Defense Infrastructure: DOD Can Improve Its Response to Environmental Exposures on Military Installations
Published: 2012-05-01T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: There have been various reported incidents of individuals being potentially exposed to environmental hazards while on military installations. Indeed, some incidents, such as contaminated air due to burn pits in Afghanistan and Iraq and contaminated water at Camp Lejeune, North Carolina, have received considerable attention, and in the case of Camp Lejeune have resulted in claims seeking billions of dollars from the government.
Public Law 111-383, §314(2011) directed GAO to assess Department of Defense (DOD) policies regarding environmental exposures. GAOs objectives were to determine (1) the extent to which DOD has policies that identify and respond to environmental exposures, (2) what programs exist to provide health care or compensation to individuals for environmental exposures, and (3) which features of other federal programs may provide options in designing future compensation programs. GAO briefed the Armed Services Committees in December 2011, to satisfy the mandate. To address these objectives, GAO reviewed relevant documentation, visited installations, and interviewed relevant officials.
section_title: What GAO Found
paragraphs: DOD relies on four types of policies to identify and respond to many but not all aspects of environmental exposures: (1) environmental restoration policies address hazardous releases at military Installations; (2) occupational and environmental health policies address workplace exposures; (3) deployment health policies address the collection of occupational and environmental health data for deployed individuals; and (4) public health emergency management policies. Nonetheless, there are some limitations in the policies coverage. For example, DODs environmental restoration policies do not specify when to conduct public health assessments at its sites beyond the initial assessment of certain priority sites required by the Superfund law. In addition, DOD has not fully documented its responses to recommendations that result from the assessments. DOD officials responsible for oversight reported that they did not know what actions, if any, installations had taken on about 80 percent of the recommendations. Without a comprehensive tracking system, DOD has no assurance that it is addressing recommendations appropriately and could be missing opportunities to identify and resolve concerns about some health threats. Further, DOD has no policy guiding services and their installations on appropriate actions to address health risks from past exposures, which DOD attributes to the Superfund law not specifically requiring responsible parties to address such risks.
Although several programs potentially provide either health care or compensation to various types of individuals suffering from environmental exposures, the ability of some individuals to actually obtain benefitsparticularly compensationis often complicated by documentary, scientific, and legal factors. First, it is often difficult to document an environmental exposure because they are often not always identified at the time they occurred. Second, it is often difficult to establish causation between an environmental exposure and a health condition, because scientific research has not always established a clear link. Third, although under certain circumstances some individuals have legal standing under the Federal Tort Claims Act to file a lawsuit against the U.S. government for damages due to an environmental exposure, damages under the Federal Tort Claims Act are not available to other types of individuals, and for certain types of claims due to legal precedent or statutes.
In several cases, Congress has established alternative programs to provide compensation to specific populations exposed to specific environmental hazards, such as for individuals involved in the production of nuclear weapons and those who worked in coal mines. Agency officials in charge of managing these alternative programs told us that certain features of these programs have proven to be beneficial to both claimants and administrators and should be considered for inclusion if any future programs are established to compensate individuals for environmental exposures on military installations. For example, Department of Labor and Department of Justice officials told GAO a compensation program that resolves claims in a nonadversarial manner and provides outreach to potential claimants is more beneficial to both claimants and administrators. In contrast, a more adversarial with limited claimant assistance usually leads to delays and increased cost for both claimants and the agency adjudicating claims.
section_title: What GAO Recommends
paragraphs: GAO is making recommendations to DOD to identify and respond to limitations in its policies for responding to environmental exposures. DOD generally disagreed with GAOs recommendations, commenting that current policies are adequate. GAO believes the recommendations remain valid, as discussed in the report.

section_title: Letter
paragraphs: Over the years, there have been various reported incidents of active and  former members of the Armed Forces, their dependents, federal  contractors, and civilian employees being exposed to environmental  hazards, such as contaminated air and water, while living and working  on military installations or while deployed on contingency operations.
Several incidents in particular—contaminated air at Naval Air Facility  Atsugi, Japan; contaminated air due to open burn pits in Afghanistan and  Iraq; and contaminated water at Camp Lejeune, North Carolina—have  recently garnered considerable congressional, public, and media  attention. At Naval Air Facility Atsugi, an off-base incinerator released  toxic fumes that drifted over the installation. The Department of Veterans  Affairs estimates that, from 1985 through 2001, over 25,000 individuals  on the installation could have been exposed to air contaminants.  Similarly, since the start of military operations in Afghanistan and Iraq, the  U.S. military and its contractors have burned solid waste, including  plastics, electronics, and appliances, in open burn pits on or near military  bases. These burn pits have produced smoke and harmful emissions that  military and other health professionals believe may cause acute and  chronic health effects. Moreover, at Camp Lejeune in the early 1980s,  volatile organic compounds were discovered in some water systems  serving installation housing areas. Exposure to certain volatile organic  compounds increases the risk of adverse health effects, including cancer.  The Congressional Budget Office estimates that 650,000 individuals were  stationed at Camp Lejeune at some point during the contamination  period, which lasted about 30 years, and officials at the Agency for Toxic  Substances and Disease Registry estimate that up to one million  individuals could have been exposed. According to the Navy, some  former residents and individuals who worked on Camp Lejeune have  recently filed administrative claims against the U.S. government totaling  billions of dollars in potential damages for health conditions alleged to  have resulted from exposure to the contaminated water. However, the  Department of Defense’s (DOD) response in identifying, studying,  addressing, and communicating these three environmental hazards has  raised congressional concerns in general about how DOD responds to  possible individual exposures to environmental hazards on its  installations. Congress has also expressed interest regarding how the  U.S. government provides compensation and medical benefits for those  who may have suffered adverse health effects from their exposure to  such hazards.
Section 314 of the Ike Skelton National Defense Authorization Act for  Fiscal Year 2011 set out a number of congressional findings related to  military environmental exposures and directed GAO to conduct an  assessment of possible exposures of individuals to environmental  hazards while living and working on military installations.that mandate, our objectives were to determine (1) the extent to which  DOD has policies for identifying and responding to possible human  exposures to environmental hazards on its installations, (2) what  programs currently exist to provide health care and compensation to  individuals for health conditions resulting from environmental exposures  on military installations and any factors that may affect how these  individuals obtain access to health care or compensation, and (3) what  features of alternative federal programs that provide medical benefits or  compensation to large groups of individuals affected by a specific  environmental exposure may be considered as possible options in the  design of any future programs for individuals harmed by environmental  hazards. To satisfy the mandate, we provided a briefing to the House and  Senate Armed Services Committees in December 2011. This report  provides additional information on the topics addressed in response to  that mandate.
