Defense Health Care: Improvements Needed in Occupational and Environmental Health Surveillance During Deployments to Address Immediate and Long-Term Health Issues
Published: 2005-07-14T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Following the 1991 Persian Gulf War, research and investigations into the causes of servicemembers' unexplained illnesses were hampered by inadequate occupational and environmental exposure data. In 1997, the Department of Defense (DOD) developed a militarywide health surveillance framework that includes occupational and environmental health surveillance (OEHS)--the regular collection and reporting of occupational and environmental health hazard data by the military services. GAO is reporting on (1) how the deployed military services have implemented DOD's policies for collecting and reporting OEHS data for Operation Iraqi Freedom (OIF) and (2) the efforts under way to use OEHS reports to address both immediate and long-term health issues of servicemembers deployed in support of OIF.
section_title: What GAO Found
paragraphs: Although OEHS data generally have been collected and reported for OIF, as required by DOD policy, the deployed military services have used different data collection methods and have not submitted all of the OEHS reports that have been completed. Data collection methods for air and soil surveillance have varied across the services, for example, although they have been using the same monitoring standard for water surveillance. Variations in data collection have been compounded by different levels of training and expertise among service personnel responsible for OEHS. For some OEHS activities, a cross-service working group has been developing standards and practices to increase uniformity of data collection among the services. In addition, while the deployed military services have been conducting OEHS activities, they have not submitted all of the OEHS reports that have been completed during OIF, which DOD officials attribute to various obstacles, such as limited access to communication equipment to transmit reports for archiving. Moreover, DOD officials did not have the required consolidated lists of all OEHS reports completed during each quarter in OIF and therefore could not identify the reports they had not received to determine the extent of noncompliance. To improve OEHS reporting compliance, DOD officials said they were revising an existing policy to add additional and more specific OEHS requirements. DOD has made progress in using OEHS reports to address immediate health risks during OIF, but limitations remain in employing these reports to address both immediate and long-term health issues. OIF was the first major deployment in which OEHS reports have been used consistently as part of operational risk management activities intended to identify and address immediate health risks and to make servicemembers aware of the health risks of potential exposures. While these efforts may help reduce health risks, DOD has no systematic efforts to evaluate their implementation in OIF. In addition, DOD's centralized archive of OEHS reports for OIF has several limitations for addressing potential long-term health effects related to occupational and environmental exposures. First, access to the centralized archive has been limited due to the security classification of most OEHS reports. Second, it will be difficult to link most OEHS reports to individual servicemembers' records because not all data on servicemembers' deployment locations have been submitted to DOD's centralized tracking database. For example, none of the military services submitted location data for the first several months of OIF. To address problems with linking OEHS reports to individual servicemembers, the deployed military services have made efforts to include OEHS monitoring summaries in the medical records of some servicemembers for either specific incidents of potential exposure or for specific locations within OIF. Third, according to DOD and VA officials, no federal research plan has been developed to evaluate the longterm health of servicemembers deployed in support of OIF, including the effects of potential exposures to occupational or environmental hazards.

section_title: Letter
paragraphs: The health effects from service in military operations have been of  increasing interest, particularly since the end of the 1991 Persian Gulf War.  Following that war, many servicemembers reported suffering from  unexplained illnesses that they attributed to their service in the Persian  Gulf and expressed concerns regarding possible exposures to chemical or  biological warfare agents or environmental contaminants. Subsequent  research and investigations into the nature and causes of these illnesses by  the Department of Defense (DOD), the Department of Veterans Affairs  (VA), the Department of Health and Human Services (HHS), the Institute of  Medicine, and a Presidential Advisory Committee were hampered by a lack  of servicemember health and deployment data, including inadequate  occupational and environmental exposure data. During deployments— particularly combat situations—the health of servicemembers can  potentially be affected by exposure to hazardous agents contained in or  produced by weapons systems, as well as exposure to environmental  contamination or toxic industrial materials.
In an effort to address continuing concerns about the health of  servicemembers during and after deployments and to improve health data  collection on potential exposures, DOD developed a militarywide health  surveillance framework in 1997 for use during deployments. A key  component of this framework is occupational and environmental health  surveillance (OEHS), an activity that includes the regular collection and  reporting of occupational and environmental health hazard data by the  military services during a deployment that can be used to monitor the  health of servicemembers and to prevent, treat, or control disease or injury.  DOD has created policies for OEHS data collection during a deployment  and for the submittal of OEHS reports to a centralized archive within  certain time frames. The military services are responsible for implementing  these policies in preparation for deployments. During a deployment, the  military services are unified under a deployment command structure and  are responsible for conducting OEHS activities in accordance with DOD  policy. For this report, we identify the military services operating in a  deployment as deployed military services.
In early 2003, servicemembers were deployed again to the Persian Gulf in  support of Operation Iraqi Freedom (OIF), and you and others raised anew  concerns about potential exposure to hazardous agents or environmental  contaminants. We are reporting on (1) how the deployed military services  have implemented DOD’s policies for collecting and reporting OEHS data  for OIF and (2) the efforts under way to use OEHS reports to address both  the immediate and long-term health issues of servicemembers deployed in  support of OIF.
To conduct our work, we reviewed pertinent policies, guidance, and  reports related to collecting and reporting OEHS data obtained from  officials at the Deployment Health Support Directorate (DHSD), the  military services, and the Joint Staff, which supports the Chairman of the  Joint Chiefs of Staff. We also conducted site visits to the Army, Navy, and  Air Force health surveillance centers that develop standards and guidance  for conducting OEHS. We interviewed DOD officials and reviewed reports  and documents identifying occupational and environmental health risks  and outlining recommendations for addressing risks at deployment sites.  We interviewed officials at the U.S. Army’s Center for Health Promotion  and Preventive Medicine (CHPPM), which archives OEHS reports, both  classified and unclassified, for all the military services. We also interviewed  officials and military service representatives at DOD’s Defense Manpower  Data Center (DMDC) on the status of a centralized deployment tracking  database to identify deployed servicemembers and record their locations  within the theater of operations. Additionally, we interviewed VA officials  on their experience in obtaining and using OEHS reports from OIF to  address the health care needs of veterans. Finally, we interviewed DOD and  VA officials to examine whether the agencies have planned or initiated  health research using OEHS reports.
