. Similarly, VA remains the primary

health care provider for those who have left military service. OSAGWI

officials told us, however, that they assist servicemembers and veterans

with health care matters related to Gulf War illnesses by providing them

with referrals to sources of health care or helping them with the

registration and examination processes associated with DOD’s

Comprehensive Clinical Evaluation Program or the VA’s Persian Gulf

Registry. OSAGWI also works with the Assistant Secretary of Defense for

Reserve Affairs to (1) help ensure that reservists receive all entitled

benefits and (2) recommend changes to legislation or rules where needed.

At the time of our review, OSAGWI believed that its core activity involved

investigating and reporting on incidents of possible exposure to chemical

and biological warfare agents and investigating related military operations

during the Gulf War. After OSAGWI has completed its investigation of an

incident, the investigator writes a summation document called a case

narrative. The purpose of OSAGWI’s case narratives is essentially to get all of

the facts before the American people about what OSAGWI has learned from

its investigation of an incident. The case narrative, a document updated as

new evidence becomes known, is to contain all important investigative

facts and OSAGWI’s assessment—in terms of “definitely,” “likely,”

“indeterminate,” “unlikely,” or “definitely not”—of the likelihood that

servicemembers were exposed to chemical or biological warfare agents.

The standard OSAGWI used for its assessments was whether all available

facts would lead a reasonable person to conclude that a chemical or

biological warfare agent was or was not present.

As of January 1, 1999, OSAGWI had published a total of 19 reports—13 case

narratives, 2 environmental exposure reports, and 4 information papers. At

Page 14 GAO/NSIAD-99-59 Gulf War Illnesses
Chapter 1 

Introduction

that time OSAGWI also had 27 active investigations under way. Appendix III

lists OSAGWI reports and their dates of publication as well as OSAGWI’s active

investigations.

Objective, Scope, and

Methodology

On July 8, 1997, the Ranking Minority Member of the House Committee on

Veterans Affairs asked us to examine OSAGWI operations. Specifically, we

were asked to (1) describe DOD’s progress in establishing an organization

to address Gulf War illnesses issues and (2) evaluate the thoroughness of

OSAGWI’s investigations into and reporting on veterans’ potential exposure

to chemical or biological agents during the Gulf War. We did not review

OSAGWI activities to coordinate and monitor research on the causes of Gulf

War illnesses because this subject is addressed by other reviews. To

determine DOD’s progress in establishing an organization to address Gulf

War illnesses issues, we obtained briefings from OSAGWI officials covering

the range of activities performed to fulfill their mission objectives and

reviewed associated documentation.

OSAGWI had issued eight case narratives at the time we began our review. It

pursued these eight cases first because they involved incidents that were

the most prominent and controversial at the time. To evaluate the

thoroughness of OSAGWI’s investigations and reporting on veterans’

possible exposures to chemical or biological warfare agents, we reviewed

six of these eight case narratives. The case narratives we selected for

review were (1) “Reported Mustard Agent Exposure”; (2) “U.S. Marine

Corps Minefield Breaching”; (3) “Fox Detections in an Ammunition Supply

Point (ASP) Orchard”; (4) “Al Jubayl, Saudi Arabia”; (5) “Al Jaber Air Base”;

and (6) “Reported Detection of Chemical Agent, Camp Monterey, Kuwait.”

We did not review the case narrative about the alleged exposure to

chemical warfare agents at Khamisiyah, Iraq, because it was already being

heavily reviewed by other organizations, such as the Presidential Advisory

Committee on Gulf War Veterans’ Illnesses and the Senate Committee on

Veterans Affairs’ Special Investigation Unit. We also did not review the

“Possible Chemical Agent on SCUD Missile Sample” case narrative

because it appeared to be less controversial than the other case narratives.

In reviewing each case narrative, we generally used as criteria OSAGWI’s

methodology, which had itself been derived from the United Nations and

other international community protocols for investigating chemical

warfare incidents. This methodology included (1) substantiating the

incident by searching for documentation from operational, intelligence,

and environmental logs; (2) documenting the medical reports related to

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Introduction

the incident; (3) interviewing appropriate people; (4) obtaining

information available to external organizations; and (5) assessing the

results. We also used the criterion that the case narrative should

accurately and fully disclose all materially significant information relevant

to the investigation of the incident in order to avoid any appearance that

OSAGWI was selectively reporting what had actually happened.

We initially traced each statement in the published case narrative to its

underlying supporting document to identify the accuracy and

completeness of the text in the narrative. For those statements missing

adequate supporting documentation, we requested that OSAGWI provide us

with the appropriate documentation. We also reviewed additional

documentation collected by the OSAGWI investigators in performing the

investigation, even though some of this documentation might not have

been cited in the published narrative. We looked for any inconsistencies in

information that was not addressed in the published narrative. In addition,

for the selected case narratives, we contacted 71 individuals interviewed

by OSAGWI that were key sources of information and requested that they

verify the accuracy and completeness of both the OSAGWI case narrative

and the OSAGWI write-up of the investigator’s discussions. We also

contacted some key participants not originally interviewed by OSAGWI to

determine whether other relevant information was available that might

affect OSAGWI’s assessment of possible exposures to chemical warfare

agents. Finally, we contacted several Gulf War veterans organizations,

including the following: the American Legion; the Disabled American

Veterans; the Veterans of Foreign Wars; the National Gulf War Resource

Center; GulfWatch; the Desert Storm Justice Foundation; the Operation

Desert Storm/Shield Association; the Gulf War Veterans of Long Island,

New York; and the Chronic Illnesses Net for Persian Gulf Veterans. We

asked them to provide us with any information they had that refuted or

added to the OSAGWI information. We did not systematically approach

veterans’ groups to obtain their assessments of overall OSAGWI

effectiveness because this was beyond the scope of our review.

To further verify the case narratives, we interviewed officials and obtained

pertinent documentary evidence from officials at the following locations:

OSAGWI, located in Falls Church, Virginia; the U.S. Army Chemical and

Biological Defense Command at Aberdeen, Maryland; the U.S. Army

Chemical Center and School at Ft. McClellan, Alabama; the Office of the

Surgeon General of the Navy, Washington, D.C.; the Naval Health Research

Center, San Diego, California; the Department of Veterans Affairs,

Washington, D.C.; the Deployment Surveillance Team, which operates the

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Introduction

Comprehensive Clinical Evaluation Program, Falls Church, Virginia; and

the U.S. Army Gulf War Declassification Project, Falls Church, Virginia.

We conducted our review from September 1997 to January 1999 in

accordance with generally accepted government auditing standards.

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Issues Related to Gulf War Illnesses

In the face of severe criticism by veterans, veterans groups, and others of

its handling of Gulf War illnesses issues, DOD committed additional

resources to its efforts to determine the cause of veterans’ health

problems. With greater resources and a much broader mandate than its

predecessor, OSAGWI has made significant progress in reestablishing

communications between DOD and veterans. In addition, OSAGWI is actively

engaged in identifying improvements DOD needs to make to protect

servicemembers on contaminated battlefields.

DOD Increases

Emphasis on

Determining Cause of

Gulf War Veterans’

Health Problems

DOD is investing significantly more resources for OSAGWI’s investigations

and outreach efforts than it did for the Persian Gulf Illnesses Investigation

Team. In 1996, the Investigation Team operated with a staff of 12 persons

and a budget of $4.1 million. In contrast, as of October 9, 1998, OSAGWI had

a staff of about 200 persons and a fiscal year 1998 budget of $29.4 million.

In addition, OSAGWI was given much broader authority than the

Investigation Team. Finally, OSAGWI reports directly to the Deputy

Secretary of Defense; the Investigation Team reported to the Assistant

Secretary of Defense for Health Affairs.

OSAGWI officials said that with an adequate budget and sufficient operating

authority within DOD, they were generally unconstrained in their efforts to

pursue OSAGWI’s mandate. According to these officials, OSAGWI’s operations

have been fully funded, and OSAGWI has had largely unrestricted access to

personnel, files, and other data necessary for its work. For example,

OSAGWI has had full access to classified information from the military

services and intelligence agency sources. To date, OSAGWI has over

12 million pages of classified information in its computerized database and

approximately 500,000 additional pages of classified data in hard-copy

format.

The Special Assistant (the head of OSAGWI) has been free to staff OSAGWI

according to his needs. This authority has made it possible for him to

obtain the expertise needed for OSAGWI’s investigations. From the start,

OSAGWI management decided to make extensive use of contractors to

quickly obtain personnel with specific expertise and maintain the

flexibility to change the mix of staffing as needed. By October 9, 1998, 173

(87 percent) of OSAGWI’s personnel were contractor employees. As needed,

OSAGWI has obtained specialized expertise from individuals in various

governmental agencies, such as the Central Intelligence Agency, the

Defense Intelligence Agency, and the Army’s Chemical and Biological

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Defense Command.1 OSAGWI also has the authority to contract with private

organizations to perform specialized functions.

OSAGWI Has

Improved

Communications With

Veterans

A key element of OSAGWI’s attempt to regain credibility with veterans,

veterans’ organizations, and the public was to improve communications

with them. OSAGWI recognized that major improvements were needed from

earlier DOD efforts to listen to veterans’ concerns and incorporate the

information they provided into DOD’s investigations and help provide

health referral services to veterans. Our review confirmed that OSAGWI has

made significant progress in establishing communications with veterans

and others.

OSAGWI established an E-mail address and encouraged veterans and others

to use both this and the DOD toll-free hotline to communicate with OSAGWI

regarding Gulf War illnesses issues. Within the first year of operation, it

received almost 1,200 letters and 2,700 E-mail messages. OSAGWI staff

contacted over 3,900 veterans through personal telephone calls, which

included the vast majority of the Investigation Team backlog of

unanswered calls from 1,200 veterans. According to OSAGWI, as of

January 1, 1999, it had received 2,850 letters and 4,906 E-mail messages

and answered 2,803 and 4,866, respectively. OSAGWI used a staff specifically

trained to deal with Gulf War veterans’ concerns, obtain information from

veterans, provide information about OSAGWI activities, and make referrals

for those needing medical support from DOD or VA.