To determine the processes DOD has in place for identifying and  responding to possible exposures to environmental hazards we reviewed  and analyzed relevant laws as well as guidance from DOD, the  Environmental Protection Agency, and the Agency for Toxic Substance  and Disease Registry. In conducting this analysis we conducted content  searches of DOD guidance documents to determine the extent to which  they addressed environmental exposures on military installations and  conducted a literature search to determine if there were any best  practices in responding to environmental exposures. We also examined  the database used to track the Agency for Toxic Substance and Disease  Registry public health assessment recommendations and DOD’s  implementation of those recommendations. In addition, we interviewed  DOD officials at the Office of the Secretary of Defense and the various  components, the Environmental Protection Agency, the National  Research Council, Agency for Toxic Substance and Disease Registry,  and some members of the Agency for Toxic Substance and Disease  Registry’s Community Assistance Panel for Camp Lejeune. We also  conducted site visits to Camp Lejeune, North Carolina and Aberdeen  Proving Ground, Maryland where the Army Public Health Command, as  DOD’s Executive Agent for interaction with the Agency of Toxic  Substances and Disease Registry, has its offices. To determine the  programs that currently exist within the federal government to provide  health benefits and compensation to individuals, we obtained, reviewed,  and analyzed relevant laws and regulations, agency guidance, and other  documentation to identify the eligibility requirements and determination  procedures and extent of compensation and medical benefits provided  through various processes currently available to different types of  individuals possibly exposed to environmental hazards while working or  living on military installations. We also interviewed officials from DOD,  Department of Veterans Affairs, Department of Labor, Department of  Justice, and officials from each of the Army, Navy, and Air Force Judge  Advocate Offices. To determine the features of alternative federal  programs that provide medical benefits and monetary compensation we  reviewed and analyzed relevant laws and regulations, agency guidance,  external studies, previous GAO reports, and other documentation to  identify other comparable federal programs that provide medical benefits  and monetary compensation to large groups of individuals that have been  exposed to a specific environmental hazard. Through discussions with  Departments of Veterans Affairs, Labor, Justice, and other federal agency  officials who administer these programs, we identified the key features  associated with each program and any challenges and lessons learned  among the different features of these programs.
We conducted this performance audit between May 2011 and May 2012,  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives. (See app. I for more  information on our scope and methodology.)
subsections: section_title: Background
subsections: section_title: Some Federal Laws Requiring Cleanup of DOD’s Hazardous Waste Include Mechanisms to Consider Exposures
paragraphs: Various environmental laws govern the identification, study, and cleanup  of environmental contamination at military installations. Under a key law,  a public health agency has responsibilities for assessing the presence  and nature of health hazards at certain DOD sites, among other items. In  addition, statutes also specify DOD responsibilities for cleanup of its  contaminated sites. These are described below:
Comprehensive Environmental Response, Compensation, and  Liability Act: Better known as “Superfund,” the 1980 act established,  among other things, government authorities to respond to actual and  threatened releases of hazardous substances, pollutants, and  contaminants that may endanger public health and the environment.   DOD uses its own environmental restoration appropriations to finance   The Environmental Protection Agency places some of  its cleanups.the most seriously contaminated sites on the National Priorities List;  141 DOD installations are currently on this list. The Comprehensive  Environmental Response, Compensation, and Liability Act also  authorized the establishment of the Agency for Toxic Substances and  Disease Registry in the Department of Health and Human Services to  assess the presence and nature of health hazards to communities  affected by Superfund sites, to inform actions to prevent or reduce  harmful exposures, and to expand the knowledge base about the  health effects that result from exposure to hazardous substances.
The Agency for Toxic Substances and Disease Registry: The  Agency for Toxic Substances and Disease Registry is to conduct  a health assessment of each site listed on the National Priorities  List. These health assessments may result in recommendations  from the Agency for Toxic Substances and Disease Registry to  the agency responsible for the site and may include actions for  reducing the public health risk or requests for additional data or  analysis. The Agency for Toxic Substances and Disease Registry  relies on records and data gathered by DOD and the  Environmental Protection Agency for the assessments. With  respect to toxic substance exposures, the agency is to maintain  current research and literature on the health effects of toxic  substances and prepare toxicological profiles, and, in cooperation  with states, establish and maintain a national registry of serious  diseases and illnesses and a national registry of persons exposed  to toxic substances, among other things.
Superfund Amendments and Reauthorization Act: In 1986, the  Superfund Amendments and Reauthorization Act added provisions to  the Comprehensive Environmental Response, Compensation, and  Liability Act, specifically governing the cleanup of federal facilities.  These provisions also require the Secretary of Defense and the  Secretary of Health and Human Services to enter into a memorandum  of understanding regarding the manner in which DOD will support  certain activities to be conducted by the Agency for Toxic Substances  and Disease Registry, including the manner for transferring funds and  personnel and for coordination of activities. Under these provisions,  a preliminary site assessment is to be completed by the responsible  agency for each property where the agency has reported generation,  storage, treatment, or disposal of hazardous waste. This preliminary  assessment is reviewed by the Environmental Protection Agency,  together with additional information, to determine whether the site  poses a threat to human health and the environment or requires  further investigation or assessment for potential inclusion on the  National Priorities List.
Defense Environmental Restoration Program: Section 211 of the  Superfund Amendments and Reauthorization Act established DOD’s  Defense Environmental Restoration Program, providing legal authority  and responsibility to DOD for cleanup activities at DOD installations  and properties, including former defense sites in the United States  and territories. DOD conducts cleanup activities under the Defense  Environmental Restoration Program at its sites listed on the National  Priorities List, as well as sites that are not. Among other things, the  Defense Environmental Restoration Program provisions require the  Secretary of Defense to take necessary actions to ensure that the  Environmental Protection Agency and state authorities receive prompt  notice of the discovery of a release or threatened release, the  associated extent of the threat to public health and the environment,  proposals to respond to such release, and initiation of any response.  Specifically, when DOD identifies releases or threatened releases of  hazardous substances, it is to notify the Environmental Protection  Agency. These provisions also require the Secretary of Defense and  the Secretary of Health and Human Services to enter into a  memorandum of understanding regarding the manner in which DOD  will support certain activities to be conducted by the Agency for Toxic  Substances and Disease Registry, including the manner for  transferring funds and personnel and for coordination of activities.
section_title: Contaminants on Military Installations and Pathways to Human Exposure
paragraphs: Military installations are the site of various mission activities such as  specialized operations and maintenance of equipment, as well as  resembling “small cities” featuring offices, housing, water and wastewater  systems, and solid and hazardous waste facilities. In some cases, these  installations and surrounding areas became contaminated due to past  storage and disposal practices for substances such as solvents,  machining oils, metalworking fluids, and metals. Many of these  contaminants, such as trichloroethylene, perchloroethylene, and vinyl  chloride, are known or suspected carcinogens. On some installations,  these contaminants have spread beyond their points of origin because  they have been transported by wind currents or have entered ground  water, resulting in potential environmental exposures.