We determined that the data from CHPPM’s OEHS archive and DMDC’s  Contingency Tracking System were sufficiently reliable for the purposes of  this report. To assess the reliability of the data, we (1) confirmed that the  data included the elements that we requested and were consistent with  provided documentation and (2) conducted detailed fact-finding interviews  with CHPPM and DMDC officials to understand how the databases were  created and to determine the limitations of the data. We conducted our  work from September 2004 through June 2005 in accordance with generally  accepted government auditing standards. (See app. I for further detail on  our scope and methodology.)
subsections: section_title: Background
paragraphs: On March 19, 2003, the United States launched military operations in Iraq.  As of the end of February 2005, an estimated 827,277 servicemembers had  been deployed in support of OIF. Deployed servicemembers, such as those  in OIF, are potentially subject to occupational and environmental hazards  that can include exposure to harmful levels of environmental contaminants  such as industrial toxic chemicals, chemical and biological warfare agents,  and radiological and nuclear contaminants. Harmful levels include high- level exposures that result in immediate health effects. Health hazards  may also include low-level exposures that could result in delayed or long- term health effects. Occupational and environmental health hazards may  include contamination from the past use of a site, from battle damage, from  stored stockpiles, from military use of hazardous materials, or from other  sources.
subsections: section_title: Federal OEHS Policy
paragraphs: As a result of numerous investigations that found inadequate data on  deployment occupational and environmental exposures to identify the  potential causes of unexplained illnesses among veterans who served in the  1991 Persian Gulf War, the federal government has increased efforts to  identify potential occupational and environmental hazards during  deployments. In 1997, a Presidential Review Directive called for a report by  the National Science and Technology Council to establish an interagency  plan to improve the federal response to the health needs of veterans and  their families related to the adverse effects of deployment. The Council  published a report that set a goal for the federal government to develop the  capability to collect and assess data associated with anticipated exposure  during deployments. Additionally, the report called for the maintenance of  the capability to identify and link exposure and health data by Social  Security number and unit identification code. Also in 1997, Public Law 105- 85 included a provision recommending that DOD ensure the deployment of  specialized units to theaters of operations to detect and monitor chemical,  biological, and similar hazards. The Presidential Review Directive and the  public law led to a number of DOD instructions, directives, and  memoranda, which have guided the collection and reporting of deployment  OEHS data. See table 1 for a list of selected DOD policies for collecting and  reporting deployment OEHS data.
section_title: DOD Entities Involved with Setting and Implementing OEHS Policy
paragraphs: DHSD makes recommendations for DOD-wide policies on OEHS data  collection and reporting during deployments to the Office of the Assistant  Secretary of Defense for Health Affairs. DHSD is assisted by the Joint  Environmental Surveillance Working Group, established in 1997, which  serves as a coordinating body to develop and make recommendations for  DOD-wide OEHS policy. The working group includes representatives from  the Army, Navy, and Air Force health surveillance centers, the Joint Staff,  other DOD entities, and VA.
Each service has a health surveillance center—CHPPM, the Navy  Environmental Health Center, and the Air Force Institute for Operational  Health—that provides training, technical guidance and assistance,  analytical support, and support for preventive medicine units in theater in  order to carry out deployment OEHS activities in accordance with DOD  policy. In addition, these consulting centers have developed and adapted  military exposure guidelines for deployment using existing national  standards for human health exposure limits and technical monitoring  procedures (e.g., standards of the U.S. Environmental Protection Agency  and the National Institute for Occupational Safety and Health) and have  worked with other agencies to develop new guidelines when none existed.  (See fig. 1.)
section_title: Deployment OEHS Reports
paragraphs: DOD policies and military service guidelines require that the preventive  medicine units of each military service be responsible for collecting and  reporting deployment OEHS data. Deployment OEHS data are generally  categorized into three types of reports: baseline, routine, or incident- driven.
Baseline reports generally include site surveys and assessments of  occupational and environmental hazards prior to deployment of  servicemembers and initial environmental health site assessments once  servicemembers are deployed.
Routine reports record the results of regular monitoring of air, water,  and soil, and of monitoring for known or possible hazards identified in  the baseline assessment.
Incident-driven reports document exposure or outbreak investigations.
There are no DOD-wide requirements on the specific number or type of  OEHS reports that must be created for each deployment location because  reports generated for each reflect the specific occupational and  environmental circumstances unique to that location. CHPPM officials said  that reports generally reflect deployment OEHS activities that are limited  to established sites such as base camps or forward operating bases;  an  exception is an investigation during an incident outside these locations.  Constraints to conducting OEHS outside of bases include risks to  servicemembers encountered while in combat and limits on the portability  of OEHS equipment. In addition, DHSD officials said that preventive  medicine units might not be aware of every potential health hazard and  therefore might be unable to conduct appropriate OEHS activities.
section_title: OEHS Reporting and Archiving Activities during Deployment
paragraphs: According to DOD policy, various entities must submit their completed  OEHS reports to CHPPM during a deployment. The deployed military  services have preventive medicine units that submit OEHS reports to their  command surgeons who review all reports and ensure that they are sent  to a centralized archive that is maintained by CHPPM. Alternatively,  preventive medicine units can be authorized to submit OEHS reports  directly to CHPPM for archiving. (See fig. 2.)
According to DOD policy, baseline and routine reports should be submitted  within 30 days of report completion. Initial incident-driven reports should  be submitted within 7 days of an incident or outbreak. Interim and final  reports for an incident should be submitted within 7 days of report  completion. In addition, the preventive medicine units are required to  provide quarterly lists of all completed deployment OEHS reports to the  command surgeons. The command surgeons review these lists, merge  them, and send CHPPM a quarterly consolidated list of all the deployment  OEHS reports it should have received.
To assess the completeness of its centralized OEHS archive, CHPPM  develops a quarterly summary report that identifies the number of baseline,  routine, and incident-driven reports that have been submitted for all bases  in a command. Additionally, this report summarizes the status of OEHS  report submissions by comparing the reports CHPPM received with the  quarterly consolidated lists from the command surgeons that outline each  of the OEHS reports that have been completed. For OIF, CHPPM is required  to provide a quarterly summary report to the commander of U.S. Central  Command on the deployed military services’ compliance with deployment  OEHS reporting requirements.
section_title: Uses of Deployment OEHS Reports
paragraphs: During deployments, military commanders can use deployment OEHS  reports completed and maintained by preventive medicine units to identify  occupational and environmental health hazards and to help guide their  risk management decision making. Commanders use an operational risk  management process to estimate health risks based on both the severity of  the risks to servicemembers and the likelihood of encountering specific  hazards. The operational risk management process, which varies slightly  across the services, includes  risk assessment, including hazard identification, to describe and  measure the potential hazards at a location;  risk control and mitigation activities intended to reduce potential   risk communication efforts to make servicemembers aware of possible  exposures, any risks to health that the exposures may pose, the  countermeasures to be employed to mitigate exposure or disease, and  any necessary medical measures or follow-up required during or after  the deployment.
Commanders balance the risk to servicemembers of encountering  occupational and environmental health hazards while deployed, even  following mitigation efforts, against the need to accomplish specific  mission requirements.