OSAGWI uses a variety of methods to disseminate information on its

operations. For example, it uses a Web site called GulfLINK on which it

publishes its case narrative reports, information papers, and much of the

supporting documentation used in its investigations. OSAGWI reports that

this site typically receives over 60,000 inquiries each week. OSAGWI also

publishes a bimonthly newsletter called GulfNEWS. Over 12,000

individuals receive the newsletter. OSAGWI’s leadership and staff have met

with veterans at 18 town hall meetings and made appearances at 41

national veterans conventions. In addition, OSAGWI officials frequently meet

with veterans and military service organizations to discuss Gulf War

illnesses topics of interest to them.

Finally, OSAGWI communicates directly with veterans that are affected by

its investigations. After OSAGWI completes an investigation and publishes

1

The Chemical and Biological Defense Command was later renamed the Soldier and Biological

Chemical Command.

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the corresponding case narrative, it sends to each affected veteran a letter

that contains a synopsis of the investigation’s results. For example,

following its investigation of the potential chemical warfare agent

exposure in Khamisiyah, Iraq, OSAGWI sent letters to 97,837 veterans

concerning the possibility that they might have been exposed to low levels

of sarin, a chemical warfare agent.

OSAGWI Has

Identified Chemical

and Biological

Warfare Force

Protection Issues

Requiring Attention

According to OSAGWI officials, OSAGWI must go beyond investigating and

reporting on possible veterans’ exposures to chemical or biological

warfare agents and identify ways to better protect servicemembers from

nontraditional battlefield threats. From its investigations and reports on

possible veterans’ exposures to chemical, biological, or environmental

agents, OSAGWI has identified force protection issues that need

improvement. These lessons learned generally fall into the following three

categories: how to build trust and confidence in DOD, how to better

account for what happened on the battlefield, and how to better protect

servicemembers on the battlefield. Specific examples of the lessons

learned include the need for

• institutionalizing a veterans’ outreach capability after OSAGWI is

disestablished;

• improving systems for tracking troop movements during a conflict so that

accurate data is available to show where individuals or units were located

on the battlefield at any point in time;

• improving wartime records development and post-war records

management systems and addressing issues such as the lack of a uniform

records management program for joint commands;

• improving chemical and biological warfare agent detection equipment to

make it less prone to false alarms and requiring doctrinal changes to

collect and retain detector-produced printouts of detections;

• implementing techniques to better safeguard the health of deployed

troops, such as deploying forward field laboratories early and taking

samples to determine whether contamination may have occurred

subsequent to the use of depleted uranium ammunition; and

• improving and implementing depleted uranium training programs.

OSAGWI is presently working with DOD agencies to implement the lessons

learned. Discussions by the Special Assistant with the Director of the Joint

Staff and the military service Chiefs of Staff resulted in revised Joint Staff

policy concerning record-keeping by joint commands. OSAGWI was also

instrumental in developing a DOD-initiated requirement for the military

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services to review their depleted uranium training programs. We did not

review what impact OSAGWI’s lessons learned have had toward making

changes within DOD. Until recently, OSAGWI had no office for monitoring

and measuring the extent to which OSAGWI lessons learned were being

acted upon. In October 1998, the Special Assistant created a new OSAGWI

directorate to focus attention on ensuring that lessons learned are

effectively communicated to and implemented by the responsible DOD

agencies.

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and Reporting Weaknesses

We reviewed six of the eight case narratives OSAGWI had published at the

time we began our review to evaluate the thoroughness and accuracy of

OSAGWI’s investigations. OSAGWI generally followed its investigation

methodology and used appropriate investigative procedures and

techniques. However, we found significant weaknesses in the scope and

quality of OSAGWI’s investigations for three of the six cases: the Reported

Exposure to Mustard Agent, the Marine Minefield Breaching, and the Al

Jubayl, Saudi Arabia, case narratives. Also, OSAGWI did not use DOD or

Department of Veterans Affairs medical databases on Gulf War illnesses in

conducting any of the six investigations. Despite the weaknesses we

noted, in all but one case—the Marine Minefield Breaching case—we

found no basis to question OSAGWI’s determinations of the likelihood that

chemical warfare agents were present.

Except for failing to take advantage of the VA and DOD medical databases,

we did not find significant weaknesses in the remaining three cases: the

Camp Monterey, the Al Jaber Airfield, and the ASP Orchard case narratives.

In investigating these cases, OSAGWI followed its methodology, identified

and interviewed important witnesses, appropriately used information from

other key sources, included all important information in the case

narratives, and accurately presented the information found. These

investigations were performed in a generally thorough manner, and the

evidence collected by OSAGWI supported its assessments.

OSAGWI officials told us that they have revised their internal review

processes for conducting and reporting investigations. They said that

(1) improvements to these processes have evolved since the publication of

the six case narratives we reviewed, (2) some of the process revisions

were influenced by the findings we reported as our review progressed, and

(3) enhancements to their processes would considerably minimize the

recurrence of similar weaknesses in future case narratives.

OSAGWI’s

Investigations and

Reporting Procedures

Have Various

Weaknesses

Our review of the six selected case narratives disclosed some weaknesses

in the investigations and in the accuracy and completeness of OSAGWI’s

reporting. OSAGWI’s investigations were usually conducted in accordance

with the established methodology. OSAGWI also generally identified and

interviewed the appropriate witnesses, obtained relevant evidence and

information, accurately documented witness testimonies, and otherwise

generally used appropriate investigative techniques and procedures.

However, we found that three of the six selected case narratives still

contained significant investigative and reporting problems. The types of

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problems varied. In three of the six case narratives, we found investigative

problems such as failures to (1) follow up with appropriate individuals to

confirm key evidence, (2) identify or ensure the validity of key physical

evidence, (3) include important information, and (4) interview key

witnesses. Following is a more detailed description of the three case

narratives containing most of these weaknesses.

Case Narrative on

Reported Exposure to

Mustard Agent

This case narrative addresses the reported exposure of an individual

soldier to mustard agent while he was exploring an Iraqi bunker. OSAGWI

assessed this incident as a “likely” exposure. OSAGWI’s assessment of this

case has been highly controversial. Some veterans organizations and

others believe that the evidence presented in OSAGWI’s case narrative and

the Army’s presentation of the Purple Heart medal to this soldier for his

injuries warranted an assessment of “definite” exposure. However, we

found that this case was affected by many investigative and evidentiary

problems. Some of these are more closely associated with shortcomings in

DOD procedural practices during the Gulf War than with how OSAGWI did its

investigation. Despite the problems identified, we believe that OSAGWI’s

original assessment of “likely” exposure remains appropriate for this case.

Incident Synopsis According to OSAGWI’s case narrative, the soldier (an Army armored cavalry

scout) was exploring enemy bunkers in southeastern Iraq near Kuwait’s

border on March 1, 1991. He entered one bunker through a tight

passageway and twice brushed against the bunker’s doorway and wall.

About 8 hours later, he began to experience a stinging pain on the skin of

his left upper arm. Three hours later, blisters had formed there. About 15

hours after the exposure, the company medic checked the soldier’s

blisters and suspected a heater burn. Eight hours later, after more blisters

had formed on the soldier’s arm, aid station medical personnel suspected

he might be a casualty of blister agent, treated him, and evacuated him to

the company support battalion. There, an Army physician photographed

the blisters and confirmed the diagnosis of exposure to a blister agent.

An Army chemical officer also observed the soldier’s blisters and

examined his clothing. He observed a wet spot on the soldier’s coveralls.

The officer took the coveralls to a Fox vehicle for testing.1

 From its tests

on March 2, 1991, the Fox vehicle reportedly confirmed the presence of a

1

The Fox Nuclear Biological and Chemical Reconnaissance Vehicle was the most sophisticated and

technically complex piece of chemical detection equipment that the United States used during the

Persian Gulf War. It was designed to provide an initial alert to warn personnel of the possible presence

of dangerous chemicals and subsequently to provide detailed confirmation by means of an on-board

mass spectrometer.

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mustard chemical warfare agent. After this positive test, the soldier’s

coveralls were buried at the scene in Iraq as contaminated waste.

On March 3, 1991, a senior medical officer (a physician and an expert in

chemical warfare agents who was also at the time the Commander of the

U.S. Army Medical Research Institute of Chemical Defense) examined the

soldier’s blisters and concluded that they had been caused by exposure to

a liquid mustard agent. This officer based his diagnosis largely on (1) the

latent period of 8 hours between exposure and the first symptoms, which

is characteristic of mustard exposure and (2) the absence of any other

known chemical compounds present on the battlefield that have this

characteristic.

On March 4, 1991, following an order from chemical officers at the division

level to confirm the positive results from the first day of Fox vehicle

testing, tests on the soldier’s flak vest were performed by two Fox

vehicles—apparently because the vest had not been buried along with the

coveralls. Initially, both Fox vehicles registered the potential presence of

chemical warfare agents, but only one was apparently able to confirm the

presence of mustard agent. At the bunker complex where the soldier was

injured, a Fox vehicle also initially detected a chemical warfare agent but

was unable to confirm the presence of mustard or any other chemical

warfare agent.

The case narrative reported that an in-theater analysis of the soldier’s

urine tested positive for thiodiglycol, a breakdown product of mustard

agent. It also reported that a second urinalysis was performed by the U.S.

Army Medical Research Institute of Chemical Defense at Aberdeen

Proving Ground, Maryland. This analysis found no evidence of

thiodiglycol. Clothing samples were also sent to the U.S. Army Chemical

Research, Development and Engineering Center for analysis. Tests of

these items also revealed no evidence of any chemical warfare agent.