An environmental exposure is quantified by estimating the amount (how  much), duration (how long), and frequency (how often) of an individual’s  exposure to a dose of a contaminant. The dose is a primary factor in  whether the exposure may result in harm to the individual. Doses below  health standards generally do not result in harm to the exposed  individuals. For environmental exposures the routes of exposure are:  (1) ingestion—for solids and liquids; (2) inhalation—for gases and  particulates; and (3) skin contact—for all types of agents. Some  contaminants can cause harm at the site of exposure—for example, the  lungs or skin—and some cause effects only after they have been  absorbed into the blood stream and carried throughout the body. In their  travel through the body, they have the potential to affect various organs in  the body—such as lungs, liver, kidneys, heart, and brain. Appendix II  contains a description of some of the contaminants found on military  installations and their effects on humans.
section_title: DOD Has Policies for Identifying and Responding to Environmental Exposures but They Have Limitations
paragraphs: DOD has four types of policies to address aspects of environmental  exposure: (1) environmental restoration policies that require the services  to identify and respond to hazardous releases at military installations,  (2) occupational and environmental health policies that require the  services to identify and respond to unsafe or unhealthy activities in DOD  workplaces, (3) deployment health policies that require the services to  collect and analyze occupational and environmental health data for  individuals deployed in military operations in order to help identify  environmental exposures, and (4) public health emergency management  policies that establish general guidance for responding to specific  situations (see fig. 1). Limitations in DOD’s environmental restoration  policies may hinder DOD’s ability to identify and respond to all  environmental exposures. DOD recently updated a directive that  complements these policies by including servicemembers’ dependents in  its system for collecting, analyzing and interpreting health-related data— called the health surveillance data system—when associated with a  public health event such as a disease outbreak or widespread exposure  incident.
Policies under the Defense Environmental Restoration Program,  established by Section 211 of the 1986 Superfund amendments, require  the services to identify and respond to hazardous releases at military  installations and offer a structure for cleanup. Under the Defense  Environmental Restoration Program, the services are required to identify  relative risks to human health and the environment from contaminated   sites––those areas with releases or threatened releases of hazardous  substances. Because there have been thousands of contaminated sites  on DOD properties, DOD prioritizes these sites for funding based on,  among other things, whether a site presently poses a risk to human  health. Within this program, DOD may conduct one or more response  actions, such as investigation and cleanup of contamination from  hazardous substances, pollutants, and contaminants, and demolition and  removal of unsafe buildings and structures. The sidebar illustrates DOD’s  approach to a hazardous release at a military installation.
subsections: section_title: DOD’s Occupational and Environmental Health Policies Require the Services to Identify and Respond to Unsafe or Unhealthy Working Conditions at Military Installations
paragraphs: DOD’s Occupational and Environmental Health policies require the  services to identify and respond to unsafe or unhealthy working  conditions at military installations in the United States and abroad. The  policies apply to DOD military and civilian personnel in any DOD  workplace and certain contractors deployed with DOD., Accordingly,  the services are responsible for establishing and publicizing programs  that encourage personnel to identify and promptly report to supervisors  situations of imminent danger. In addition, according to these policies, the  services must conduct surveys of workplaces to identify potential  exposures and other worker safety and health risks, and establish  workplace exposure profiles. They may also conduct periodic  assessments to identify worksite environmental hazards.
DOD Manual 6055.05-M, Occupational Medical Examinations and Surveillance Manual  (May 2, 2007). suggest that an occupational environmental hazard exists, DOD’s  occupational and environmental health policies call for the development  of appropriate targeted intervention programs to reduce the occurrence of  occupational injury and illness. The sidebar illustrates the use of this type  of policy in a workplace condition.
section_title: DOD’s Deployment Health Policies Require the Services to Collect and Analyze Data on Individuals in Deployment Settings
paragraphs: DOD’s deployment health policies require the services to regularly collect  and report a variety of data for deployed individuals to identify and  respond to health threats they may have encountered during  deployments. These policies apply to servicemembers, DOD civilian  employees, and, depending on the contract, deployed DOD contractor  personnel. These individuals may be subject to hazards that can include  exposure to harmful levels of contaminants such as industrial toxic  chemicals, chemical and biological warfare agents, and radiological and  nuclear contaminants. Since harmful levels of exposure can result in  immediate health effects or delayed or long-term health effects, the  policies establish a system whereby DOD gathers and reports a variety of  data on its servicemembers and civilian employees and examines the  data over time to address specific exposure-related questions. DOD  established specific guidance for the services in 2006 and again in 2007  that lay out data collection requirements.
DOD collects three types of data: (1) occupational and environmental  health surveillance data, including ambient air, water, and soil samples;  (2) daily individual servicemember location data, such as the duty station;  and (3) health outcome data, acquired from servicemember medical  records. The Defense Occupational and Environmental Health Readiness  System (DOEHRS) Environmental Health module was developed to  capture data about existing environmental conditions in contingency  operations—military operations in which members of the armed forces  are involved in actions against an enemy of the United States or against  an opposing military force. Table 1 provides examples of the types of data  collected before, during, and after deployment.
The Armed Forces Health Surveillance Center regularly monitors the  health outcomes of both deployed and nondeployed servicemembers on  a population-wide basis for abnormal trends that may indicate an adverse  health outcome. In addition, it publishes a monthly report that reviews the  incidence of a variety of deployment-related conditions, such as traumatic  brain injury and motor vehicle accidents. The Millennium Cohort Study, an  ongoing health evaluation led by the Naval Health Research Center,  examines and issues reports on deployment-related health issues, for  example the effects of deployment on servicemembers’ respiratory  systems.
While DOD has made progress in identifying potential occupational and  environmental health hazards during deployments since the 1991 Gulf  War, technological challenges remain. Currently, DOD estimates  exposures using occupational and environmental health surveillance data  coupled with individuals’ once-daily location tracking information, but  cannot precisely determine exposure concentrations and durations that  provide individuals’ unique exposure profiles. According to DOD officials,  problems with collecting individual exposure data for all types of  environmental exposures could be addressed in some cases by the use  of certain dosimeters or exposure biomarkers, but such technologies  have not been developed for all types of exposure hazards. DOD officials  reported that DOD has partnered with the National Institute for  Environmental Health Sciences and the National Research Council to  learn more about the potential use of these technologies. They also told  us that DOD is in the process of developing a personal dosimeter for  naphthalene––a fuel component that may be carcinogenic––which they  consider to be an important first step toward developing dosimeters for  other chemicals and health threats. In addition to the technological  limitations, DOD officials said there are logistical difficulties associated  with the implementation of individual sampling devices on deployed  personnel. The sidebar illustrates DOD’s data collection efforts and  challenges in Afghanistan and Iraq.