Along with health encounter and servicemember location data, archived  deployment OEHS reports are needed by researchers to conduct  epidemiologic studies on the long-term health issues of deployed  servicemembers. These data are needed, for example, by VA, which in 2002  expanded the scope of its health research to include research on the  potential long-term health effects of hazardous military deployments on  servicemembers. In a letter to the Secretary of Defense in 2003, VA said it  was important for DOD to collect adequate health and exposure data from  deployed servicemembers to ensure VA’s ability to provide veterans’ health  care and disability compensation. VA noted in the letter that much of the  controversy over the health problems of veterans who fought in the 1991  Persian Gulf War could have been avoided had more extensive surveillance  data been collected. VA asked in the letter that it be allowed access to any  unclassified data collected during deployments on the possible exposure of  servicemembers to environmental hazards of all kinds.
section_title: Deployed Military Services Use Varying Approaches to Collect OEHS Data and Have Not Submitted All OEHS Reports for OIF
paragraphs: The deployed military services generally have collected and reported OEHS  data for OIF, as required by DOD policy. However, the deployed military  services have not used all of the same OEHS data collection standards and  practices, because each service has its own authority to implement broad  DOD policies. To increase data collection uniformity, the Joint  Environmental Surveillance Working Group has made some progress in  devising cross-service standards and practices for some OEHS activities. In  addition, the deployed military services have not submitted all of the OEHS  reports they have completed for OIF to CHPPM’s centralized archive, as  required by DOD policy. However, CHPPM officials said that they could not  measure the magnitude of noncompliance because they have not received  all of the required quarterly consolidated lists of OEHS reports that have  been completed. To improve OEHS reporting compliance, DOD officials  said they were revising an existing policy to add additional and more  specific OEHS requirements.
subsections: section_title: Data Collection Standards and Practices Vary by Service, Although Preliminary Efforts Are Under Way to Increase Uniformity
paragraphs: OEHS data collection standards and practices have varied among the  military services because each service has its own authority to implement  broad DOD policies and the services have taken somewhat different  approaches. For example, although one water monitoring standard has  been adopted by all military services, the services have different standards  for both air and soil monitoring. As a result, for similar OEHS events,  preventive medicine units may collect and report different types of data.  Each military service’s OEHS practices for implementing data collection  standards also have differed, due to the varying levels of training and  expertise among the service’s preventive medicine units. For example,  CHPPM officials said that Air Force and Navy preventive medicine units  had more specialized personnel with a narrower focus on specific OEHS  activities than Army preventive medicine units, which included more  generalist personnel who conducted a broader range of OEHS activities.  Air Force preventive medicine units generally have included a flight  surgeon, a public health officer, and bioenvironmental engineers. Navy  preventive medicine units generally have included a preventive medicine  physician, an industrial hygienist, a microbiologist, and an entomologist. In  contrast, Army preventive medicine unit personnel generally have  consisted of environmental science officers and technicians.
DOD officials also said other issues could contribute to differences in data  collected during OIF. DHSD officials said that variation in OEHS data  collection practices could occur as a result of resource limitations during a  deployment. For example, some preventive medicine units may not be fully  staffed at some bases. A Navy official also said that OEHS data collection  can vary as different commanders set guidelines for implementing OEHS  activities in the deployment theater.
To increase the uniformity of OEHS standards and practices for  deployments, the military services have made some progress—particularly  in the last 2 years—through their collaboration as members of the Joint  Environmental Surveillance Working Group. For example, the working  group has developed a uniform standard, which has been adopted by all the  military services, for conducting environmental health site assessments,  which are a type of baseline OEHS report. These assessments have been  used in OIF to evaluate potential environmental exposures that could have  an impact on the health of deployed servicemembers and determine the  types of routine OEHS monitoring that should be conducted. Also, within  the working group, three subgroups—laboratory, field water, and  equipment—have been formed to foster the exchange of information  among the military services in developing uniform joint OEHS standards  and practices for deployments. For example, DHSD officials said the  equipment subgroup has been working collaboratively to determine the  best OEHS instruments to use for a particular type of location in a  deployment. Another effort by the working group included devising a joint  standard for the amount of OEHS data needed to sufficiently determine the  severity of potential health hazards at a site. However, DOD officials  estimated in late 2004 that it would take 2 years or more for this standard to  be completed and approved.
section_title: Deployed Military Services Have Not Submitted All Required OEHS Reports for OIF, and the Magnitude of Noncompliance Is Unknown
paragraphs: The deployed military services have not submitted all the OEHS reports  that the preventive medicine units completed during OIF to CHPPM for  archiving, according to CHPPM officials. Since January 2004, CHPPM has  compiled four summary reports that included data on the number of OEHS  reports submitted to CHPPM’s archive for OIF. However, these summary  reports have not provided information on the actual magnitude of  noncompliance with report submission requirements because CHPPM has  not received all consolidated lists of completed OEHS reports that should  be submitted quarterly. These consolidated lists were intended to provide a  key inventory of all OEHS reports that had been completed during OIF.  Because there are no requirements on the specific number or type of OEHS  reports that must be created for each base, the quarterly consolidated lists  are CHPPM’s only means of assessing compliance with OEHS report  submission requirements. Our analysis of data supporting the four  summary reports found that, overall, 239 of the 277 bases had at least  one OEHS baseline (139) or routine (211) report submitted to CHPPM’s  centralized archive through December 2004.
DOD officials suggested several obstacles that may have hindered OEHS  reporting compliance during OIF. For example, CHPPM officials said there  are other, higher priority operational demands that commanders must  address during a deployment, so OEHS report submission may be a lower  priority. In addition, CHPPM officials said that some of the deployed  military services’ preventive medicine units might not understand the types  of OEHS reports to be submitted or might view them as an additional  paperwork burden. CHPPM and other DOD officials added that some  preventive medicine units might have limited access to communication  equipment to send reports to CHPPM for archiving. CHPPM officials also  said that while they had the sole archiving responsibility, CHPPM did not  have the authority to enforce OEHS reporting compliance for OIF; this  authority rests with the Joint Staff and the commander in charge of the  deployment.
DOD has several efforts under way to improve OEHS reporting  compliance. CHPPM officials said they have increased communication  with deployed preventive medicine units and have facilitated coordination  among each service’s preventive medicine units prior to deployment.  CHPPM has also conducted additional OEHS training for some preventive  medicine units prior to deployment, including both refresher courses and  information about potential hazards specific to the locations where the  units were being deployed. In addition, DHSD officials said they were  revising an existing policy (DOD Instruction 6490.3; see table 1) to add  additional and more specific OEHS requirements. However, at the time of  our review, a draft of the revision had not been released and, therefore,  specific details about these revisions were not available.
section_title: Progress Made in Using OEHS Reports to Address Immediate Health Risks, Though Limitations Remain for Addressing Both Immediate and Long-term Health Issues
paragraphs: DOD has made progress using OEHS reports to address immediate health  risks during OIF, but limitations remain in employing these reports to  address both immediate and long-term health issues. During OIF, OEHS  reports have been used as part of operational risk management activities  intended to assess, mitigate, and communicate to servicemembers any  potential hazards at a location. While there have been no systematic efforts  by DOD or the military services to establish a system to monitor the  implementation of OEHS risk management activities, DHSD officials said  relatively low rates of disease and nonbattle injury in OIF were considered  an indication of OEHS effectiveness. In addition, DOD’s centralized archive  of OEHS reports for OIF is limited in its ability to provide information on  the potential long-term health effects related to occupational and  environmental exposures for several reasons, including limited access to  most OEHS reports because of security classification, incomplete data on  servicemembers’ deployment locations, and the lack of a comprehensive  federal research plan incorporating the use of archived OEHS reports.
subsections: section_title: Progress Made in Using Deployment OEHS Data and Reports in Risk Management, but DOD Does Not Monitor Implementation of These Efforts
paragraphs: To identify and reduce the risk of immediate health hazards in OIF, all of  the military services have used preventive medicine units’ OEHS data and  reports in an operational risk management process. A DOD official said  that while DOD had begun to implement risk management to address  occupational and environmental hazards in other recent deployments, OIF  was the first major deployment to apply this process throughout the  deployed military services’ day-to-day activities, beginning at the start of  the operation. The operational risk management process includes risk  assessments of deployment locations, risk mitigation activities to limit  potential exposures, and risk communication to servicemembers and  commanders about potential hazards.