However, the negative test results from one of the urinalyses were not

considered unusual due to the low level of the exposure.

OSAGWI based its assessment of “likely” exposure primarily on the

following factors: (1) the medical assessments of two physicians who

examined the soldier—a senior medical officer and a physician who had

recently been trained to identify chemical warfare agent injuries; (2) the

latent period of 8 hours between the soldier’s exposure and his first

symptoms, which is consistent with exposure to mustard agent; and

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(3) the positive detections of mustard agent made in-theater from analyses

of the soldier’s clothing and urine.

Our Review of OSAGWI’s

Investigation

We agree with OSAGWI’s assessment that exposure to a chemical agent was

“likely.” However, we found several investigative procedural problems

with this case, primarily concerning insufficient follow-up with witnesses,

failure to interview key officials about tests conducted on the soldier’s

clothing, and uncertainties about the identity and validity of key physical

evidence sent to the United States for testing.

First, information we discovered causes us to question the existence of the

soldier’s positive in-theater urinalysis for mustard agent. OSAGWI based the

existence of this test on an Army Central Command message reporting a

positive in-theater test for thiodiglycol. However, OSAGWI was unable to

find any documented test results from this urinalysis, and OSAGWI

investigators did not perform sufficient follow-up with the involved

individuals to verify that this test had actually taken place.

In discussing what OSAGWI knew about the positive in-theater urinalysis, we

learned that OSAGWI had not interviewed either the senior medical officer

or the officer who wrote the message describing the positive in-theater

analysis during its investigation. Instead OSAGWI relied upon the senior

medical officer’s testimony to the Presidential Advisory Committee, his

medical journal article, and his review of OSAGWI’s draft case narrative.

However, this procedure failed to identify important information. In early

1998, our subsequent interviews with the senior medical officer and

OSAGWI’s interviews with him revealed that he was unaware of the

existence of any in-theater urinalysis involving the soldier. He also stated

that, because of his position in the theater as the head of a team of

scientists responsible for assessing any chemical casualties, he would have

known about the existence of any positive urinalysis performed there. We

then contacted the officer who had written the Army Central Command

message and asked him about his basis for reporting the positive

urinalysis. He told us that his message was based on 3rd Armored Division

reports that the senior medical officer had found thiodiglycol in the

soldier’s urine specimen. The available evidence is thus contradictory and

insufficient to establish that this test actually occurred.

Second, the results of the tests conducted on March 2, 1991 (the first day

of testing), for mustard agent on the soldier’s clothing cannot be

confirmed with the available documentation, and OSAGWI did not interview

some key officials involved in the case about the tests. According to the

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Commander of the Fox vehicle involved, the Fox tests on the soldier’s

clothing conducted on March 2, 1991, indicated the presence of blister

agent on the soldier’s coveralls. However, the Fox printout of the test

results was apparently lost. We located and interviewed the Fox test

operator involved, who told us that several tests were conducted on the

soldier’s clothing that day and that there was one positive confirmation for

mustard agent. During our review, OSAGWI found a printout from one of

these tests in its files, but it was negative for chemical agent. We noted

that this printout had not been logged into OSAGWI’s document receipt

system. We also noted that OSAGWI had never interviewed the Fox vehicle

Commander in person or the operator who conducted the tests. OSAGWI

relied upon information provided by E-mail from the Commander of the

Fox vehicles involved because he was then stationed in Germany and

could not easily be interviewed in person. OSAGWI said it did not interview

the test operator because it could not locate him.

On the second day of Fox testing, the Fox Commander returned with both

the original and a second Fox vehicle to confirm the positive test results

from the first day of Fox testing of the soldier’s clothing. One of the Fox

vehicles was unable to confirm the presence of mustard agent on the

soldier’s flak vest because of a high concentration of oil products on the

vest.2

 The other Fox vehicle, whose detailed confirmatory procedure was

videotaped by a crewmember but for which the printout is unavailable, did

show the presence of mustard agent. DOD sent the printout from the

original Fox vehicle and the videotape from the second one to the U.S.

Army Chemical and Biological Defense Command at Aberdeen Proving

Ground, Maryland, for analysis. A Command expert found that the

surviving printout did not confirm the presence of chemical warfare agent

when the detailed confirmatory procedure was performed. However, after

examining the printout and viewing the videotape, this official concluded

that the incident had involved an actual mustard agent detection.

We found other procedural discrepancies that raise questions regarding

this case. First, DOD did not adequately identify or ensure the validity of

important physical evidence. We noticed a difference between the

inventory of items that the Commander of the Fox vehicles had reportedly

packaged for shipment back to the United States for analysis and the items

that were received at the U.S. Army Chemical Research, Development and

Engineering Center. The Commander reported on his inventory list that he

did not include samples from the soldier’s coveralls since they were

unavailable; however, the Center’s inventory showed receipt of such

2

This was confirmed by analysis of the available printout from these Fox vehicle tests.

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samples. When we interviewed the Commander, he told us that he

believed the sample material was in fact from the Commander’s own

protective suit that he wore during the Fox vehicle testing. These

discrepancies raise the possibility that either someone recovered the

soldier’s coveralls and then repackaged the contents for shipment to the

United States or that at least some of the clothing sent back to the United

States for testing was not the soldier’s. The circumstances surrounding the

testing of the soldier’s clothing in-theater thus remain unclear. It is

impossible to determine whether the samples are actually from this

soldier.

In discussing the investigative weaknesses we found, the OSAGWI lead

investigator told us that this investigation had begun under the

Investigation Team before OSAGWI was established and that the case was

carried over to OSAGWI. She said that the case’s outcome appeared to be

obvious on the surface—particularly since the soldier had received a

medical diagnosis indicating exposure to mustard agent. She said that the

investigation process at OSAGWI has matured since this case narrative was

published. She also said that OSAGWI would do more cross-checking of the

facts if this investigation were being done today.

Despite the investigation’s shortcomings, we believe that OSAGWI’s

assessment of “likely” exposure to a chemical warfare agent in this case is

reasonable. The senior medical officer’s clinical diagnosis that the soldier’s

injuries were caused by exposure to mustard agent is significant in that

this expert in chemical warfare agents made his assessment

contemporaneously at the time of the injury and continues to believe that

the latent period of 8 hours from exposure to the first symptoms supports

his diagnosis. In addition, an expert at the U.S. Army Chemical and

Biological Defense Command, after reviewing the Fox vehicle printout and

viewing a videotape of another Fox vehicle conducting tests, concluded

that this incident involved a valid detection of mustard agent. However, we

believe the lack of confirmation of exposure through urinalysis or retained

confirmatory printouts from the Fox vehicles involved prevents OSAGWI’s

exposure assessment in this case from being classified as “definitely.”

Marine Minefield

Breaching Case Narrative

This case narrative addresses reports that U.S. Marines might have been

exposed to chemical warfare agents while breaching minefield barriers on

the first day of Operation Desert Storm’s ground war. OSAGWI concluded

that the presence of chemical warfare agents was “unlikely” during this

incident, in part because it found that no mechanism was present for

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delivering such agents. However, we found that OSAGWI overlooked

information indicating that a means for delivering chemical warfare agents

might have been present, and that the case narrative does not include

other relevant information indicating that chemical warfare agents might

have been present. We believe that these shortcomings are sufficient to

cause a reasonable person to question OSAGWI’s assessment.

Incident Synopsis On February 24, 1991, the first day of Operation Desert Storm’s ground

war, Marine Corps forces breached two rows of minefields that stretched

for miles near the border between Saudi Arabia and Kuwait. As they

passed through the first row of minefields, two Fox vehicles (one assigned

to units of the 1st Marine Division and another assigned to the 2nd Marine

Division) indicated potential detections of chemical agents. The detection

by the 1st Division’s Fox vehicle was described as a trace detection of

such a small magnitude that no official report of the detection was made

and no Fox printout was kept to document the detection. OSAGWI

concluded that the presence of chemical warfare agents in the 1st Division

area was “unlikely.”

The detection by the 2nd Division’s Fox vehicle, however, indicated the

potential presence of mustard, sarin, and lewisite—all chemical warfare

agents. In this instance, the Fox vehicle printouts were kept, but because

of the hostile environment, the Fox vehicle was not stopped to perform a

more detailed confirmation procedure to conclusively determine whether

chemical warfare agents were present.

One possible chemical warfare agent injury was reported during the

breaching: a 2nd Division Marine riding in an amphibious assault vehicle at

the time of the detection claimed his hands were burned, presumably by a

chemical warfare agent, as he closed the vehicle hatch after hearing the

Fox vehicle alert by radio. However, the validity of this reported injury

was controversial. Some witnesses supported the Marine’s claim that his

hands were blistered, but the examining physician stated that the Marine

had no injury of any kind.

In investigating the breaching incident, OSAGWI interviewed key

participants in the breaching operations, including members of the Fox

vehicle crews, chemical warfare specialists, some unit commanders, the

Marine who claimed to have been injured, other Marines from the injured

man’s unit, and the medical personnel who examined him. The

investigators also reviewed unit logs and other pertinent documentation,

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including classified data, and consulted with Fox vehicle and chemical

weapons technical experts.

On the basis of reviews of the 2nd Division Fox vehicles’ printouts by

three different laboratories, OSAGWI concluded that the Fox vehicle

detections were false alarms, probably caused by the high concentrations

of smoke from oil well fires and petroleum particles in the atmosphere.

OSAGWI further indicated that except for the possible injury to one Marine,

no other troops reported claimed chemical warfare agent injuries. In its

overall assessment of the incident, OSAGWI stated that the presence of

chemical warfare agent was “unlikely.” In supporting its assessment,

OSAGWI stated that since no chemical land mines were ever found in Kuwait

and since no artillery fire was encountered by the Marines who breached

the first row of mines, there was no delivery mechanism for chemical

warfare agents.