section_title: DOD’s Policy on Public Health Emergency Management Establishes General Guidance and References Additional Documents for More Specific Guidance
paragraphs: DOD’s Public Health Emergency Management policy establishes  guidance for the services in responding to public health emergencies,  such as natural disasters or nuclear attacks, to protect installations,  facilities, and personnel—including military and civilian personnel,  dependents of military and civilian personnel, contractors, and other  individuals visiting installations that are located either in or outside of the  United States. While DOD officials told us the policy does not specify  what steps should be taken immediately following an emergency, it does  reference a number of other policies—including DOD’s Installation  Emergency Management Program policy and Installation Chemical,  Biological, Radiological, Nuclear, and High-Yield Explosive Emergency  Response Guidelines—and gives the Under Secretary of Defense for  Personnel and Readiness the authority to issue additional implementing   DOD’s Installation Emergency Management Program policy  guidance.aligns DOD emergency management activities with national  preparedness and response guidelines and covers a range of potential  hazards, including natural hazards, such as earthquakes and tsunamis,  and human-caused hazards, including air or water contamination and  terrorist attacks. According to a DOD official, each public health  emergency is different, and the types of data that should be collected will  depend on the significance of the hazard. This official told us that  standard risk assessment models are applied in such emergencies and  public health and occupational and environmental health professionals  make decisions on how to respond on a case-by-case basis, based on  what they perceive the health threat to be. The sidebar illustrates DOD’s  response to the 2011 Fukushima Daiichi disaster in Japan.
section_title: Limitations in DOD’s Environmental Restoration Policies May Hinder Its Ability to Identify and Respond to Exposures
paragraphs: For DOD sites proposed for or listed on the National Priorities List, the  Agency for Toxic Substances and Disease Registry conducts a public  health assessment of the site that may result in recommendations to  DOD. Some assessments may also identify serious public health  concerns known as “findings of significant risk.” The Defense  Environmental Restoration Program’s management guidance states that  DOD is to track the Agency for Toxic Substances and Disease Registry’s  progress in completing public health assessments. This guidance is,  however, silent regarding what actions DOD should take in response to  these recommendations and findings of significant risk or the timeliness of  its response. According to a 1995 Guidelines document signed by the  Deputy Under Secretary of Defense (Environmental Security) and the  Assistant Surgeon General, DOD installations and the Agency for Toxic  Substances and Disease Registry are supposed to report annually on  actions taken in response to the recommendations resulting from health  assessments, among other items.  A 2011 memorandum of  understanding between DOD and the Department of Health and Human  Services explicitly cites the Guidelines but gives no direction regarding its  further implementation. The memorandum of understanding documents  the working relationship between the two agencies but currently the  process they follow does not ensure that status information on the  recommendations is provided to or documented by the office of the DOD  lead agent for the Agency for Toxic Substances and Disease Registry  program. Status information may indicate that a recommendation has  been fully implemented; a recommendation will be implemented in the  future, as part of a planned study; DOD does not agree with a  recommendation; or other relevant information. Under the Superfund law,  department heads are to take steps to reduce the exposure and eliminate  or substantially mitigate the risk if the Agency for Toxic Substances and  Disease Registry finds that an exposure presents a significant risk to  human health. Furthermore, federal internal control standards  encourage the prompt resolution of audits and reviews, which would  include public health assessments.
DOD developed a tracking system that identifies characteristics such as  the date and nature of recommendations to particular installations;  however, it does not always identify whether each installation responded  to the recommendations or findings of significant risk. As a result,  according to the DOD lead agent, the tracking system does not reflect  what actions, if any, DOD took on about 80 percent of the approximately  1,200 recommendations made since the inception of the environmental  restoration program.
According to DOD officials, the installations are expected to elevate  matters of concern with the public health agency’s recommendations to  the Office of the Secretary of Defense as needed, but otherwise, the lead  agent’s office does not systematically monitor recommendations or  findings of significant risk. The Defense Environmental Restoration  Program management guidance states that the Office of the Secretary of  Defense provides oversight to the lead agent and components on Agency  for Toxic Substances and Disease Registry involvement at installations.  While DOD officials said they rely on individual installations to respond to  recommendations from the Agency for Toxic Substances Disease  Registry, without accurate data or a systematic means to track the status  of responses to recommendations and findings of significant risk, the  Office of the Secretary of Defense has no assurance that installations  have responded to known public health risks. The sidebar illustrates  DOD’s approach to a draft public health assessment with DOD-wide  implications.
DOD’s Defense Environmental Restoration Program management  guidance does not address if or when DOD components should  voluntarily seek a public health assessment at National Priorities List sites  beyond the initial assessment completed when a site is proposed for the  list. After the initial public health assessment, it may take many years for  site characterization and restoration. During that period additional  contaminants or exposure pathways may be discovered that could make  the original public health assessment obsolete. In addition, the guidance  does not require public health assessments for non-National Priorities List  sites, which could have environmental hazards equivalent to sites on the  National Priorities List, and despite the fact that officials from the Agency  for Toxic Substances and Disease Registry said that the majority of their  DOD-related work in recent years involves non-National Priorities List  sites. According to federal internal control guidelines, management  should assess the risks faced from external (and internal) sources and  decide what actions to take to mitigate them. While DOD officials said  that DOD relies on the judgment of environmental professionals at the  installations, without a standard set of guidelines on when to request a  public health assessment other than an initial assessment for a site on  the National Priorities List, DOD lacks assurance that it is consistently  identifying and addressing possible health risks from exposures at some  National Priorities List sites and non-National Priorities List sites.
DOD’s Defense Environmental Restoration Program is focused on  cleanup to avoid present and future exposures but does not provide  guidance on whether or when DOD should assess public health risks  from past exposures or identify potentially affected individuals. For  example, at Camp Lejeune, while environmental compliance and Defense  Environmental Restoration Program policies were relevant to the actions  taken to provide safe drinking water and to begin investigating the  groundwater contamination, there was no policy guiding installations on  what actions it should consider to address past exposures. Instead, most  actions to address past exposures have come about based on Agency for  Toxic Substances and Disease Registry studies and congressional  direction.
