Defense Health Care: Occupational and Environmental Health Surveillance Conducted During Deployments Needs Improvement
Published: 2005-07-19T00:00:00

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 a lack of servicemember health and deployment data, including 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. This testimony is based on GAO's report, entitled Defense Health Care: Improvements Needed in Occupational and Environmental Health Surveillance during Deployment to Address Immediate and Long-term Heath Issues (GAO-05-632). The testimony presents findings about how the deployed military services have implemented DOD's policies for collecting and reporting OEHS data for Operation Iraqi Freedom (OIF) and 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. 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. Moreover, DOD officials could not identify the reports they had not received to determine the extent of noncompliance. 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. OEHS reports have been used consistently during OIF as part of operational risk management activities intended to identify and address immediate health risks and to make servicemembers aware of the risks of potential exposures. While these efforts may help in reducing health risks, DOD has not systematically evaluated their implementation during OIF. 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. To address problems with linking OEHS reports to individual servicemembers, the deployed military services have tried 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. Additionally, according to DOD and Veterans Affairs (VA) officials, no federal research plan has been developed to evaluate the long-term health of servicemembers deployed in support of OIF, including the effects of potential exposures to occupational or environmental hazards. GAO's report made several recommendations, including that the Secretary of Defense improve deployment OEHS data collection and reporting and evaluate OEHS risk management activities and that the Secretaries of Defense and Veterans Affairs jointly develop a federal research plan to address long-term health effects of OIF deployment. DOD plans to take steps to meet the intent of our first recommendation and partially concurred with the other recommendations. VA concurred with our recommendation for a joint federal research plan.

section_title: Letter
paragraphs: I am pleased to be here today as you consider the efforts by the deployed  military services to implement policies for collecting and reporting  occupational and environmental health surveillance data for Operation  Iraqi Freedom (OIF) and the work under way to use these data to address  both the immediate and long-term health issues of servicemembers  deployed in support of OIF. The health effects from service in military  operations have been of increasing interest since the end of the 1991  Persian Gulf War—an interest that was renewed when servicemembers  were deployed in early 2003 to the Persian Gulf in support of OIF.  Following the 1991 Gulf War, many servicemembers reported suffering  from unexplained illnesses that they attributed to their service in the  Persian Gulf and expressed concerns about 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.
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 for use during deployments beginning in 1997. 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 specified 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. Throughout this testimony, we identify the  military services operating in a deployment as “deployed military  services.”
My remarks will summarize our findings 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. My statement is based on our  report, entitled Defense Health Care: Improvements Needed in  Occupatonal and Environmenta Hea h Surve ance during Deployments  t t GAO-05-632), which is  being released today.  o Address Immediae and Long-erm Health Issues ( To do this 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  Deployment Manpower Data Center 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 to evaluate the long-term health of  servicemembers deployed in support of OIF using OEHS reports. We  conducted our work from September 2004 through June 2005 in  accordance with generally accepted government auditing standards.
In summary, although OEHS data generally have been collected and  reported for OIF, as required by DOD policy, the deployed military  services have used different data collection methods and have not  submitted all of the OEHS reports that have been completed. Data  collection methods for air and soil surveillance have varied across the  services, for example, although they have been using the same monitoring  standard for water surveillance. Compounding these differences among  the services were varying levels of training and expertise among the  deployed military service personnel who were responsible for conducting  OEHS activities, resulting in differing practices for implementing data  collection standards. For some OEHS activities, a cross-service working  group, called the Joint Environmental Surveillance Working Group, has  been developing standards and practices to increase uniformity of data  collection among the services. In addition, the deployed military services  have not submitted to CHPPM all OEHS reports that have been completed  during OIF, as required by DOD policy. While 239 of the 277 OIF bases had  at least one OEHS report submitted to CHPPM’s centralized archive as of  December 2004, CHPPM could not measure the magnitude of  noncompliance because not all of the required consolidated lists that  identify all OEHS reports completed during each quarter in OIF had been  submitted. Therefore, CHPPM could not compare the reports that it had  received against the list of reports that had been completed. According to  CHPPM officials, obstacles to the services’ reporting compliance may have  included a lack of understanding by some within the deployed military  services about the type of OEHS reports that should have been submitted.  In addition, OEHS report submission may be given a lower priority  compared to other deployment mission activities. Also, while CHPPM is  responsible for OEHS archiving, it has no authority to enforce report  submission requirements. To improve OEHS reporting compliance, DOD  officials said they were revising an existing policy to add additional and  more specific OEHS requirements.
DOD has made progress using OEHS reports to address immediate health  risks during OIF, but limitations remain in employing these reports to  address both immediate and long-term health issues. OIF is the first major  deployment in which OEHS reports have been used consistently as part of  operational risk management activities intended to identify and address  immediate health risks. These activities included health risk assessments  that described and measured the potential hazards at a site, risk mitigation  activities intended to reduce potential exposure, and risk communication  efforts undertaken to make servicemembers aware of the possible health  risks of potential exposures. While these efforts may help reduce health  risks, there is no assurance that they have been effective because DOD has  not systematically evaluated the implementation of OEHS risk  management activities in OIF. Despite progress in the use of OEHS  information to identify and address immediate health risks, CHPPM’s  centralized archive of OEHS reports for OIF has limitations for addressing  potential long-term health effects related to occupational and  environmental exposures for several reasons. First, access to CHPPM’s  OEHS archive has been limited because most OEHS reports are  classified—which restricts their use by VA, medical professionals, and  interested researchers. Second, it will be difficult to link most OEHS  reports to individual servicemembers because not all data on  servicemembers’ deployment locations have been submitted to DOD’s  centralized tracking database. For example, none of the military services  submitted location data for the first several months of OIF. To address  problems with linking OEHS reports to individual servicemembers, the  deployed military services have made efforts to include OEHS summaries  in the medical records of some servicemembers for either specific  incidents of potential exposure or for specific locations within OIF, such  as air bases. Additionally, according to DOD and VA officials, no  comprehensive federal research plan incorporating the use of the archived  OEHS reports has been developed to address the long-term health  consequences of service in OIF.