Our Review of OSAGWI’s

Investigation

OSAGWI overlooked a key piece of evidence and did not report other

significant information in its case narrative. OSAGWI concluded that the

Marines had encountered no Iraqi artillery fire as they moved through the

first row of Iraqi minefields. This conclusion was based on comments

made by the commanding officer and others of the Marine company that

carried out the minefield breach where the 2nd Division Fox vehicle

reported the presence of a chemical warfare agent. However, our review

of OSAGWI files disclosed a Marine Corps unit log entry indicating that Iraqi

artillery and mortar fire was present during the first minefield breach. The

OSAGWI investigator told us that he had inadvertently overlooked this

information during his investigation. We also interviewed Marines who

told us that Iraqi artillery and mortar fire was present as they passed

through the first minefield. Consequently, we believe a delivery

mechanism for chemical warfare agent may have been present.

Also, the timing of events was significant. For example, the log entry

indicating that enemy artillery was encountered was made around

6:15 a.m. on February 24, 1991. The Fox vehicle detection was made at

6:22 a.m. of that same day. The Marine who claimed to be injured was

riding in an amphibious assault vehicle that was following the Fox vehicle.

He said his injury occurred just after he heard the Fox vehicle’s report of

the chemical warfare agent detection over the radio.

We also learned that the Commander of the 2nd Division’s Fox vehicle told

OSAGWI investigators that chemical detection paper taped to the outside of

the Fox vehicle was noted to have changed colors after passing through

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the first minefield (indicating possible contact with a chemical agent).

However, this information was not reported in OSAGWI’s narrative. The

OSAGWI investigator said that this information was omitted because

technical experts had told him that the detection paper could change

colors because of the heavy concentrations of petroleum products in the

air coming from the oil well fires the Iraqis had set. Furthermore, as

mentioned in the case narrative, three different laboratories had reviewed

the Fox vehicle printout and concluded that the detections were probably

false alarms. The narrative did not point out, however, that one of the

three laboratories had also said that it could not rule out the possibility of

the presence of a chemical warfare agent.

Finally, a classified document in OSAGWI’s files contained intelligence

evidence not included in the narrative that could support the possibility of

an Iraqi chemical attack. This information, some of which has since been

declassified, refers to a report indicating the end of a chemical attack on

February 24, 1991, the same date as this incident. OSAGWI was aware of this

information, but because of its vagueness, unknown origin, fragmentary

nature, and time of report (about 4 hours after the breaching event), it was

not given much weight during OSAGWI’s analysis. We agree that the

potential impact of this evidence is unclear. However, when combined

with the other information we have cited, it provides additional cause for

further investigation by OSAGWI, regardless of its potential for association

with this case.

We believe that OSAGWI’s assessment of “unlikely” in this case is subject to

question. While the information we found does not conclusively prove that

chemical warfare agents were present, it does increase the potential that

some might have been present. In our opinion, the weaknesses we found

in this case narrative are sufficient to warrant OSAGWI’s reconsideration of

its assessment. We discussed our findings with OSAGWI investigators and

officials, and they agreed that this information needs to be evaluated.

OSAGWI officials told us they would include this information in their

follow-up investigation of the minefield breaching incident and would

address the questions we raised.

Al Jubayl, Saudi Arabia,

Case Narrative

Regarding this case narrative about three significant events occurring in

the Al Jubayl area during the Persian Gulf War, OSAGWI concluded that the

presence of chemical warfare agents was “unlikely” for one of the events

and “definitely did not occur” in the remaining two. We believe that the

available evidence generally supports OSAGWI’s assessment, but OSAGWI is

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still performing work regarding alternate explanations for some events

affecting this case. However, we also found that OSAGWI did not include

important information in this case narrative regarding the unusually high

levels of post-war veterans’ complaints of medical symptoms they

associated with the incidents involved in this case. Furthermore, OSAGWI

did not adequately identify and coordinate some of this information that

could potentially provide evidence to help resolve research questions

concerning whether there is a correlation between high levels of reported

Gulf War illnesses symptoms and duty during the Gulf War at Al Jubayl.

Incident Synopsis Al Jubayl is the largest of eight planned industrial cities in Saudi Arabia. It

consists of an industrial zone and port facilities, as well as residential and

other noncommercial areas. The Al Jubayl area was developed during the

early 1980s along what was then essentially undeveloped coast line and

was designed to take advantage of Saudi Arabia’s vast oil resources. Al

Jubayl played a crucial role during the Gulf War—many U.S. and coalition

military units either passed through or were stationed there.

OSAGWI’s case narrative addresses three separate events that allegedly

involved exposure to chemical agents in the Al Jubayl area: the “loud

noise” event and alerts on January 19 through 21, 1991; an Iraqi SCUD

missile attack on February 16, 1991; and a noxious fumes event on

March 19, 1991, which some U.S. military personnel claim caused them to

experience medical problems and turned portions of the T-shirts they

were wearing from brown to purple.

The need for OSAGWI to investigate these events was underscored by

concerns about Gulf War illnesses expressed in a May 1994 report of the

U.S. Senate’s Banking, Housing, and Urban Affairs Committee (known as

the Riegle Committee) by veterans of Naval Mobile Construction Battalion

24 (NMCB-24). NMCB-24 was a reserve “Seabee” or military construction

battalion of 724 enlisted persons and 24 officers. During Operation Desert

Shield/Desert Storm, NMCB-24 was stationed alongside NMCB-40, an active

duty “Seabee” battalion. Both units occupied Camp 13, a housing and

billeting area located in the Al Jubayl industrial zone that was commanded

by the senior officer of NMCB-40.

The “Loud Noise” Event OSAGWI found that the “loud noise” event actually referred to several loud

explosive-like noises and related events occurring between January 19 and

21, 1991. As stated in the OSAGWI narrative and confirmed by our review,

early on January 19, a very loud noise like an explosion was heard

throughout the Al Jubayl area. Units in the area subsequently reported

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additional explosions, went on alert, and conducted tests for the presence

of a chemical warfare agent. A variety of confusing and contradictory

actions subsequently occurred. All NMCB-24 tests for chemical warfare

agent were officially reported as negative, but one member of this unit

alleged that he had obtained positive test results for a chemical warfare

agent in two of three attempts. British units in the vicinity initially

reported positive tests for a chemical warfare agent, but detection teams

sent to investigate these reports were unable to confirm any such agents.

Some eyewitnesses from NMCB-24 reported a large fireball that illuminated

the sky and medical symptoms such as runny noses, burning sensations,

blisters, and numbness. They stated that those experiencing symptoms

reported for medical attention within the next few days. However, other

NMCB-24 personnel said that although they were unprotected during these

events, they experienced no such symptoms. After reviewing NMCB-24’s

medical logs, neither OSAGWI nor we found any records indicating that

medical attention for these symptoms was sought on or shortly after

January 19, 1991. OSAGWI and our interviews with the NMCB-24 Commander,

medical personnel, and senior noncommissioned officers similarly

revealed no evidence that any medical attention was sought.

OSAGWI found, and we confirmed, that many coalition aircraft were

engaged in the air war on the day in question, and Air Force records show

that two coalition aircraft flew over the Al Jubayl area at supersonic speed

during the early hours of January 19, 1991. OSAGWI concluded that the loud

noise and related events were due to sonic booms from these aircraft. It

also concluded that the presence of chemical or biological warfare agents

was “unlikely” because (1) DOD records show that no SCUD missiles were

launched toward Saudi Arabia by Iraq on January 19, (2) no verifiable tests

in the Al Jubayl area were positive for chemical warfare agents, and (3) no

records were found of any individual receiving treatment for symptoms

associated with exposure to chemical or biological warfare agents.

On January 20-21, 1991, air raid sirens and explosions were heard again in

the Al Jubayl area, but available records reviewed by OSAGWI, and checked

by us, indicated that chemical detection tests were again negative. OSAGWI

again concluded that the presence of chemical or biological warfare

agents was “unlikely” because (1) records show a SCUD missile aimed at

Dhahran was intercepted and destroyed at high altitude by a Patriot air

defense missile at approximately the same time as this incident, (2) there

is no record of an impact site in the Al Jubayl area, and (3) no records

were found of anyone receiving medical treatment for symptoms

associated with exposure to chemical or biological warfare agents.

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The SCUD Missile Attack A second possible exposure of veterans to chemical and biological warfare

agents in the Al Jubayl area occurred as the result of an Iraqi SCUD missile

attack early in the morning of February 16, 1991. The OSAGWI narrative

explains that U.S. national sensors detected this missile early in flight and

provided warning of the launch. The missile landed in the waters of Al

Jubayl harbor, and the site of impact was quickly found and marked by

Coast Guard and Navy boat crews. Later that day, a Navy explosive

ordnance disposal team surveyed the marked area with an underwater

television system and located missile debris on the harbor’s bottom.

Divers confirmed that the missile had broken apart and that the site

contained an intact SCUD warhead, guidance section, rocket motor, and

miscellaneous components. Recovery of the smaller SCUD components

began on February 19 and concluded with the warhead on March 2. During

the recovery operation, tests were conducted, but no evidence was found

indicating the presence of chemical or biological agents. The Joint

Captured Material Exploitation Center then took custody of the SCUD

components, which were subsequently shipped to the Army Missile

Command in Huntsville, Alabama. The Command’s evaluation of the

recovered SCUD missile components confirmed that the warhead did not

contain chemical or biological warfare agent.

Some eyewitnesses to this event reported that the SCUD missile was

intercepted and shot down by a Patriot missile and during this process

could have dispersed chemical or biological warfare agents over Al Jubayl.

A Patriot battery was defending Al Jubayl at the time. However, OSAGWI

found and we confirmed that this battery was not operational for

maintenance reasons at the time of the attack and therefore was not able

to engage the SCUD. OSAGWI concluded in its case narrative that while an

Iraqi SCUD missile had hit the waters of Al Jubayl harbor, it had not

detonated, had caused no damage or injuries, had tested negative for

chemical warfare agents, and therefore was definitely not armed with

chemical warfare agents.