DOD officials told us that the Agency for Toxic Substances and Disease Registry,  however, may consider risks posed by past exposures. DOD officials told us that there  were only two examples of DOD attempting to identify individuals who might have been  affected by past environmental exposures: (1) the ongoing efforts at determining the  health effects of contaminated drinking water at Camp Lejeune; and (2) notifying, via the  Internal Revenue Service, former residents about radon levels at higher than regulatory  standards in 2007 and 2008 in some housing at the Marine Corps Logistics Base, Albany,  Georgia. The Agency for Toxic Substances and Disease Registry officials told us that,  from a public health point of view, they would consider notification of prior site occupants  when notification could result in actions that directly benefit people’s health, such as  where past exposures are considered likely to have caused an increased incidence of a  disease for which early screening has proven beneficial. prior site occupants when notification could result in actions that directly  benefit people’s health. Moreover, where there has been a release of  hazardous substances and where DOD is the lead agency, section 111(g)  of the Superfund law, in conjunction with an executive order, requires  DOD to notify potentially injured parties of such releases. However, it  is not required to notify individuals directly; rather, it can issue a broad,  public announcement, such as a newspaper notice. As a result,  potentially affected individuals may not be aware of their exposure and  subsequent health risks.
section_title: Revised DOD Policy May Reduce Previous Gap in DOD’s Response to Exposures
paragraphs: During the course of our review, we found that servicemembers’  dependents living on permanent overseas installations in nonemergency  situations were not covered by any of the policies, but a revised policy  may reduce this gap. For example, servicemembers’ dependents, who  were potentially exposed to contaminated air while at the Naval base in  Atsugi, Japan, were not covered by any of the four types of policies.  Specifically, according to DOD officials, the base was exempt from  (1) environmental restoration policies because these policies apply only in  the United States, (2) occupational and environmental health policies  because the exposures occurred outside of the workplace,  (3) deployment policies because permanent installations are not  considered deployments, and (4) the public health emergency  management policy because it did not fit the definition of a public health  emergency. As such, no DOD policy existed to guide the Navy on their  approach to conducting environmental surveillance, medical testing, or  notification of the potentially exposed dependents. In February 2012,  DOD revised its comprehensive health surveillance directive to include  servicemembers’ dependents when collecting health surveillance data in  the case of a possible environmental exposure or public health event at a  domestic or overseas installation. DOD officials told us the revised  directive has the potential to improve DOD’s response to environmental  exposures, but not necessarily past exposures, since those would be  addressed on a case-by-case basis. However, it is too soon to determine  how this directive will be implemented and whether it will improve DOD’s  ability to address dependents potentially affected by exposures.
section_title: Several Programs May Provide Health Care or Compensation for Environmental Exposures but Access May Be Affected by Various Factors
paragraphs: Although several programs potentially provide either health care or  compensation to active servicemembers, military retirees, veterans,  dependents, federal workers, or contractors suffering from adverse health  conditions potentially caused by environmental exposures, the ability of  some individuals to establish eligibility and actually obtain these  benefits—particularly compensation—is often affected by documentary,  scientific, and legal factors.
subsections: section_title: Several Programs May Provide Health Care or Health Benefits for Individuals Harmed by Environmental Exposures While Working or Residing on Military Installations
paragraphs: Servicemembers, veterans, military retirees, and their dependents,  federal workers, and some contractors may have access to health care or  health benefits either through the Departments of Defense, Labor, and  Veterans Affairs, state workers’ compensation, or a private health care  program regardless of the cause of the condition. Individuals, depending  on their eligibility, may obtain health care or health benefits from one or  more of the following programs:
TRICARE: DOD’s TRICARE program may provide health care to  servicemembers and their dependents, eligible National Guard and  Reserve personnel and their dependents, and military retirees and  their dependents and survivors. Servicemembers include members of  the National Guard and Reserves on active duty for at least 30 days.
Administration, within the Department of Veterans Affairs may provide  health care to veterans, military retirees, and certain other individuals  through numerous outpatient clinics, medical centers, and long-term  health care facilities. The Veterans Health Administration may also  provide health coverage to spouses, survivors, and children of  veterans who are permanently and totally disabled from a service- connected disability or who died in the line of duty or from a service- connected disability.
Federal Employees’ Health Benefits: The Federal Employees’  Health Benefits program, which is administered by the Office of  Personnel Management, may provide health care benefits to federal  workers who choose to enroll.
Federal Employee Compensation Act: For appropriated fund  employees, the Department of Labor’s Federal Employees  Compensation Act program may provide benefits, including medical  care, to covered employees who experience work-related injuries.  When necessary, the Federal Employees Compensation Act program  also provides vocational rehabilitation assistance to help injured  workers return to work.
Nonappropriated Fund Instrumentalities Act: Under the  Nonappropriated Fund Instrumentalities Act, an extension of the  Longshore and Harbor Workers’ Compensation Act, civilian employees employed by nonappropriated fund operations at domestic  and overseas military bases (e.g., base exchanges, child care, food  service, housekeeping, etc) may receive medical treatment for work- related injuries, including those resulting from environmental  exposures.
Defense Base Act: The Defense Base Act, an extension of the  Department of Labor’s Longshore and Harbor Workers’  Compensation Program Act, requires U.S. government contractors  and subcontractors to purchase workers’ compensation insurance  coverage for their employees working overseas. This insurance  would cover medical treatment required as a result of work-related  injuries.
State Workers Compensation: Some state workers’ compensation  programs may also provide health care benefits for work-related  health conditions to contractors working in the United States, although  eligibility requirements and benefits may vary from state to state. In  some instances, the federal Longshore and Harbor Workers  Compensation Act may provide such benefits.
section_title: Several Programs May Provide Compensation for Individuals Harmed by Environmental Exposures While Working or Residing on Military Installations
paragraphs: The Departments of Defense, Veterans Affairs, and Labor, as well as  some state workers’ compensation programs may also provide  compensation to servicemembers, military retirees, veterans, federal  workers, and contractors for service or work-related health conditions  associated with issues such as exposure to environmental hazards.  These programs include:
DOD’s Disability Evaluation System: The Department of Defense  Disability Evaluation System may provide compensation to  servicemembers for service-connected health conditions.  Servicemembers may receive either a lump sum for their health  condition or monthly compensation, depending on the severity of the  condition.
Veterans Benefits Administration: The Veterans Benefits  Administration programs within the Department of Veterans Affairs  may provide monthly compensation to military retirees and veterans  with service-connected health conditions and sometimes their  dependents and survivors.
Federal Employees’ Compensation Act: The Federal Employees’  Compensation Act program may provide wage-replacement  compensation to covered employees with work-related health  conditions.
Nonappropriated Fund Instrumentalities Act: The Nonappropriated  Fund Instrumentalities Act, an extension of the Longshore and Harbor  Workers’ Compensation Act, provides disability compensation for  work-related injuries and survivor benefits for civilian employees  employed by nonappropriated fund operations at domestic and  overseas military bases (e.g., base exchanges, child care, food  service, housekeeping, etc). Vocational rehabilitation services are  available to assist permanently disabled workers to return to work.
Defense Base Act: The Defense Base Act, an extension of the  Longshore and Harbor Workers’ Compensation Act, may provide  financial compensation to eligible civilian employees of U.S.  government contractors with work-related health conditions who  perform work overseas.
State Workers Compensation: Some state workers compensation  programs may provide wage-replacement compensation for work- related health conditions to contractors at military installations within  the United States, although eligibility requirements and benefits may  vary from state to state. In some instances, the federal Longshore and  Harbor Workers Compensation Act may provide such benefits.