Risk Assessments. Preventive medicine units from each of the services  have generally used OEHS information and reports to develop risk  assessments that characterized known or potential hazards when new  bases were opened in OIF. CHPPM’s formal risk assessments have also  been summarized or updated to include the findings of baseline and  routine OEHS monitoring conducted while bases are occupied by  servicemembers, CHPPM officials said. During deployments,  commanders have used risk assessments to balance the identified risk  of occupational and environmental health hazards, and other  operational risks, with mission requirements. Alternatively, some  preventive medicine units have addressed hazards identified through  risk assessments without initially involving a commander. A Navy  official said that, for example, if a preventive medicine unit found  elevated bacteria levels when monitoring a drinking water purification  system, the unit would likely order that the system be shut down and  corrected and then notify the commander of the action in a summary  report of OEHS activities. Generally, OEHS risk assessments for OIF  have involved analysis of the results of air, water, or soil monitoring.  CHPPM officials said that most risk assessments that they have received  characterized locations in OIF as having a low risk of posing health  hazards to servicemembers.
Risk Control and Mitigation. Using risk assessment findings, preventive  medicine units have recommended risk control and mitigation activities  to commanders that were intended to reduce potential exposures at  specific locations. For OIF, risk control and mitigation  recommendations at bases have included such actions as modifying  work schedules, requiring individuals to wear protective equipment, and  increasing sampling to assess any changes and improve confidence in  the accuracy of the risk estimate.
Risk Communication. Risk assessment findings have also been used in  risk communication efforts, such as providing access to information on  a Web site or conducting health briefings to make servicemembers  aware of occupational and environmental health risks during a  deployment and the recommended efforts to control or mitigate those  risks, including the need for medical follow-up. Many of the risk  assessments for OIF we reviewed recommended that health risks be  communicated to servicemembers.
The experience at Port Shuaiba, Kuwait, provides an illustration of the risk  management process. Officials determined that Port Shuaiba, which had a  moderate risk rating in numerous OEHS risk assessments, had the highest  assessed risk for potential environmental exposures identified in OIF. The  site is a deepwater port used for bringing in heavy equipment in support of  OIF, and a large number of servicemembers have been permanently or  temporarily stationed at this site. CHPPM officials said reported concerns  about air quality problems, such as sulfur dioxide emissions and  windblown dust and sand particles, and the concentration of a large  number of industrial facilities at Port Shuaiba led to this risk  characterization as a result of multiple OEHS risk assessments conducted  before and during OIF. Risk mitigation recommendations that have been  implemented at Port Shuaiba include increasing air monitoring to  continuous, 24-hour sampling; implementing the use of standard protective  equipment, such as goggles and face kerchiefs; and using dust suppression  measures, such as laying gravel over the entire location to reduce dust.  CHPPM officials said they were uncertain whether some other risk  mitigation recommendations for Port Shuaiba had been implemented, such  as requiring servicemembers to stay inside buildings or tents as much as  possible when air pollution levels are high or increasing the number of  servicemembers available for operations to reduce the duration of shifts.  On the basis of recommendations from the risk assessments, military  officials have been attempting to transfer the activities at Port Shuaiba to a  nearby port that does not have industrial facilities, but servicemembers  have continued to live and work at the site, though in greatly reduced  numbers, CHPPM officials said. CHPPM officials said they have  recommended extensive risk communication activities at Port Shuaiba,  including providing information to servicemembers in town hall meetings  and through posters and handouts in dining facilities. In addition, CHPPM  officials said they have worked with commanders to allow CHPPM to  provide briefings about the identified and potential health hazards as soon  as new military units arrive at Port Shuaiba.
While risk management activities have become more widespread in OIF  compared with previous deployments, DOD officials have not conducted  systematic monitoring of deployed military services’ efforts to conduct  OEHS risk management activities. As of March 2005, neither DOD nor the  military services had established a system to examine whether required  risk assessments had been conducted, or to record and track resulting  recommendations for risk mitigation or risk communication activities. In  the absence of a systematic monitoring process, CHPPM officials said they  conducted ad hoc reviews of implementation of risk management  recommendations for sites where continued, widespread OEHS monitoring  has occurred, such as at Port Shuaiba and other locations with elevated  risks. DHSD officials said they have initiated planning for a comprehensive  quality assurance program for deployment health that would address OEHS  risk management, but the program was still under development.
DHSD and military service officials said that developing a monitoring  system for risk management activities would face several challenges. In  response to recommendations for risk mitigation and risk communication  activities, commanders may have issued written orders and guidance that  were not always stored in a centralized, permanent database that could be  used to track risk management activities. Additionally, DHSD officials told  us that risk management decisions have sometimes been recorded in  commanders’ personal journals or diaries, rather than issued as orders that  could be stored in a centralized, permanent database.
In lieu of a monitoring system, DHSD officials said the rates of disease and  nonbattle injury in OIF are considered by DOD as a general measure or  indicator of OEHS effectiveness. As of January 2005, OIF had a 4 percent  total disease and nonbattle injury rate—in other words, an average of 4  percent of servicemembers deployed in support of OIF had been seen by  medical units for an injury or illness in any given week. This rate is the  lowest DOD has ever documented for a major deployment, according to  DHSD officials. For example, the total disease and nonbattle injury rate for  the 1991 Gulf War was about 6.5 percent, and the total rate for Operation  Enduring Freedom in Central Asia has been about 5 percent. However,  while this indicator provides general information on servicemembers’  health status, it is not directly linked to specific OEHS activities and  therefore is not a clear measure of their effectiveness.
section_title: Access to Most Archived OEHS Reports Is Limited by Security Classification
paragraphs: Access to archived OEHS reports by VA, medical professionals, and  interested researchers has been limited by the security classification of  most OEHS reports. Typically, OEHS reports are classified if the specific  location where monitoring activities occur is identified. VA officials said  they would like to have access to OEHS reports in order to ensure  appropriate postwar health care and disability compensation for veterans,  and to assist in future research studies. However, VA officials said that they  did not expect access to OEHS reports to improve until OIF has ended  because of security concerns.