The Purple T-Shirt Event The third known possibility of exposure to chemical agents at Al Jubayl

occurred on March 19, 1991, when personnel from NMCB-24 were exposed

to unidentified airborne noxious fumes. These fumes affected nine

persons working in three separate groups. They experienced acute

symptoms such as burning throats, eyes, and noses and difficulty in

breathing. In addition, portions of the brown T-shirts being worn by these

individuals turned purple, as did some of the individuals’ combat boots.

Seven persons composing two of the groups immediately sought medical

attention and returned to work with no further symptoms after showering

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and changing clothes. The two persons in the third group did not seek

medical assistance and continued to work. The nine persons involved

stated that they had experienced a choking sensation when a noxious

cloud enveloped them. None saw the origin of the cloud, but all believed it

had come from one of the industrial plants located nearby.

Evidence collected by OSAGWI regarding the source of the noxious fumes

was inconclusive. One eyewitness of the event said that he had seen

purple dust falling in the area that was coming from a smokestack at a

nearby fertilizer plant. The Navy’s Environmental and Preventive Medicine

Unit No. 2 (EPMU-2) conducted an environmental/occupational hazard

investigation and site visit to Al Jubayl in 1994. The resulting EPMU-2 study

did not determine the source of the irritant. It noted, however, that the

camp was located in a heavily industrialized area and that emissions from

a petrochemical plant or from a spill within the camp’s motor park could

have been the source of the irritant. The T-shirts and the boots that

changed color were given to unnamed U.S. military and Saudi officials.

However, the chain of custody cannot be identified, and no reports have

been found other than an informal telephone call to NMCB-24 shortly after

the incident indicating that “there was nothing to worry about.” The U.S.

Army Material Test Directorate and the Natick Research Development and

Engineering Center later conducted tests on the type of military T-shirts

involved. The Natick tests showed that these T-shirts do turn purple when

exposed to acids such as sulfuric (battery) acid or oxides from nitric acid.

OSAGWI concluded that chemical warfare agents were definitely not

involved in the purple T-shirt event. OSAGWI reached this conclusion

because (1) the event occurred after the cessation of Gulf War hostilities,

(2) there was no record of hostile attack during the time period of the

event, and (3) the types of medical problems affecting the individuals

involved and their rapid recovery are not consistent with exposure to

chemical warfare agents.

Our Review of OSAGWI’s

Investigation

As a result of our review of evidence, procedures, and other information

obtained from OSAGWI and other sources regarding the Al Jubayl case

narrative, we generally concur that OSAGWI’s assessments of whether

chemical warfare agents were present are reasonable. The evidence

generally supports OSAGWI’s assessment that chemical warfare agents were

“definitely not” involved in the SCUD missile and purple T-shirt events.

The loud noise incident involved some contradictions in evidence or

testimony that we could not resolve, but our work confirmed the

credibility of the vast majority of the evidence used by OSAGWI. We noted

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the existence of another potential explanation of some of the events

involved in the loud noise incident. Some documents and other evidence

we acquired from a veterans’ organization indicate that an Iraqi aircraft or

a patrol boat might have been involved in an attempted chemical attack on

Al Jubayl at the time of this incident. OSAGWI is currently investigating this

version of events. However, pending the outcome of this continuing

investigation, we believe that the currently available evidence still

provides a reasonable level of support for OSAGWI’s conclusion that

exposure to chemical warfare agents was “unlikely” in this incident.

Although we concur with OSAGWI’s assessments in the Al Jubayl case, we

believe that the case narrative is not complete and could be misleading

because it does not mention the fact that many members of NMCB-24 have

reported unusually high levels of health problems since their service in the

Persian Gulf War. We also found that OSAGWI had not coordinated some

information developed during this investigation with the Naval Health

Research Center for inclusion in its Gulf War illnesses research on

Seabees.

OSAGWI’s Al Jubayl case narrative states that the methodology it used was

designed to investigate reports of exposure to chemical warfare agents

and to determine whether chemical weapons were used. OSAGWI officials

told us that in this case they had expanded their methodology to include a

considerable amount of information in the narrative regarding

environmental cleanliness factors affecting the Al Jubayl area. They said

they had done this in an effort to better explain the circumstances of the

case because some veterans had expressed concern over the hazardous

materials they could have been exposed to while they were in Al Jubayl.

The narrative thus contained much information explaining that (1) Saudi

environmental protection standards were equivalent to those of the U.S.

Environmental Protection Agency, (2) these standards were monitored

and maintained by the Saudis throughout Operation Desert Storm/Desert

Shield, and (3) Saudi monitoring records indicate no detections that

normal standards were exceeded on the date of the purple T-shirt incident.

The environmental data included in the narrative, much of which was

obtained by EPMU-2, thus indicated that Al Jubayl was no worse or better

than comparable industrialized sites in the United States.

We concur that OSAGWI’s decision to expand its stated methodology in

order to include this information was appropriate. As indicated at the

beginning of the narrative, OSAGWI’s charge is to investigate all possible

causes of Gulf War illnesses. However, most of the information presented

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in this case narrative leads the reader to conclude that exposure to either

chemical warfare agents or other chemical agents at Al Jubayl was

“unlikely” and probably did not involve a health threat in the limited

incident involving the purple T-shirts. The narrative mentions that some

NMCB-24 veterans testified before the Congress (the Riegle Commission)

but does not state why. The narrative text also contains no information

regarding significant DOD actions taken to address the high incidence of

post-war health problems reported by members of NMCB-24.

DOD has long been aware of health problems reported by NMCB-24. In 1992,

DOD began to identify clusters of military personnel who were complaining

of medical symptoms they attributed to their Gulf War service. As a result,

DOD initiated two field investigations. One of these, performed at the

request of the Navy Surgeon General, was a study of illnesses reported by

members and former members of NMCB-24 conducted during 1993-94 by the

same unit (EPMU-2) that conducted the Al Jubayl environmental study.

EPMU-2 personnel visited 6 of NMCB-24’s 12 detachments during this period,

conducted a questionnaire study, performed medical examinations,

reviewed military and other medical records, interviewed veterans and

family members, and otherwise attempted to identify prevalent symptoms

experienced by the members of NMCB-24 and diagnoses of their illnesses.

Much of the information they collected was computerized and used to

produce a series of tables and other statistical data relevant to Gulf War

illnesses issues and included in EPMU-2’s final report. This report contained

the following conclusions:

• A significant number of NMCB-24 veterans of the Gulf War have

experienced an array of nonspecific symptoms since returning from the

Persian Gulf. More than 41 percent of the veterans from three of the six

detachments experienced 10 or more symptoms.

• No common syndrome or diagnosis was identified in these veterans.

• The diagnoses identified were the same as those that might be expected in

a group of the same age that had not served in the Persian Gulf War.

• More research was needed.

Our review of OSAGWI’s files, our visit to EPMU-2, our interviews of current

and former EPMU-2 officials, and our review of all remaining EPMU-2

documentation related to this study revealed additional information. For

example, 44 of the 67 witnesses OSAGWI interviewed regarding the facts of

the loud noise incident are now reporting health problems they attribute to

their service during the Persian Gulf War. A former EPMU-2 physician

directly involved in the EPMU-2 study told us that while he had no factual

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baseline for comparison, it appeared to him that the frequency of

symptoms found in NMCB-24 veterans was greater than the frequency to be

expected in the general population. This observation, along with the high

symptom rates, was one of the reasons the EPMU-2 report recommended

more research. NMCB-24 veterans have been involved in testimony before

the Congress regarding health problems they attribute to their service in

the Persian Gulf War, and the Naval Health Research Center in San Diego,

California, is currently performing a major, multiyear, Gulf War

illnesses-related epidemiological study involving the vast majority of the

Navy’s Seabees. NMCB-24 veterans have also been the subject of several

additional research studies related to Gulf War illnesses.

OSAGWI was aware of the existence of the EPMU-2 medical study and had a

copy on file that was originally obtained by its predecessor, the Persian

Gulf Illnesses Investigation Team, in 1996. However, no OSAGWI

investigators visited EPMU-2 to review files regarding this study. No

information regarding this study, the Naval Health Research Center

research project, or other epidemiological studies or research on Gulf War

illnesses was included in the case narrative. A high-ranking OSAGWI official

told us that OSAGWI investigators had been instructed to consider such

medical information as outside their charter for inclusion in the case

narratives. This official said that they had been so instructed because this

line of inquiry was more appropriately the responsibility of the Office of

the Assistant Secretary of Defense for Health Affairs and because OSAGWI

did not have the expertise to conduct or evaluate epidemiological studies

such as the one performed by EPMU-2.

We believe that much more information regarding the health complaints of

NMCB-24 veterans should have been included in the case narrative. OSAGWI

was aware of this information and could have included it without

conducting or evaluating epidemiological studies. Including information

developed by EPMU-2 regarding the environmental cleanliness of Al Jubayl

but excluding EPMU-2’s report and other information specifically related to

post-war health complaints by NMCB-24 veterans makes OSAGWI vulnerable

to an appearance of bias. Such omissions tend to reinforce the beliefs of

some that DOD is inappropriately withholding information.

We also found that some information developed by OSAGWI might have

significantly added to what is known about Gulf War illnesses issues

involving NMCB-24 had OSAGWI coordinated the information with the Naval

Health Research Center for use in its currently ongoing Seabee

epidemiological study. For example, as determined by OSAGWI and reported

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in the Al Jubayl case narrative, both NMCB-24 and NMCB-40 were located at

Camp 13 during Operations Desert Shield and Desert Storm. Complaints

by NMCB veterans regarding post-war medical problems they attribute to

Persian Gulf service are well known, having been the subject of several

congressional hearings, various research efforts, and other activities

addressing Gulf War illnesses issues. An OSAGWI official told us that

interviews with selected NMCB-40 personnel indicated that personnel from

this unit were not experiencing health problems of the same nature and

extent as those reported by NMCB-24 veterans.