Although spouses and dependents who are injured while residing on  military installations may access health care through TRICARE or other  health care programs, they are not eligible to receive financial  compensation from the Departments of Defense, Veterans Affairs, or  Labor, under the above programs, for adverse health conditions resulting  from environmental exposures on military installations. They may,  however, file a tort claim against the federal government seeking financial  compensation under the Federal Tort Claims Act. The act provides a  means for some individuals injured by wrongful or negligent acts or  omissions of federal employees to receive compensation from the U.S.  government through an administrative claim process or, if not resolved at  the administrative level, through the federal courts, subject to certain  exceptions. For example, claimants will be unable to recover in cases in  which federal employees took actions that are susceptible to policy  analysis.
section_title: Access to Compensation Is Often Affected by Documentary, Scientific, and Legal Factors
paragraphs: Although the above programs potentially provide either health care or  compensation to active servicemembers, veterans, military retirees, and  their dependents; federal workers; or contractors suffering from adverse  health conditions potentially caused by environmental exposures, the  ability of some individuals to establish eligibility and actually obtain these  benefits—particularly compensation—is often affected by documentary,  scientific, and legal factors.
Obtaining compensation for an environmental exposure may depend on  an individual’s ability to document an actual exposure to a contaminant,  since establishing a causal link between the exposure and the adverse  health condition may be necessary for obtaining certain benefits or  compensation under many existing adjudication processes. This usually  requires not only documentation of a release of a contaminant but also  that the individual was potentially exposed to the contaminant (i.e., in the  area of the release at the time and place it occurred) at a level plausibly  related to an adverse health outcome. However, it is often difficult to  document the specific time, place, or level of an environmental exposure  because such exposures are not always identified, defined, and  measured at the time of the occurrence since adverse effects of the  exposure may not be immediately apparent. This is true for environmental  exposures both on and off military installations. When environmental  exposures are not identified at the time of the release, the opportunity to  collect data on both the level of exposure and individuals present at the  time of the release may be lost. For example, in 2010 we reported that  U.S. forces in Afghanistan and Iraq did not sample or monitor burn pit  emissions as provided by a key U.S. Central Command regulation, and,  as a result, the health impacts of burn pit exposure on individuals are not  well understood. Although DOD and the Department of Veterans Affairs  have commissioned studies to enhance their understanding of burn pit  emissions, the current lack of data on emissions specific to burn pits and  related exposures limit efforts to characterize potential health impacts on  servicemembers and contractors.
Agent Orange is a mixture of herbicides initially developed to control broad-leafed  weeds in agricultural settings. In large quantities, it causes large-scale defoliation. It  primarily was used during the Vietnam War to defoliate large areas in order to deprive the  opposition forces of cover and food crops. Between 1962 and 1971, more than 21 million  gallons of Agent Orange were sprayed across Southeast Asia. Though the military was  unaware of it at the time of its initial use, it was later discovered that Agent Orange also  contained a dioxin, which is a by-product of the manufacturing process. This dioxin is  classified as a human carcinogen. According to the Department of Veterans Affairs,  cancers currently associated with exposure to Agent Orange and other herbicides are  chronic lymphocytic leukemia, Hodgkin’s lymphoma, multiple myeloma, non-Hodgkin’s  lymphoma, prostate cancer, various respiratory cancers (lung, bronchus, larynx, trachea),  and some soft tissue sarcomas. of institutional knowledge resulting from staff turnover over the years.  This lack of records may continue to be an issue, particularly for  exposures occurring in the past that may at some point in the future result  in adverse health conditions. For example, some veterans returning from  Afghanistan and Iraq blame emissions from open air burn pits for several  health conditions, including respiratory illnesses. However, the Institute of  Medicine recently issued a report that was inconclusive regarding the  connection between burn pit emissions and adverse health conditions.  One of the major reasons cited by the Institute of Medicine for the  inconclusive results was insufficient data on troops’ exposures to open air  burn pits. According to the study, some of the incomplete information that  hampered the Institute’s analysis included information on how many  people worked in or near the pits, for how long, and how frequently.
In many cases, obtaining compensation for an environmental exposure  further depends on an individual’s ability to establish causation between  an exposure and the adverse health condition, but this is often difficult  because scientific research has not always established a clear link  between the contaminant and an adverse health effect. This is true for  environmental exposures both on and off military installations. Further  complicating the matter is the fact that for many environmental exposures  there is a latency period—the time period from initial exposure to a  contaminant and the date an adverse health condition is diagnosed.  When there is a long latency period between an environmental exposure  and an adverse health condition, choosing between multiple causes of  exposure may be difficult. Where multiple alternative causes are present,  science is often unable to demonstrate that a particular individual’s  environmental exposure was the cause of the condition. For example, it is  difficult to definitively rule out other environmental or lifestyle risk factors  that could have caused the condition during the years between the  exposure and the appearance of the condition. Indeed, another major  reason cited by the Institute of Medicine for the inconclusive results of  their burn pit study was high background levels of ambient pollution from  other sources, such as diesel fumes and dust that might also be  responsible for the respiratory conditions. According to the Institute of  Medicine, because of the existence of these pollutants, it could not  establish a conclusive link between burn pit emissions and the adverse  health conditions being experienced by some individuals.
The water contamination at Camp Lejeune further underscores the  difficulties associated with these documentary and scientific factors.  Specifically, little data exist regarding Camp Lejeune’s past water quality  tests and the extent to which contaminants were found in the water. As a  result, the Agency for Toxic Substances and Diseases Registry is  conducting a water modeling assessment to fill in the gaps in the data.  The Agency for Toxic Substances and Diseases Registry hopes the water  modeling will help identify the time and place certain areas at Camp  Lejeune received contaminated drinking water and ultimately help to  determine who was exposed, at what levels, and for how long. For  example, the data collection efforts for the Agency for Toxic Substances  and Diseases Registry’s studies revealed that the area serviced by  Holcomb Boulevard water system on Camp Lejeune received water that  may have contained volatile organic compounds for a longer period than  was previously thought. Furthermore, once it has been established that a  veteran was exposed to contaminated water at Camp Lejeune, the  Department of Veterans Affairs needs to determine whether the alleged  health condition can generally be caused by the exposures received  during service and whether the health condition in a specific claim was  caused by the exposure in deciding whether to provide compensation.  These difficulties may affect veterans’ ability to obtain benefits and  compensation. Data provided by the Department of Veterans Affairs show  that in calendar year 2011, the department completed decisions on 849  claims from veterans alleging an adverse health condition resulting from  the contaminated water at Camp Lejeune. Of these 849 claims, 212  (25 percent) claims were granted and 637 (75 percent) were denied.  According to the Department of Veterans Affairs, those claims that were  denied failed to demonstrate one or more of the following: (1) service at  Camp Lejeune during the period of water contamination, (2) a current  disease or disability, or (3) a medical nexus or link between a current  disability and service at Camp Lejeune. According to the Department of  Veterans Affairs, a total of 1,151 claims are still being adjudicated.