Although access to OEHS reports has been restricted, VA officials said they  have tried to anticipate likely occupational and environmental health  concerns for OIF based on experience from the 1991 Persian Gulf War and  on CHPPM’s research on the medical and environmental health conditions  that exist or might develop in the region. Using this information, VA has  developed study guides for physicians on such topics as health effects from  radiation and traumatic brain injury and also has written letters for OIF  veterans about these issues.
DOD has begun reviewing classification policies for OEHS reports, as  required by the Ronald W. Reagan National Defense Authorization Act for  Fiscal Year 2005. A DHSD official said that DOD’s newly created Joint  Medical Readiness Oversight Committee is expected to review ways to  reduce or limit the classification of data, including data that are potentially  useful for monitoring and assessing the health of servicemembers who  have been exposed to occupational or environmental hazards during  deployments.
section_title: Difficulties Exist in Linking Archived OEHS Reports to Individual Servicemembers, but Some Efforts Are Under Way to Include Information in Medical Records
paragraphs: Linking OEHS reports from the archive to individual servicemembers will  be difficult because DOD’s centralized tracking database for recording  servicemembers’ deployment locations currently does not contain  complete or comparable data. In May 1997, we reported that the ability to  track the movement of individual servicemembers within the theater is  important for accurately identifying exposures of servicemembers to  health hazards. However, DMDC’s centralized database has continued to  experience problems in obtaining complete, comparable data from the  services on the location of servicemembers during deployments, as  required by DOD policies. DMDC officials said the military services had  not reported location data for all servicemembers for OIF. As of October  2004, the Army, Air Force, and Marine Corps each had submitted location  data for approximately 80 percent of their deployed servicemembers, and  the Navy had submitted location data for about 60 percent of its deployed  servicemembers. Additionally, the specificity of location data has varied  by service. For example, the Marine Corps has provided location of  servicemembers only by country, whereas each of the other military  services has provided more detailed location information for some of their  servicemembers, such as base camp name or grid coordinate locations.  Furthermore, the military services did not begin providing detailed location  data until OIF had been ongoing for several months.
DHSD officials said they have been revising an existing policy to provide  additional requirements for location data that are collected by the military  services, such as a daily location record with grid coordinates or latitude  and longitude coordinates for all servicemembers. Though the revised  policy has not been published, as of May 2005 the Army and the Marine  Corps had implemented a new joint location database in support of OIF  that addresses these revisions.
During OIF, some efforts have been made to include information about  specific incidents of potential and actual exposure to occupational or  environmental health hazards in the medical records of servicemembers  who may be affected. According to DOD officials, after preventive  medicine units have investigated incidents involving potential exposure,  they generally have developed narrative summaries of events and the  results of any medical procedures for inclusion in affected  servicemembers’ medical records. Additionally, rosters were generally  developed of servicemembers directly affected and of servicemembers  who did not have any acute symptoms but were in the vicinity of the  incident. For example, in investigating an incident involving a chemical  agent used in an improvised explosive device, CHPPM officials said that  two soldiers who were directly involved were treated at a medical clinic,  and their treatment and the exposure were recorded in their medical  records. Although 31 servicemembers who were providing security in the  area were asymptomatic, doctors were documenting this potential  exposure in their medical records.
In addition, the military services have taken some steps to include  summaries of potential exposures to occupational and environmental  health hazards in the medical records of servicemembers deployed to  specific locations. The Air Force has created summaries of these hazards at  deployed air bases and has required that these be placed in the medical  records of all Air Force servicemembers stationed at these bases. (See app.  II for an example.) However, Air Force officials said no follow-up activities  have been conducted specifically to determine whether all Air Force  servicemembers have had the summaries placed in their medical records.  In addition, the Army and Navy jointly created a summary of potential  exposure for the medical records of servicemembers stationed at Port  Shuaiba. Since December 2004, port officials have made efforts to make the  summary available to servicemembers stationed at Port Shuaiba so that  these servicemembers can include the summary in their medical records.  However, there has been no effort to retroactively include the summary in  the medical records of servicemembers stationed at the port prior to that  time.
section_title: No Federal Research Plan Exists for Using OEHS Reports to Follow the Health of OIF Servicemembers over Time
paragraphs: According to DOD and VA officials, no federal research plan that includes  the use of archived OEHS reports has been developed to evaluate the long- term health of servicemembers deployed in support of OIF, including the  effects of potential exposure to occupational or environmental hazards. In  February 1998 we noted that the federal government lacked a proactive  strategy to conduct research into Gulf War veterans’ health problems and  suggested that delays in planning complicated researchers’ tasks by  limiting opportunities to collect critical data. However, the Deployment  Health Working Group, a federal interagency body responsible for  coordinating research on all hazardous deployments, recently began  discussions on the first steps needed to develop a research plan for OIF.  At its January 2005 meeting, the working group tasked its research  subcommittee to develop a complete list of research projects currently  under way that may be related to OIF. VA officials noted that because OIF  is ongoing, the working group would have to determine how to address a  study population that changes as the number of servicemembers deployed  in support of OIF changes.
Although no coordinated federal research plan has been developed, there  are some separate federal research studies under way that may follow the  health of OIF servicemembers. For example, in 2000 VA and DOD  collaborated to develop the Millennium Cohort study, a 21-year longitudinal  study evaluating the health of both deployed and nondeployed military  personnel throughout their military careers and after leaving military  service. According to the principal investigator, the Millennium Cohort  study was designed to examine the health effects of specific deployments if  enough servicemembers in that deployment enrolled in the study. However,  the principal investigator said that as of February 2005 researchers had not  identified how many servicemembers deployed in support of OIF had  enrolled in the study. Additionally, a VA researcher has received funding to  study mortality rates among OIF servicemembers. According to the  researcher, if occupational and environmental data are available, the study  will include the evaluation of mortality outcomes in relation to potential  exposure for OIF servicemembers.
section_title: Conclusions
paragraphs: Since the 1991 Persian Gulf War, DOD has made progress in improving  occupational and environmental health data collection through its  development of a militarywide health surveillance framework for use  during deployments. However, these efforts still could be strengthened.  OEHS data that the deployed military services have collected during OIF  may not always be comparable because of variations among the services’  data collection standards and practices. As a result of these variations, the  amount and comprehensiveness of data for servicemembers from one  military service may be more extensive than for servicemembers from  another service. Additionally, the deployed military services’ uncertain  compliance with OEHS report submission requirements casts doubts on  the completeness of CHPPM’s OEHS archive. These data shortcomings, in  conjunction with the incomplete data in DOD’s centralized tracking  database of servicemembers’ deployment locations, limit CHPPM’s ability  to respond to requests for OEHS information about possible exposure to  occupational and environmental health hazards of those who are serving or  have served in OIF. Other limitations may also impede the  comprehensiveness of the archived OEHS reports, including the inability to  collect OEHS data outside of base camps and a lack of knowledge of all  potential health hazards. Nonetheless, these limitations do not outweigh  the need to collect data on known or expected hazards in order to make  every effort to address potential health issues. DHSD officials have said  they are revising an existing policy on OEHS data collection and reporting  to add additional and more specific OEHS requirements. However, unless  the military services take measures to direct those responsible for OEHS  activities to proactively implement the new requirements, the services’  efforts to collect and report OEHS data may not improve.