Since NMCB-24 and NMCB-40 occupied the same camp at Al Jubayl, we

believe that a determination of whether NMCB-40 veterans are encountering

medical problems similar to those being reported by NMCB-24 veterans

would be of considerable interest to those concerned with resolving Gulf

War illnesses issues. The Naval Health Research Center study is obtaining

for analysis a wide range of Gulf War illnesses-related information from

current and former Seabees and plans to perform a multifaceted analysis

of the information collected.

In August 1998, Naval Health Research Center officials told us they had

coordinated with OSAGWI officials regarding the Seabee study on several

occasions but that OSAGWI officials had not informed them of the

relationship between NMCB-24 and NMCB-40. The study’s methodology

therefore did not include plans to specifically compare Gulf War illnesses

information obtained from veterans of these two units. They

acknowledged, however, that such comparisons could be conducted and

that they might provide useful information. They said they would be

willing to discuss adding such comparisons if OSAGWI officials requested

that they do so. We believe such comparisons, especially regarding the

extent and nature of post-war medical symptoms, might provide

information important to OSAGWI’s investigation and reporting of Gulf War

illnesses issues involving the Al Jubayl and other case narratives.

OSAGWI officials agreed that the Al Jubayl case narrative needed to be

modified to acknowledge the high rate of symptoms reported by members

of NMCB-24 and that they would modify the case narrative accordingly.

They also told us they would coordinate with the Naval Health Research

Center regarding new information that might be developed through

comparisons of NMCB-24 and NMCB-40 data in the Naval Health Research

Center Seabee study.

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OSAGWI Did Not Use

DOD and VA Medical

Databases in

Conducting Its

Investigations for

Cases We Reviewed

DOD and the VA maintain databases that contain self-reported health

information and clinical information on thousands of Gulf War veterans.

Some of these veterans may have symptoms associated with Gulf War

illnesses. Although OSAGWI’s methodology calls for the use of the DOD and

VA databases in its investigations, we found it did not access them for the

six case narratives selected for our review. Therefore, OSAGWI missed an

opportunity to determine whether individuals involved in possible

exposure incidents were also reporting symptoms in the databases.

Information thus obtained could provide leads to help scope and guide the

nature of the investigation and potentially could be combined with other

evidence and research efforts conducted by DOD and others to help

evaluate whether chemical warfare agents might have been present.

Gulf War Illnesses

Databases Maintained by

DOD and VA

In response to the complaints of many military personnel that returned

from the Gulf War with health problems they believed were related to their

deployment, DOD and VA created programs to track the health of Gulf War

veterans. Information collected in these programs is stored in databases

that describe the health status of a large group of Gulf War veterans who

have undergone a standardized examination process to document their

health.

DOD’s Comprehensive Clinical

Evaluation Program

The multiphase Comprehensive Clinical Evaluation Program (CCEP) was

implemented by DOD in June 1994 to provide a systematic clinical

evaluation for the diagnosis and treatment of active duty military

personnel who have medical complaints they believe could be related to

their service in the Persian Gulf. Phase I of the CCEP consists of a medical

history, physical examinations, and laboratory tests that are comparable to

an evaluation conducted during an inpatient internal medicine hospital

admission. CCEP participants are evaluated by a primary care physician at

their local medical treatment facility and receive specialty consultations if

deemed appropriate.

The primary care physician may refer patients to phase II for further

specialty consultations depending on the clinical findings of phase I. 

Phase II evaluations consist of targeted, symptom-specific examinations;

laboratory tests; and consultations. During this phase, potential causes of

unexplained illnesses are assessed, including infectious agents,

environmental exposures, psychological factors, and vaccines. DOD

maintains a database that summarizes the clinical evaluations of CCEP

participants. The database shows self-reported complaints and symptoms

from everyone and physician diagnoses for examined participants. In

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addition, the database shows unit assignments, medical complaints,

diagnoses, and possible exposures of individuals who were part of units

during the Gulf War that may have come in contact with chemical warfare

agents or other environmental hazards. As of October 31, 1998, the CCEP

database contained health information on 34,963 service members who

had received clinical evaluations as a part of the program.

VA’s Persian Gulf Registry The VA’s Persian Gulf Registry (VA Registry) was established in 1992. Any

Gulf War veteran may participate in the registry, even if that person has no

current health complaints. Like the CCEP, the registry consists of a

two-phase examination process. During phase I, the veteran completes a

standardized questionnaire on exposures during the Gulf War and health

complaints and undergoes a physical examination with laboratory testing.

Veterans who have health problems that remain undiagnosed after phase I

are referred to more extensive phase II medical evaluations.

VA maintains a database that summarizes the results of clinical evaluations

of registry participants. It contains information on symptoms and

complaints self-reported by veterans and diagnosed by physicians. It also

contains information on exposures, birth defects, and undiagnosed

illnesses. Like the DOD database, the registry database also contains

information on which units the participants were assigned to during the

Gulf War. As of July 31,1998, the VA Registry contained information on the

health conditions of 70,051 Gulf War veterans who had physical

examinations under the VA program.

Identifying Program

Participants Could Help

OSAGWI Better Focus Its

Investigative Efforts

Each of the case narratives selected for our review describes possible

chemical exposure incidents that involve individuals acting alone or as a

part of larger units. Many of these individuals may have enrolled in either

the CCEP or the VA Registry. OSAGWI could use this data to identify whether

individuals involved in the incidents described in the case narratives might

be experiencing health problems.

Several of the case narratives included in our review describe events that

could have been the subject of further analysis using the CCEP and VA

Registry. For example, OSAGWI’s ASP Orchard case narrative describes

chemical warfare agent alarms at an ammunition storage facility near an

orchard outside Kuwait City, Kuwait. OSAGWI collected information from

many of the personnel that inspected this facility and from a variety of

other sources, such as the Central Intelligence Agency and the Defense

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Intelligence Agency. OSAGWI concluded that the alarms were false and that

chemical warfare agents probably had not been stored at this facility.

However, for the six case narratives we reviewed, OSAGWI investigators did

not query the CCEP or the VA Registry in an attempt to determine whether

any of the several personnel that inspected the site or any of the hundreds

of other personnel encamped nearby had enrolled and had reported or

been diagnosed with health problems. Although it would not be definitive,

unusually high levels of participation accompanied by the reporting of

certain health problems and possible exposures might have led OSAGWI to

investigate further. Performing this investigative step would serve to

enhance the credibility of OSAGWI’s case narratives and would confirm

OSAGWI’s intention to investigate these events leaving no stone unturned.

We noted that OSAGWI’s investigative methodology includes the use of the

CCEP and the VA registry and that OSAGWI had used such an analysis in

investigating the Khamisiyah incident and in developing its Depleted

Uranium environmental exposure report issued on August 4, 1998. For

example, in performing the investigation on depleted uranium, OSAGWI

investigators queried the CCEP to determine whether an unusually high

proportion of the participants involved in the case had experienced kidney

damage—a possible medical effect of being exposed to depleted uranium.

According to OSAGWI, the analysis showed that these CCEP participants did

not suffer unusually high rates of kidney damage compared to the general

U.S. population.

Three Case Narratives

Appear to Have Been

Appropriately

Investigated

Except for not using the DOD and VA medical databases, the Al Jaber Air

Base, ASP Orchard, and Camp Monterey case narratives generally did not

have the weaknesses we found in the other three cases. In investigating

these cases, OSAGWI followed its methodology, identified and interviewed

important witnesses, appropriately used information from other key

sources, included all important information, and accurately presented the

information found. These investigations were performed in a thorough

manner, and the evidence collected by OSAGWI convincingly supported its

assessments.

The Camp Monterey case is a good example. In this case, soldiers of the

8th U.S. Army Infantry Division were moving wooden Iraqi crates

containing metal canisters out of a building in a bivouac area north of

Kuwait City, Kuwait, so that it could be used to house troops. One of the

canisters broke open, spilling a white powder-like substance and causing

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several soldiers to become ill. At the request of the local commander, two

Fox vehicles tested the spilled substance. Both Fox vehicles initially

reported detections of sarin, a deadly nerve agent, and this apparently led

to some initial reports that soldiers had been exposed to a nerve agent.

Later, mass spectrometer tests by these Fox vehicles confirmed that the

substance was actually a relatively harmless riot control agent rather than

sarin. OSAGWI found, and we confirmed, that after interviewing the

personnel present (including the Fox crews) and after reviewing Fox crew

and laboratory analyses of the Fox printouts, the initial alarm for sarin was

an error. Similarly, in both the Al Jaber and ASP Orchard cases, initial Fox

alarms for persistent chemical warfare agent could not be confirmed in

some instances even by repeated attempts by the same Fox vehicles.

OSAGWI concluded, and we agreed, that had the chemical warfare agents

been present, they would have been detected in the repeated tests.

OSAGWI Has Made

Changes to Improve

Its Investigative and

Reporting Processes

We believe that inadequate quality control procedures within OSAGWI

contributed to the investigative and reporting problems discussed in this

report. During our review of OSAGWI operations, we periodically briefed

OSAGWI officials on the nature and types of weaknesses we had found and

on our preliminary observations. OSAGWI officials agreed that they needed

to improve their investigations and their reporting of the investigation

results. They said that they have instituted several changes to their internal

quality assurance practices that they believe will considerably strengthen

their investigative and reporting processes.

According to OSAGWI officials, their current investigative and reporting

process has evolved over the 2 years since OSAGWI was established.

Consequently, certain enhancements are now in place that were not

present when the six case narratives we reviewed were published. More

specifically, OSAGWI now requires its investigators to prepare a written

investigation plan. The investigation plan must specify the information that

will be obtained, the direction the investigation will take, and the

schedule. The plan is expected to mirror the overall methodology adopted

by the division within the Investigation and Analysis Directorate for its

investigations. The division chief is to review the investigation plan and

provide feedback to the investigator on the scope and direction of the

investigation and the proposed schedule. Following approval of the plan

by the division chief, the investigator can begin the investigation.