Active duty servicemembers, military retirees, veterans, and other federal  workers are able to seek compensation through Departments of Defense,  Veterans Affairs, and Labor programs, but other individuals may need to  seek a remedy under the Federal Tort Claims Act. Certain individuals  have legal standing under the Federal Tort Claims Act to file a lawsuit  against the U.S. government for damages due to an environmental  exposure under some circumstances. But damages under the Federal  Tort Claims Act are not available to other types of individuals, and for  certain types of claims, due to legal precedent or statutes. For example,  most active duty servicemembers, military retirees, and veterans may not  bring suit under the Federal Tort Claims Act due to the doctrine outlined  in the Supreme Court case Feres v. United States, and its successor  cases, for personal injuries that arise incident to their military service, and  such claims or lawsuits they attempt to file under the Federal Tort Claims  Act are subject to dismissal. However, active duty servicemembers,  military retirees, and veterans may be eligible for compensation through  Department of Defense or Veterans Affairs programs. Similarly, the  Federal Employees’ Compensation Act provides the exclusive remedy for  federal workers and their dependents if the worker is injured or killed in  the performance of duties. Thus, the disability compensation, medical,  and other benefits provided for under the Federal Employees’  Compensation Act are the exclusive means by which federal workers can  seek compensation from the U.S. government. While compensation  programs are established for some individuals who work on military  installations, others, including dependents and contractors, may choose  to pursue legal damages from the U.S. government, under the Federal  Tort Claims Act, for injuries they sustained as a result of an environmental  exposure.
Although the Federal Employees’ Compensation Act effectively bars  federal workers and their dependents from pursuing compensation  through tort claims in civil lawsuits, contractors may pursue damages from the U.S. government for an  environmental exposure received on the job and dependents of active  duty servicemembers may seek compensation for their own personal  injuries. However, success under the Federal Tort Claims Act may be  unlikely. The discretionary function exception within the Federal Tort  Claims Act prevents recovery for health conditions caused by  discretionary actions or omissions of federal employees in cases in which  the employees’ actions are susceptible to policy analysis.
5 U.S.C. §8116 (c).
Department of Justice officials, this includes many decisions made by  federal personnel, although not in cases where the government ignores a  specific and mandatory agency rule or policy. Department of Justice  officials told us that, as a result, many claims against the U.S.  government alleging harm due to governmental negligence are eventually  dismissed.
According to Navy officials, as of January 2012, about 2,900 former  residents and former employees of Camp Lejeune had filed administrative  claims against the U.S. government for adverse health effects, alleged to  have resulted from contaminated water, seeking billions of dollars in  potential damages. In accordance with limitations on adjudication of  claims, set out in the National Defense Authorization Acts for Fiscal Years  2011 and 2012, the Navy stated it is currently not adjudicating these  claims, and is awaiting the outcome of several ongoing and planned  studies by the Agency for Toxic Substances and Diseases Registry. In  addition to filing administrative claims with the Navy, some claimants  have also exercised their rights under the Federal Tort Claims Act and  filed lawsuits against the U.S. government in federal district courts.  According to the Department of Justice, as of March 2012, 12 of the  approximately 2,900 administrative claims had resulted in the filing of  lawsuits in federal district court. Among other things, we were told that  some of these lawsuits seek damages for various physical ailments and  emotional distress alleged to have resulted from the government’s alleged  negligence in protecting the water supply at Camp Lejeune. Furthermore,  Department of Defense officials told us that lawsuits have been filed in  federal court in at least 43 states in which current and former  servicemembers have alleged, among other things, that a contractor’s  negligent management of burn pit operations, contrary to applicable  contract provisions, exposed them to air pollutants that subsequently  caused adverse health conditions. According to officials, the contractor  has moved to dismiss the suits, arguing, among other things, that it  cannot be held liable for any health conditions that may have occurred to  service personnel because its burn pit activities occurred at the direction  of the military.
section_title: Actions Taken to Limit Difficulties Associated with These Factors
paragraphs: In an effort to limit some of the difficulties associated with these factors,  Congress has, in some cases, created presumptions that bridge gaps in  the evidence related to causation and documentation, making it easier for  a group of veterans to be compensated. For example, to qualify for a  Department of Veterans Affairs disability compensation claim, a veteran is  normally required to demonstrate the following: (1) that a health condition  currently exists, (2) that an event of disease or injury occurred or was  aggravated in the line of duty, and (3) that a medical connection or  “nexus” can be shown between the service event and the existing health  condition. However, when the exposures of military personnel in Vietnam  to Agent Orange could not be clearly documented, Congress enacted  legislation establishing the presumption that veterans who served in  Vietnam during a specified time frame, and subsequently developed  certain health conditions, provided in the statute or prescribed in  regulations, had been exposed. This presumption relieves the veteran  of proving one or more of the eligibility requirements for direct service  connection and shifts the burden of proof from the veteran to the  government in order to rebut the presumption.
In addition, DOD and Department of Veterans Affairs officials told us they  are taking steps to overcome some of the difficulties in confirming  scientific links between certain contaminants and adverse health  conditions and in maintaining documentation regarding environmental  exposures. DOD officials told us they are potentially implementing an  electronic individual longitudinal exposure record for every  servicemember that would be designed to provide linkages between  differing types of data—environmental monitoring, biomarkers, and troop  locations and activity—and an individual’s medical records. DOD and the  Department of Veterans Affairs are also conducting scientific studies  designed to follow a large group of individuals over a long period of time  to determine any increased incidence of diseases, including those due to  a potential environmental exposure. For example, the Millennium Cohort  Study, an ongoing health evaluation led by the Naval Health Research  Center, is targeted at examining deployment-related health conditions by  comparing a cohort of servicemembers that were deployed and a cohort  that was not deployed. According to Department of Veterans Affairs  officials, conducting these types of scientific studies will provide  documentation and scientific information on adverse health conditions,  that if found to be significantly different between deployed and  nondeployed servicemembers, may provide officials with information to  further examine the link between potential environmental exposures and  adverse health conditions. These efforts may provide exposure-related  documentation that is currently not readily available, and may remove  some of the burden of documenting an environmental exposure.
section_title: Certain Features of Alternative Programs for Compensation Established for Specific Environmental Exposures May Provide Potential Options for Future Programs
paragraphs: Beyond the previously discussed traditional avenues generally available  for seeking compensation for work-related injuries or injuries resulting  from an environmental exposure, Congress has, in some cases,  established alternative programs to provide compensation and some  medical benefits to specific populations harmed by specific environmental  exposures. The structures of these alternative programs for  compensation vary and the programs are not generally designed to  address all past or future environmental exposures occurring on military  installations, such as those discussed in this report. However, in the past  few years, Congress has considered several legislative options to provide  benefits and compensation for certain individuals exposed to specific  environmental hazards on military installations. Some features of the  alternative programs for compensation may help to inform any future  compensation programs that Congress may choose to create.
subsections: section_title: Congress Has Established Alternative Programs for Compensation for Specific Populations Harmed by Specific Environmental Exposures
paragraphs: See the Radiation Exposure Compensation Act, Pub. L. No. 101-426 (1990), codified at  42 U.S.C. §2210 note, as amended.