DOD’s risk management efforts during OIF represent a positive step in  helping to mitigate potential environmental and occupational risks of  deployment. But the effects of such efforts are unknown without  systematic monitoring of the deployed military services’ implementation  activities. Rates of disease and nonbattle injury have been used as an  overall surrogate outcome measure for risk management in OIF, but DOD  and the military services currently are unable to ascertain how and to what  extent risk management efforts have contributed to the relatively low  disease and nonbattle injury rate for OIF.
Although OEHS reports alone are not sufficient to identify the causes of  potential long-term health effects in deployed servicemembers, they are an  integral component of research to evaluate the long-term health of  deployed servicemembers. However, efforts by a joint DOD and VA  working group to develop a federal research plan for OIF that would  include examining the effects of potential exposure to occupational and  environmental health hazards have just begun, despite similarities in  deployment location to the 1991 Persian Gulf War. Unless DOD addresses  OEHS data collection and reporting weaknesses and develops a federal  research plan for OIF with VA, the departments ultimately may face the  same criticisms they faced following the first Gulf War over their inability  to adequately address the long-term health issues of servicemembers.
section_title: Recommendations for Executive Action
paragraphs: We are making recommendations aimed at improving the collection and  reporting of OEHS data during deployments and improving OEHS risk  management. To improve the collection and reporting of OEHS data during  deployments and the linking of OEHS reports to servicemembers, we  recommend that the Secretary of Defense ensure that cross-service  guidance is created to implement DOD’s policy, once that policy has been  revised, which addresses improvements to conducting OEHS activities and  to reporting the locations of servicemembers during deployment.
To improve the use of OEHS reports to address the immediate health risks  of servicemembers during deployments, we recommend that the Secretary  of Defense ensure that the military services jointly establish and implement  procedures to evaluate the effectiveness of risk management efforts.
To better anticipate and understand the potential long-term health effects  of deployment in support of OIF, we recommend that the Secretary of  Defense and the Secretary of Veterans Affairs work together to develop a  federal research plan to follow the health of these servicemembers that  would include the use of archived OEHS reports.
section_title: Agency Comments and Our Evaluation
paragraphs: We requested comments on a draft of this report from DOD and VA. Both  agencies provided written comments that are reprinted in appendixes III  and IV. DOD also provided technical comments that we incorporated where  appropriate.
In commenting on this draft, DOD did not concur with our  recommendation that the military services jointly develop implementation  guidance for DOD’s policy on OEHS during deployments, once that policy  has been revised. However, DOD stated that officials are planning steps  that will meet the intent of our recommendation to improve the collection  and reporting of OEHS data during deployments. DHSD officials stated that  cross-service implementation guidance for the revised policy on  deployment OEHS would be developed by the Joint Staff instead of by the  individual military services, as we originally recommended. We believe that  the development of cross-service implementation guidance is a critical  element needed to improve OEHS data collection and reporting during  deployments, regardless of the entity responsible for developing this  guidance. Therefore, we modified the wording of our recommendation to  clarify our intent that joint guidance be developed.
DOD partially concurred with our recommendation that the military  services jointly establish and implement procedures to evaluate the  effectiveness of risk management efforts. DOD stated that OEHS reports  would be of no value for “immediate” health risks, except for incident- driven reports, and assumed that we were referring to health risks that may  occur once servicemembers return from a deployment. However, our  findings describe the OEHS operational risk management process that is  specifically conducted during a deployment, including risk assessment, risk  mitigation, and risk communication activities that are used to identify and  reduce the risk of immediate health hazards. Additionally, DOD stated that  it has procedures in place to evaluate OEHS risk management through a  jointly established and implemented lessons learned process. Because the  lessons learned process was not raised by agency officials during our  review, we did not determine whether it would systematically monitor or  evaluate the effectiveness of OEHS risk management activities. However,  in further discussions, DHSD officials told us that they were not aware of  any lessons learned reports related to OEHS risk management for OIF.
DOD partially concurs with our recommendation that DOD and VA work  together to develop a federal research plan to follow the health of  servicemembers deployed in support of OIF that would include the use of  archived OEHS reports. Although DOD states that it agrees with the  importance of following the health of its servicemembers, its response  focuses on initiatives for the electronic exchange of clinical health  information with VA. In further discussions, DHSD officials explained that  analysis of this clinical information could lead to the development of  research hypotheses and, ultimately, research questions that would guide  federal health research. Although DOD officials stated that they have not  yet linked any occupational or environmental exposures to specific adverse  health effects, there is no certainty that long-term health effects related to  these types of exposures will not appear in veterans of OIF. Federal  research has not clearly identified the causes of unexplained illnesses  reported by servicemembers who served in the 1991 Persian Gulf War, and  OIF servicemembers are serving in the same region for longer periods of  time.
Separately, VA concurred with our recommendation to work jointly with  DOD to develop a federal research plan to follow the health of OIF  servicemembers. VA confirmed that the Deployment Health Working  Group, which includes DOD officials, had initiated steps in January 2005  toward developing a comprehensive joint federal surveillance plan to  evaluate the long-term health of servicemembers returning from both OIF  and Operation Enduring Freedom (OEF). However, more importantly, the  difference in VA and DOD’s responses to this recommendation illustrates a  disconnect between each agency’s understanding of whether and how such  a federal research plan should be established. Therefore, continued  collaboration between the agencies to formulate a mutually agreeable  process for proactively creating a federal research plan would be beneficial  in facilitating both agencies’ ability to anticipate and understand the  potential long-term health effects related to OIF deployment versus taking  a more reactive stance in waiting to see what types of health problems may  surface.
In its response, VA also contends that we overstate problems related to its  ability to access DOD’s classified occupational and environmental health  data. VA notes that it has staff with the necessary security clearances to  examine classified OEHS reports, so that there is no barrier to access.  However, during our review VA officials expressed concerns that they did  not have OEHS data and that access to the data was difficult. Even if VA  staff have security clearances that enable them to examine OEHS data, any  materials that arise from the use of classified documents, such as research  papers or other publications, would likely be restricted. Therefore, these  results would have limited use, as they cannot be broadly shared with other  researchers and the general public. Nonetheless, VA maintains that  development of a systematic method to tabulate and organize the exposure  data is needed, as is a complete roster of OIF and OEF veterans, pre- and  post-deployment health screening data, and a complete roster of the most  seriously injured veterans. We agree that a systematic method to organize  and share OEHS data is important. This issue could be addressed within  the efforts to develop a federal research plan.