Also, the process now includes a requirement for a team directional

guidance meeting when the investigation is 50- to 75-percent complete. At

Page 42 GAO/NSIAD-99-59 Gulf War Illnesses
Chapter 3 

Some Case Narratives Have Investigative

and Reporting Weaknesses

this meeting, the investigator briefs a small group of analysts from within

the investigator’s division on the investigation’s scope, direction, and

findings to that point. The purpose of the meeting is to identify at an early

stage any problems in the direction of the investigation and to identify any

major information sources that are not being used.

According to OSAGWI, each case investigation is now periodically reviewed

by the Director of the Investigations and Analysis Directorate to allow the

Director to adjust, as necessary, the scope of the investigation and the

case narrative development. Furthermore, the peer review process for

case narratives is now more robust because the peer review team,

comprising experienced individuals, reviews the completed case narrative

along with the source materials. The peer reviewers are responsible for

ensuring that the text in the case narrative is supported by the source

material and also for identifying portions of the text needing footnotes to

source materials. In addition, an OSAGWI official said the internal review of

case narratives by key individuals within the OSAGWI organization is more

rigorous than it used to be. OSAGWI officials believe that these

enhancements to their review processes will preclude the recurrence of

the types of investigative and reporting weaknesses we found.

Conclusions The weaknesses in the scope and quality of OSAGWI’s investigations and in

reporting the results of these investigations in the Reported Exposure to

Mustard Agent, Marine Minefield Breaching, and Al Jubayl case narratives

are significant; however, we agree with OSAGWI’s assessments of the

likelihood of the presence of chemical warfare agents in all but the Marine

Minefield Breaching case narrative. In our opinion, the lack of effective

quality assurance policies and practices within OSAGWI contributed to the

weaknesses we noted. A stronger quality control mechanism for its

investigations would provide greater assurance that all relevant facts are

included and that the information presented is accurately and properly

sourced. More consistent use of some types of medical information would

also strengthen the rigor of OSAGWI’s investigations. By querying available

medical databases for all cases, OSAGWI investigators might have been able

to better determine whether personnel at or near the sites of incidents had

reported or been diagnosed with unusual health problems, thus helping

indicate whether increased investigative efforts regarding the potential

presence of chemical warfare agents or other environmental hazards in

these incidents might be appropriate.

Page 43 GAO/NSIAD-99-59 Gulf War Illnesses
Chapter 3 

Some Case Narratives Have Investigative

and Reporting Weaknesses

OSAGWI’s changes to its internal review process appear to be positive steps

in ensuring the quality of investigations and the related case narrative

reports. Because OSAGWI initiated these changes after the case narratives

we reviewed were published, we could not determine their effectiveness in

ensuring the quality of OSAGWI investigations and reports. However, the

procedures should incorporate two features to enhance the credibility of

the review process. First, it is critical that those named to review OSAGWI’s

investigations are independent of the team investigating the incidents to

avoid the appearance of a conflict of interest. Second, it is important that

the procedures in place lead reviewers to thoroughly check to ensure that

all relevant information obtained by the investigation teams has been

included in the case narrative reports, that all important leads have been

pursued, and that the investigation team has reached conclusions that are

fully substantiated by the facts.

Information about the potential for differences in the occurrence of Gulf

War illnesses symptoms between NMCB-24 and NMCB-40 developed during

the Al Jubayl case investigation was not shared with the Naval Health

Research Center for consideration for inclusion in its ongoing Gulf War

illnesses research. We believe this information has potential for use in

helping DOD evaluate issues related to the high levels of health problems

reported by many of the Seabees stationed at Al Jubayl during the Gulf

War.

Recommendations To ensure that OSAGWI’s case narratives contain all relevant facts, we

recommend that the Secretary of Defense direct the Special Assistant for

Gulf War Illnesses to

• revise the Marine Minefield Breaching, Exposure to Mustard Agent, and Al

Jubayl, Saudi Arabia, case narratives to reflect the new and/or unreported

information noted in our report and

• examine whether it should change its conclusion about the likelihood of

the presence of chemical warfare agents in the Marine Minefield Breaching

case from “unlikely” to “indeterminate” in light of the additional

information now known about this case.

To enhance the thoroughness of OSAGWI’s investigative and reporting

practices, we recommend that the Secretary of Defense direct the Special

Assistant for Gulf War Illnesses to

Page 44 GAO/NSIAD-99-59 Gulf War Illnesses
Chapter 3 

Some Case Narratives Have Investigative

and Reporting Weaknesses

• use the DOD and VA Gulf War clinical databases to assist in designing the

nature and scope of all OSAGWI investigations;

• include relevant medical information in its case narratives where it is

needed to fully explain incidents of possible exposure to chemical agents

or other potential causes of Gulf War illnesses; and

• ensure that its internal review procedures provide that (1) those reviewing

an investigation and related report are independent of the team

investigating the incident and (2) steps are in place that will lead the

reviewers to thoroughly check that all relevant information obtained by

the investigation teams has been included in the case narrative reports, all

conclusions have been fully substantiated by the facts, and that all logical

leads have been pursued.

Because of the potential research value of information developed through

OSAGWI investigations, we further recommend that OSAGWI contact the

Naval Health Research Center regarding the usefulness and desirability of

comparing data between the veterans of NMCB-24 and NMCB-40 for purposes

such as helping to determine whether veterans of these two units are

reporting the same types and numbers of symptoms.

Agency Comments

and Our Evaluation

DOD generally concurred with a draft of this report, agreeing to revise the

case narratives we reviewed to include new or unreported data, and to

reassess case narrative findings based upon any new evidence. In

particular, DOD agreed to update the Marine Minefield Breaching case to

reflect new information, conduct additional analysis on the issue of

artillery fire during the breaching operation, and reassess its conclusions

as appropriate.

DOD disagreed with our proposed use of the CCEP and the VA Gulf War

Health Examination Registry in OSAGWI investigations. In commenting on

this report, DOD stated it was concerned that these databases might be

inappropriately used to establish a causal relationship between an event

and the medical findings of the registries. DOD therefore maintains it would

be inappropriate for case investigations, which were designed to report

simply on what happened on the battlefield, to make assumptions about

the significance or validity of the data in these databases without the

establishment of a causal association by scientific research. DOD also

stated concerns about preempting scientific research in this area and

drawing premature conclusions that would be fallacious. However, DOD

agreed that these databases need to be examined and analyzed for what

they can contribute to understanding the illnesses of Gulf War veterans,

Page 45 GAO/NSIAD-99-59 Gulf War Illnesses
Chapter 3 

Some Case Narratives Have Investigative

and Reporting Weaknesses

and noted that the Department has been involved in a number of research

and other analyses of these databases.

We agree that information from these databases should not be used by

investigators to establish a causal association and/or conclusions as

described by DOD, and did not intend that it should be used for this

purpose. We also agree that the establishment of Gulf War illnesses causal

relationships is most appropriately a research activity. However, we also

believe that the VA and DOD databases could potentially provide relevant

information to the investigator about whether individuals who were at or

near a site under investigation are reporting health problems, and that this

information could be appropriately used, when combined with other

information, to help guide the nature and scope of OSAGWI investigations.

For example, case investigators could use VA Registry and CCEP data,

particularly where it shows that large numbers of individuals at or near a

given site are reporting health problems, as an indicator for providing

investigative leads and for use in establishing the nature and scope of an

investigation. This does not mean, as implied in DOD’s comments, that such

use of these databases would entail routine inclusion of the reviewed data

in the published case narratives, their use as a replacement for research

activities, or that its use would result in interpretations of

non-scientifically based cause and effect relationships. We believe that

these databases can be used by investigators to help guide and scope their

efforts without entailing the types of misuse described by DOD. We

modified the final report text and recommendatons to clarify our position

regarding this finding.

DOD agreed that the Al Jubayl case narrative needed to be modified to

place the events of this incident in fuller context, and that this would

include that some servicemembers stationed at Al Jubayl, especially

members of NMCB-24, have reported high levels of health problems. DOD

also agreed to request that the Naval Health Research Center undertake an

analytical comparison regarding NMCB-24 and NMCB-40, and that

independent reviewers are critical to a thorough and acceptable report on

OSAGWI investigations.

VA also disagreed with our proposed use of the CCEP and the VA Gulf War

Health Examination Registry in OSAGWI investigations in its written

comments on a draft of this report. VA’s comments were similar to DOD’s

regarding this matter. VA also expressed doubts regarding the usefulness to

research of data comparisons involving NMCB-24 and NMCB-40.

Page 46 GAO/NSIAD-99-59 Gulf War Illnesses
Chapter 3 

Some Case Narratives Have Investigative

and Reporting Weaknesses

Additional discussion of DOD’s and VA’s comments and our evaluation is

included in appendixes I and II.

Page 47 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I 

Comments From the Department of Defense

Page 48 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I 

Comments From the Department of Defense

See comment 1.

Page 49 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I 

Comments From the Department of Defense

Page 50 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I 

Comments From the Department of Defense

Now on pp. 8 and 44.

See comment 2.

Now on p. 8.

Page 51 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I 

Comments From the Department of Defense

Now on pp. 8 and 44-45.

Page 52 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I 

Comments From the Department of Defense

Page 53 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I 

Comments From the Department of Defense

Now on p. 45.

See comment 3.

Page 54 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I 

Comments From the Department of Defense

Now on p. 25.

See comment 4.

See comment 5.

Now on p. 30.

See comment 6.

Now on p. 31.

See comment 7.

Now on p. 35.

See comment 7.

Now on p. 3.

Page 55 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I 

Comments From the Department of Defense

See comment 8.