In the report we are issuing today, we recommend that the Secretary of  Defense ensure that cross-service guidance is developed to implement  DOD’s revised policy for OEHS during deployments and ensure that the  military services jointly establish and implement procedures to evaluate  the effectiveness of risk management strategies during deployments. We  also 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 OIF servicemembers over time that would include the use of  OEHS reports. In commenting on a draft of this report, DOD stated that  cross-service guidance meeting the intent of our recommendation would  be developed by the Joint Staff instead of the military services. DOD  partially concurred with our other recommendations. VA concurred with  our recommendation to work with DOD to jointly develop a federal  research plan to follow the long-term health of OIF servicemembers.
subsections: section_title: Background
paragraphs: 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 such things as 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 exposure to identify the  potential causes of unexplained illnesses among veterans who served in  the 1991 Persian Gulf War, the federal government 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 that have guided the collection  and reporting of 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 OEHS health surveillance centers, the  Joint Staff, other DOD entities, and VA.
Each service has a health surveillance center—the 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 the  theater in order to carry out deployment OEHS activities in accordance  with DOD policy. In addition, these 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 developed by 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 location 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 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. This report also summarizes the status of OEHS  report submissions by comparing the reports CHPPM receives with the  quarterly consolidated lists from the command surgeons that list 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 the  specific hazard. 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. The operational risk  management process, which varies slightly across the services, includes  risk assessment, including hazard identification, to describe and measure  the potential hazards at a location; risk control and mitigation activities intended to reduce potential  exposures; and risk communication efforts to make servicemembers aware of possible  exposures, any risks to health that they may pose, the countermeasures to  be employed to mitigate exposure or disease outcome, and any necessary  medical measures or follow-up required during or after the deployment.
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 on servicemembers in hazardous  military deployments. 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 used different 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 because of 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.
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 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. 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 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 the revision  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 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. 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. 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, although DHSD  officials said they considered the relatively low rates of disease and  nonbattle injury in OIF 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 their 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: DOD Has Made Progress in Using Deployment OEHS Data and Reports in Risk Management but 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. 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.
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, Kuwait, a deepwater  port where a large number of servicemembers have been stationed, or  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 that DOD considers the  rates of disease and nonbattle injury in OIF 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,  because of these security concerns, they did not expect access to OEHS  reports to improve until OIF has ended.
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 or 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, the Defense Manpower Data Center’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. Data  center 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 have been affected. According to DOD officials, preventive  medicine units have been investigating incidents involving potential  exposure during the deployment. For a given incident, a narrative  summary of events and the results of any medical procedures generally  were included 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. I 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. Similarly, the Army and Navy jointly created a summary of  potential exposure for the medical records of servicemembers stationed at  Port Shuaiba, the deepwater port used for bringing in heavy equipment in  support of OIF where a large number of servicemembers have been  permanently or temporarily stationed. 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, other  separate federal research studies are underway 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. In another effort, 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: Concluding Observations
paragraphs: As we stated in our report, DOD’s efforts to collect and report OEHS data  could be strengthened. Currently, 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.  Additionally, the deployed military services’ uncertain compliance with  OEHS report submission requirements casts doubt on the completeness of  CHPPM’s OEHS archive. These data shortcomings, combined with  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. DOD 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. Consequently, we recommended that the Secretary  of Defense ensure that cross-service guidance is created to implement  DOD’s policy, once that policy has been revised, to improve the collection  and reporting of OEHS data during deployments and the linking of OEHS  reports to servicemembers. DOD responded that cross-service  implementation guidance for the revised policy on deployment OEHS  would be developed by the Joint Staff.
While DOD’s risk management efforts during OIF represent a positive step  in helping to mitigate potential environmental and occupational risks of  deployment, the lack of systematic monitoring of the deployed military  services’ implementation activities prevents full knowledge of their  effectiveness. Therefore, we recommended that the military services  jointly establish and implement procedures to evaluate the effectiveness of  risk management efforts. DOD partially concurred with our  recommendation and stated that it has procedures in place to evaluate  OEHS risk management through a jointly established and implemented  lessons learned process. However, in further discussions, DOD officials  told us that they were not aware of any lessons learned reports related to  OEHS risk management for OIF.
Furthermore, 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. As a  result, we recommended 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. DOD  partially concurred with our recommendation, and VA concurred. 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.
Mr. Chairman, this completes my prepared statement. I would be happy to  respond to any question you or other Members of the Subcommittee may  have at this time.
section_title: GAO Contact and Staff Acknowledgments
paragraphs: For further information about this testimony, please contact Marcia  Crosse at (202) 512-7119 or crossem@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on the  last page of this testimony. In addition to the contacts named above,  Bonnie Anderson, Assistant Director, Karen Doran, Beth Morrison, John  Oh, Danielle Organek, and Roseanne Price also made key contributions to  this testimony.
section_title: Appendix I: Example of an Occupational and Environmental Health Surveillance Summary Created by the Air Force
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