As arranged with your office, unless you release its contents earlier, we  plan no further distribution of this report until 30 days after its issuance  date. At that time, we will send copies of this report to the Secretary of  Defense and the Secretary of Veterans Affairs. We will also provide copies  to others upon request. In addition, the report will be available at no charge  on GAO’s Web site at http://www.gao.gov.
If you or your staff has any questions about this report, please call me at  (202) 512-7119. Bonnie Anderson, Karen Doran, John Oh, Danielle Organek,  and Roseanne Price also made key contributions to this report.
section_title: Scope and Methodology
paragraphs: To describe how the military services have implemented the Department of  Defense’s (DOD) policies for collecting and reporting occupational and  environmental health surveillance (OEHS) data for Operation Iraqi  Freedom (OIF), we reviewed pertinent DOD policies and military services’  guidance that delineated the requirements for OEHS data collection and  reporting. We interviewed officials at the Deployment Health Support  Directorate (DHSD) and the Joint Staff to obtain a broad overview of  DOD’s OEHS activities in OIF. We also interviewed officials at each of the  military services’ health centers—the U.S. Army Center for Health  Promotion and Preventive Medicine (CHPPM), the Navy Environmental  Health Center, and the Air Force Institute for Operational Health—to  obtain information about each service’s OEHS data collection standards  and practices, training of preventive medicine units for OIF, obstacles that  could hinder OEHS data collection and reporting, and efforts to improve  reporting compliance. Additionally, we interviewed members of the Joint  Environmental Surveillance Working Group to discuss the purpose and  structure of the working group and efforts related to increasing the  uniformity of OEHS standards and practices for deployments.
To determine if the military services were submitting OEHS reports to  CHPPM’s centralized archive, we obtained and reviewed CHPPM’s  quarterly summary reports, which provided the total number of bases that  have submitted at least one report in each of the categories of baseline,  routine, or incident-driven reports for the U.S. Central Command’s  (CENTCOM) area of responsibility, details about consolidated lists of  reports, and information about other OEHS reporting compliance issues.  The summary reports did not show report submission by individual bases  or, other than for the first summary report, separately identify OIF bases  from all others in the CENTCOM area of responsibility. For each of the  summary reports, CHPPM provided us with supporting documents that  included lists of the bases specific to OIF and, for each base, whether it had  submitted baseline, routine, or incident-driven reports. We attempted to  include only unique OIF bases in our analysis; however, CHPPM officials  told us that a few duplicate OIF bases may be included in our analysis due  to reasons such as frequent base openings and closures and base name  changes. We used these supporting documents to identify the number and  percentage of bases with and without baseline or routine reports during the  reporting periods. Incident-driven reports reflect OEHS investigations of  unexpected incidents and would not be submitted to CHPPM’s archive  according to any identified pattern. Therefore, we did not review the  services’ submission of incident-driven reports. Because OEHS reports  generally are classified, we did not report on the specifics contained in  these reports.
We determined that the data from CHPPM’s OEHS archive were sufficiently  reliable for the purposes of this report by (1) confirming the data included  the elements that we requested and were consistent with provided  documentation and (2) conducting detailed fact-finding interviews with  CHPPM officials to understand how the data were obtained and to  determine the limitations of the data. To characterize the OEHS reports for  OIF submitted to CHPPM, we discussed the numbers of reports submitted  and characterized the categories of reports using percentages. While the  OEHS reports were contained in a computerized archive, there was no  formal database in which the information from the reports could have been  extracted into data fields. Instead, the archived reports were Microsoft  Word documents, Microsoft Excel spreadsheets, Adobe Acrobat files,  scanned images, or e-mail text that were organized by either military base  or type of report. Therefore, there was no specific database with data fields  that could be examined through a data reliability test.
To identify the efforts to use OEHS reports to address the more immediate  health issues of servicemembers deployed in support of OIF, we reviewed  DOD policies and documents describing the operational risk management  process. Additionally, we reviewed 28 risk assessment reports and the risk  mitigation efforts and risk communication activities that resulted from  these assessments. We also reviewed and summarized risk management  activities for Port Shuaiba, Kuwait. We interviewed officials from CHPPM  responsible for OEHS risk management activities at Port Shuaiba and  discussed quality assurance efforts related to these activities. We also  interviewed officials from DHSD about additional OEHS-related quality  assurance programs.
To identify the efforts under way to use OEHS reports to address the long- term health issues of servicemembers deployed in support of OIF, we  interviewed Department of Veterans Affairs (VA) and DOD officials to  examine access to OEHS reports and use of OEHS reports for VA, and  reviewed laws relating to classification of documents. Additionally, we  reviewed relevant VA documents to determine the ways in which VA can  use OEHS reports and to determine its efforts to anticipate OEHS issues.
To determine the difficulties in linking OEHS reports to the individual  records of servicemembers, we interviewed officials and military  representatives at DOD’s Defense Manpower Data Center (DMDC)  regarding the status of the Contingency Tracking System, a centralized  tracking database to identify deployed servicemembers and track their  movements within the theater of operations. To help identify problems with  this system, we asked DMDC to provide information about the amount of  location data submitted by each military service to this database. To assess  the reliability of the data submitted by each military service, we (1)  interviewed DMDC officials about limitations of the system and (2)  confirmed that the data included the elements we requested and were  consistent with provided documentation. We tested the data electronically  to ensure that the numbers were accurately calculated. Given our research  questions and discussions with DMCD officials regarding the centralized  system, we determined that these data were reliable for our purposes.
We interviewed CHPPM officials to examine efforts to include information  from investigations of potential exposures to occupational and  environmental health hazards in servicemembers’ medical records, and  reviewed summary documents related to potential occupational and  environmental exposures. We also interviewed Army, Air Force, and Navy  officials to discuss these summary documents and determine efforts in  place to ensure that these documents were placed in the medical records.  We also examined other documents, including DOD policies, federal laws,  and interagency coordinating council meeting minutes relating to OEHS.
We interviewed DOD and VA officials to determine whether a federal  research plan using OEHS reports had been developed to evaluate the long- term health of servicemembers deployed in support of OIF. We also  reviewed documents, including the meeting minutes of an interagency  group and documents relating to a current collaborative study between  DOD and VA. We performed our work from September 2004 through June  2005 in accordance with generally accepted government auditing  standards.
section_title: Example of an Occupational and Environmental Health Surveillance Summary Created by the Air Force during Operation Iraqi Freedom
paragraphs: SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each  entry)
ENVIRO NMENTAL/OCCUPAT IONAL  HEAL TH WORK PLACE  EXPOSURE  DATA  This a sse ssm ent covers individuals deployed to BAGHDAD AIR B ASE  (BDAB), IRAQ  for the time period 15 DEC 03 to 30 APR 2004.
Purpose:    To  comply  with  the  deployment  health  surveillan ce  requirements  of  Presidential  Review  Directive  5  and  JCSM  0006-02,  Updated  Procedures  for  Deployment  Health  Surveillan ce  and  Readiness.    CENTAF/SG  officially  sanctions  use  of  this  form  and  recommends it be maintained in the individual s permanent medical record with the  DD Form 2796, Post Deployment Health  Assessment, covering the same time period.