Page 56 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I 

Comments From the Department of Defense

The following are our comments on the Department of Defense’s (DOD)

letter dated February 4, 1999.

GAO Comments 1. Our report states that the Office of the Special Assistant for Gulf War

Illnesses (OSAGWI) case investigators did not attempt to use Comprehensive

Clinical Evaluation Programs (CCEP) or Department of Veterans Affairs

(VA) registry information in the six cases we reviewed. The report

acknowledges OSAGWI’s use of the CCEP and VA registry regarding to the

Khamisiyah incident and the Depleted Uranium Environmental Exposure

Report.

2. Our report recommends that OSAGWI examine whether to change its

conclusion about the likelihood of exposure to a chemical agent in light of

the additional information now known about this case. We agree that

additional assessment is needed by OSAGWI to make this determination, and

that some of the evidence regarding this incident is contradictory and

otherwise in need of additional analysis. Until additional analysis is

performed, it is not clear whether the likelihood of the presence of a

chemical warfare agent in this case should be assessed as “unlikely” or

“indeterminate.” However, we believe the new evidence tends to increase

the possibility that an “indeterminate” assessment might be more

appropriate.

3. OSAGWI should have identified the potential research value of

information it had in its files regarding the relationship between Naval

Mobile Construction Battalion 24 (NMCB-24) and NMCB-40, and shared this

information with researchers at the Naval Health Research Center for use

in the Seabee study—a major Gulf War illnesses research project. We

agree that this finding cannot be used by itself as sufficient evidence to

show an overall lack of diligence by OSAGWI in sharing information from

case investigations with researchers. However, the fact that neither we nor

OSAGWI could find any evidence that an attempt was made to identify or

coordinate this information in the Al Jubayl case does raise questions

about the adequacy and effectiveness of OSAGWI procedures for identifying

and referring this kind of information. The word “diligence” was removed

from the final report.

4. The sentence referring to how the OSAGWI investigator should have been

alerted to the need for further investigation based on the absence of

thiodiglycol in the urine sample has been deleted from the final report. We

Page 57 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I 

Comments From the Department of Defense

agree that other inferences could also be drawn from the absence of

thiodiglycol in this analysis.

5. Information has been added to the final report regarding the senior

medical officer’s testimony, his medical journal article, and his review of

the narrative draft. However, OSAGWI was remiss in failing to interview the

senior medical officer, especially in view of the importance of this witness’

involvement in the case. This officer was still on active duty and stationed

in the Washington, D.C., area at the time of our review. OSAGWI could have

avoided some of the accuracy problems associated with this case narrative

had it interviewed this officer prior to publication of the narrative.

6. We agree that this message was fragmentary, incomplete, and leaves

many unanswered questions about its meaningfulness and reliability.

However, this message deserves further investigation because of its date

and reference to a chemical attack. In our opinion, the fact that the

message was received hours after the incident does not rule out the

possibility there could have been a delay between the time of the event

and the time the message was transmitted. Even if the message is shown

to be unassociated with the incident in question, its very nature justifies

further investigation by OSAGWI. OSAGWI officials agreed that they would

attempt to investigate further.

7. We agree with OSAGWI regarding the need for caution when interpreting

the relationship between an event, medical findings of the CCEP and VA

registries, and other medical information. Accordingly, the final report text

was modified regarding the term “direct linkage with post-war veterans’

complaints.”

We do not agree that the issue in point necessarily implies such

connotations. Our concern is simply that while the Al Jubayl narrative

contains much information to the effect that chemical warfare agents were

either “definitely not” or “unlikely” to have been present at Al Jubayl and

that the Al Jubayl area appeared environmentally clean during the Gulf

War, it fails to point out that (1) many servicemembers stationed there are

now reporting unusually high levels of health problems and (2) DOD has

conducted or is conducting several investigations and major research

projects addressing this issue. These important facts need to be mentioned

in the case narrative. If DOD is concerned about the possible misuse of

information regarding reported veterans’ illnesses, then the need for

caution regarding its use and research implications could also be included

Page 58 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I 

Comments From the Department of Defense

in the case narrative. We trust that OSAGWI’s planned modifications to the

Al Jubayl case narrative will resolve this issue.

8. In response to this comment, we have changed the report in several

places to refrain from using the word “disclose.” However, in the case

narrative involving the Seabees, as well as in one other case, OSAGWI for

various reasons originally chose not to include information that we believe

should have been included.

Page 59 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix II 

Comments From the Department of

Veterans Affairs

Now on pp. 39-41.

Now on p. 39.

See comment 1.

Page 60 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix II 

Comments From the Department of

Veterans Affairs

Now on p. 45.

See comment 2.

See comment 3.

Page 61 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix II 

Comments From the Department of

Veterans Affairs

The following are our comments on VA’s letter dated February 10, 1999.

GAO Comments 1. We are not suggesting that OSAGWI should use data from the DOD and VA

registries to reach conclusions about causal relationships between

participants’ health outcomes and the likelihood of their exposure to

chemical warfare agents. We recognize that these databases contain the

results of medical examinations for voluntary, self-selected individuals

that if used for research purposes could be affected by participation bias.

However, the databases contain information about whether the

participants believe that they were exposed to various chemical or

environmental hazards, their general health status, and the results of

medical examinations performed by DOD or VA. It is also possible that some

or many of these participants may have been at or near a site under

investigation by OSAGWI. Consequently, the databases may contain

potentially relevant information about individuals that were at a site under

investigation by OSAGWI—information which OSAGWI did not access for the

cases we reviewed. We are not suggesting that this information would

necessarily change the course of the OSAGWI investigation; however, review

of this information could possibly suggest additional investigative steps

that should be undertaken.

2. In our report, we recommend that OSAGWI contact the Naval Health

Research Center regarding the usefulness and desirability of comparing

data about veterans of NMCB-24 and NMCB-40. Center researchers told us

that such a comparison might be useful. The point of our recommendation

is that information developed in OSAGWI investigations that might have

research usefulness should be forwarded to organizations performing the

research. DOD agreed with this recommendation. Furthermore, it should be

noted that the Seabee study is one of the research projects being

performed under the management of the Research Working Group of

Persian Gulf Veterans Coordinating Board (Project DOD-1E) and as such is

one of the federally sponsored research projects addressing Gulf War

illnesses. This project is using scientific methods for collecting data from

both former and current Seabees and plans a multifaceted comparison of

this data. We made no judgments regarding what the outcome of this work

might be or how it might be reviewed by the epidemiology research

community. However, we believe that all data or ideas for comparisons

that might have applicability to Gulf War illnesses research should be

forwarded for consideration by the appropriate research organization.

Otherwise, an opportunity for learning more about Gulf War illnesses

could be missed.

Page 62 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix II 

Comments From the Department of

Veterans Affairs

3. OSAGWI’s own methodology for chemical incident investigations, which

was derived from the United Nations and the international community,

calls for obtaining information from the DOD and VA registries about the

medical condition of personnel involved in an incident under investigation.

We are not suggesting that OSAGWI establish a hypothesis from which it

could derive undisputed conclusions. We are suggesting that the DOD and

VA databases may contain potentially relevant information that could assist

OSAGWI in determining the scope and nature of its investigations.

Page 63 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix III 

OSAGWI Reports and Active Investigations

Table I.1 lists reports published by OSAGWI. It is followed by a listing of

active OSAGWI investigations.

Table I.1: OSAGWI Published Case

Narratives, Information Papers, and

Environmental Exposure Reports (as

of Jan. 1, 1999) 

Case name Publication date

Khamisiyah April 15, 1997

Camp Monterey May 22, 1997

Fox Information Paper July 29, 1997

Marine Minefield Breaching July 29, 1997

Al Jubayl, Saudi Arabia August 13, 1997

SCUD Piece August 13, 1997

Exposure to Mustard Agent August 28, 1997

Al Jaber Air Base September 25, 1997

ASP/Orchard September 25, 1997

M8A1 Information Paper October 30, 1997

MOPP Information Paper October 30, 1997

Medical Surveillance During ODS/DS

Information Paper

November 6, 1997

Tallil Air Base November 13, 1997

Kuwaiti Girls’ School March 19, 1998

An Nasiriyah SW August 4, 1998

Czech/French Detections August 4, 1998

Depleted Uranium Environmental Exposure

Report

August 4, 1998

11th Marines November 5, 1998

Oil Well Fire Environmental Exposure Report November 5, 1998

Active OSAGWI

Investigations (as of

Jan. 1,1999)

Air Campaign Information Paper

Al Muthanna

Biological Warfare

CARC Paint Environmental Exposure Report

Cement Factory

Chemical Munitions Markings Information Paper

Chemical Weapons Sites

Edgewood Tapes

Injured Marine

Khamisiyah - Update

M256 Information Paper

Marine Breaching Followup

Medical Record Keeping Information Paper

Page 64 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix III 

OSAGWI Reports and Active Investigations

Medical Surveillance Information Paper

Muhammadiyat

Pesticides/Insecticides Environmental Exposure Report

Possible Terrorist Attack at Al Jubayl

Possible Post-War Chemical Warfare Use on Iraqis

Rafha M256 Detections

Inhibited Red Fuming Nitric Acid Information Paper

Retrograde Equipment Environmental Exposure Report

Sand Environmental Exposure Report

SCUD Information Paper

Ukhaydir

Vaccine Administration Information Paper

XM21 RSCAAL Detection

JCMEC-TEU Sampling Process Information Paper

Page 65 GAO/NSIAD-99-59 Gulf War Illnesses
Appendix IV 

Major Contributors to This Report

National Security and

International Affairs

Division, Washington,

D.C.

Donald L. Patton

William W. Cawood

Raymond G. Bickert

William J. Rigazio

Norfolk Field Office Steve J. Fox

Lynn C. Johnson

William L. Mathers

(703223) Page 66 GAO/NSIAD-99-59 Gulf War Illnesses
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