Camps Sather and Griffin, the primary AF locations on Baghdad International A irport (BIAP), were part of the Iraqi Military Training  portion  of  BIAP.    However,  this  specific  area  was  not  heavily  used.    The  small  Iraqi  terminal  on  site  was  for  military  guests  and  distinguished visitors.  Base housing and training was on the other side of the main road outside Camp Sather.  While there is farming  around  BIAP,  we  are  not  aware  of  any  specific  farming  activities  within  Camp  Sather;  however,  there  is  evidence  of  flooded  fields  in/around Camp Griffin.  We are als o not aware of any major spills  within the BIAP AF cantonment.   BDAB   refers to both Camps  Sather and Griffin.
SSN/ID NO.
REGISTER NO.
WARD NO.
Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE  STANDARD FORM 600 (REV. 6-97)
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each  entry)
ENVIRO NMENTAL/OCCUPAT IONAL  HEAL TH WORK PLACE  EXPOSURE  DATA (continued)  medical record, individual reported no adverse contact (i.e. bites).  Feral cats and dogs have als o been noted in the area.  Rats and mice   have been a nuisance; one rat bite was reported in the summer of 2003.  6.    Waste  Sites/Was te  Disposal:    Hazar dous  waste  storage  on  BDAB  is limited to used and off-spec POL products, and small s pill  cleanup residue.  Currently, proper handling, storage, and disposal of industrial waste generated on base (mainly oil, fuel and hydraulic  fluid) are strictly enforced.  Airborne exposure to base personnel from stored waste is assessed as minimal to nonexistent.  No obvious  signs of significant past spills  or tank leakage were noted when coalition forces occupied BIAP, although POL personnel did drain and  remove several ex tant tanks.  Trash and garbage are containerized and routinely collected by contractors.  Latrines are pumped out by  trucks and waste is disposed off-BIAP.    7.  Nuclear, Biological or Chemical (NBC) Weapon Exposure:   There has been no evidence of any use, storage, release, or ex posure  of NBC agents to personnel at this site.  8.  Agricultural Emissions:  Surrounding land is moderately agricultural.  Many farms are within 1-2 miles of the perimeter fence,  with  numerous  potentially  flooded  fields  for  rice  cultivation.    Aerial  photos  previous  to  May  2003  revealed  that  much  of  BIAP,  including  parts  of  the  AF  cantonment,  were  rice  cultivation  areas.    While  we  haven t  witnessed  any  significant  application,  herbicide/pesticide  use  probably  routinely  occurs  just  outside  the  base.    However,  airborne  exposure  to  base  personnel  is  assessed  as  minimal to nonexistent.  .  Depleted Uranium (DU):  DU is a component of some aircraft present and/or transient on/through BDAB.  There is no evidence of  DU munitions having been expended at BIAP.  Therefore, there is no potential air borne exposure to DU.  Exposure is classified as far  below permissible exposure levels.  10.    Hazardous  Materia ls:    There  are  only  a  few  permanent  structures  on  BDAB.    Both  lead-based  paint  and  potential  as bestos- containing material have been tentatively identified in various locations on BIAP; however, personnel are not performing activities that  involve  routine  exposure,  thereby  minimizin g  health  risk.    There  were  multiple  sites  where  Iraqi  hazar dous  materials   caches  were  located; however, personnel exposures were minimize d/eliminated by removing or limiting access to the materials .
Occupational Exposure Data and Risk Asse ssment:  1.  Noise:  Aircraft, aircraft ground equipment, generators and other equipment produce hazar dous noise.  Workers routinely exposed to  hazar dous noise are those working on or near the flight line and/or in selected industrial  shops.  These workers have comparable noise  exposure at home station and are on the hearing conservation program.  For all in dividuals, appropriate hearing protection is provided  for protection again st hazar dous noise.  Additionally, the whole of Camp Sather is within 300 yards of an extremely active flightline.  2.  Heat Stress:  Daily temperature range: Mar - Oct from 75 F  to 125 F ; Nov - Feb from 55 F to 95 F.  Personnel are continually  educated  on  heat  stress  dangers,  water  intake  and  work/rest  cycles.    Unless  separately  documented,  individual  had  no  heat  related  injury.   3.    Airborne  Exposure  to  Chemical  Hazards:    Unless  sp ecified  in  a  duty-specific  supplement,  individual  exposure  to  chemical  inhalation is considered similar  to duties performed at home station.  On base industrial ac tivities include routine aircraft, equipment  and  installatio n  maintenance.  Generally, majority of the chemicals  used on BDAB are oils, greases, lubricants, hydraulic fluids a nd  fuel.  Little to no corrosion control activities are performed and no solvent tanks exist on site.  No industrial ac tivity is performed that  generates, or has been expected to generate, airborne exposures above  permissible exposure levels or medical action levels.  4.  Chemical Contact and Eye Protection:  Unless sp ecified in a job-specific supplement, individual exposure to chemical contact is  considered  similar   to  duties  performed  at  home  station.    Workers  are  provided  appropriate  protective  equipment  (i.e.  nitrile/rubber  gloves, goggles, safety glasses and face s hields) when and where needed.  5.  Radiation:  Ionizing radiation is emitted from medical/dental x-ray and OSI operations, and low-level radioactive materials  present  in equipment such as chemical ag ent monitors and alar ms.  No worker has been identified as exceed ing 10% of the 5 REM/year OSHA  permissible  exposure  level.    Radio  frequency  (RF)  radiation  is  emitted  from  multiple  radar  systems  and  communication  equipment.  Systems are marked with warning signs and communication workers recei ve appropriate training.  Unless otherwise documented, no  worker has been identified as ex ceed ing RF-radiation permissible ex posure limits.  Significant UV radiation from the sun is expected on  exposed  unprotected  skin.    BDAB  personnel  have  been  advised  to minimize  sun exposure through the use of sunscreen and wear of  sleeves down.  Additionally, BDAB is a high light level environment.  Many cases of photosensitivity dermatitis were observed.  Some  were  no  doubt  exacerbated  by  the  use  of  doxycycline for malaria prophylaxis.  Unless otherwise stated in medical record, individual  reported no radiation/light related injuries.  6.    Er gonomics:    Individual  exposure  to  ergonomic  stress from job related duty is substantially similar  to duties performed at home  station, with potential moderate increase in lifting involved with unique deployment requirements such as erection of tents and shelters.  Unless otherwise stated in medical record, individual reported no ergonomic stress related injuries.  7.    Bloodborne  Pathogens:    Individual  exposure  to  bloodborne  pathogens  from  job  related  duty  is  considered  similar   to  duties  performed at home station.  Applicable workers are provided appropriate protective equipment and have been placed on the bloodborne  pathogen program.  Unless otherwise stated elsewhere in the medical record, individual reported no significant unprotected ex posures.
section_title: Comments from the Department of Defense
section_title: Appendix IV