See Title IV of the Federal Coal Mine Health and Safety Act of 1969, Pub. L. No. 91- 173 (1969), codified at 30 U.S.C. Chapter 22, Subchapter IV, as amended. miner’s income assistance may be augmented on behalf of certain  dependent family members. The program also provides income  assistance to the survivors of miners who died due to black lung  disease and to certain survivors of miners who were awarded benefits  as a result of lifetime claims.these three programs exceeded initial estimates as the federal role in  the programs expanded.
The sidebar illustrates how costs in  While these alternative programs for compensation were each designed  to compensate individuals injured by exposure to harmful contaminants,  the way in which the programs are structured varies, including who  administers the program, how it is funded, and the benefits it provides.  For example:
Administration: The administration of the programs differs. For  example, the Department of Justice administers the Radiation  Exposure Compensation Program. In contrast, the Department of  Labor administers the Black Lung Program, and shares responsibility  for administering the Energy Employees Occupational Illness  Compensation Program with the Departments of Health and Human  Services, Energy and Justice. Responsibility for administering the  Black Lung Program has changed since its inception. Specifically,  claims for the Black Lung Program were initially processed and paid  by the Social Security Administration but, as designed by the original  legislation, the Department of Labor began processing claims in 1973  and took over all Black Lung Program claims processing in 1997. In  2002, Congress officially transferred all legal responsibility and  funding for the program to the Department of Labor.
Funding: Funding for the three programs varies. Although initially  funded solely through annual appropriations, the Black Lung Program  is now funded largely by the coal mining industry. Individual claims  are paid either by a responsible coal mine operator (or its insurance  carrier) or by the Black Lung Disability Trust Fund, which is financed  by an excise tax on coal and supplemented by additional funds. In  contrast, the Energy Employees Occupational Illness Compensation  Program and the Radiation Exposure Compensation Program are  completely federally funded.
Benefits: Benefits also vary among the three programs. Some of the  benefits they provide include lump sum compensation payments and  payments for lost wages, medical and rehabilitation costs, and  attorney’s fees. For example, the Black Lung Program provides  diagnostic testing for miners; monthly payments based on the federal  salary scale for eligible miners or their survivors; medical treatment for  eligible miners; and, in some cases, payment of claimants’ attorney  fees. The Radiation Exposure Compensation Program, in contrast,  provides only a lump sum payment for restitution to those that  developed adverse health conditions or their survivors.
section_title: Certain Features of These Programs May Provide Potential Options for Future Programs
paragraphs: In the past few years, Congress has considered several legislative  options to specifically provide compensation and benefits for individuals  exposed to specific environmental hazards on military installations. The  alternative programs for compensation that we examined contain certain  features that may provide potential options if future programs for  environmental exposure compensation are considered. These features  address such issues as whether to use an adversarial or nonadversarial  approach to adjudicating claims, the kinds of outreach and claims  assistance offered, how eligibility for benefits is determined, and the  frequencies and types of payments when such compensation is awarded.
The Radiation Exposure Compensation Program and the Energy  Employees Occupational Illness Compensation Program resolve claims in  a nonadversarial manner; thus, claims are adjudicated through a process  in which the adjudicator investigates the facts of the case to determine  the eligibility of the claimant.adversarial; thus, claims are adjudicated through a process in which two  opposing parties, such as the coal miner and his former employer,  present their arguments for and against awarding compensation, and   In contrast, the Black Lung Program is  responsibility for the payment of benefits is assigned to the liable party if  the claim is approved. In this process, the coal mine operators typically  serve as the opposing party to the claimant, and if a claimant is awarded  benefits, the mine operator determined to be the responsible employer of  the miner must generally pay the benefits, either directly or through  insurance. If no mine operator can be held liable for payments, the Black  Lung Disability Trust Fund pays the cost of black lung claims from funds  collected through an excise tax on coal.
Department of Labor officials told us that they prefer the nonadversarial  features of the Radiation Exposure Compensation Program and the  Energy Employees Occupational Illness Compensation Program because  these features can improve the timeliness of processing claims.  Conversely, the adversarial features in the Black Lung Program have  contributed to delays in reaching a final disposition of claims by allowing  opposing parties to provide evidence to refute initial claims and to appeal  claim decisions. For example, a party displeased with the initial decision  of the Division of Coal Mine Workers’ Compensation in the Department of  Labor’s Office of Workers’ Compensation Programs can request a  hearing with a Department of Labor Administrative Law Judge within 30  days after the Office of Workers’ Compensation Program decision is filed.  Dissatisfied parties can appeal Administrative Law Judge decisions to the  Department of Labor Benefits Review Board and Benefits Review Board  decisions can be appealed to the appropriate United States Circuit Court  of Appeals. Finally, Circuit Court of Appeals decisions may be appealed  to the Supreme Court of the United States. In 2009, GAO found that this  structure led to a high rate of appeals that prolong the resolution of  claims. Both miners and coal mine operators frequently seek appeals,  and for those claimants awarded compensation during the initial  adjudication in fiscal year 2008, the coal mine operators found liable   Since  appealed the decision approximately 80 percent of the time.decisions are routinely appealed, GAO previously found that each level of  appeal review can take up to a year to adjudicate; ultimately, a claim may  remain in the adjudication process for years with the administering federal  agency incurring the cost for the years of processing the claim. For  example, for claims between 2001 and 2008, 28 percent of the claims of  miners awarded compensation from coal mine operators spent 3 to 8  years within the adjudication process. During this period, the claimant’s  ultimate entitlement to compensation will remain in doubt.
All three programs provide outreach and assistance services to potential  claimants. The Energy Employees Occupational Illness Compensation  Program sponsors outreach activities, including town hall meetings and  traveling resource centers, to disseminate information about benefits and  provide assistance to claimants in applying for benefits. For the Black  Lung Program, 15 black lung grantees, which provide specialized  diagnosis and treatment services, outreach, and educational programs to  help patients and their families deal with the disease have been  established through grants from the Department of Health and Human  Services. The Radiation Exposure Compensation Program has  established grant-based Radiation Exposure Screening and Education  Programs that support programs for health screening, education, medical  referral, and appropriate follow-up services for eligible individuals.
Departments of Labor and Justice officials told us that when programs  provide outreach and assistance to potential claimants both claimants  and administrators benefit because the filed claims are more complete  and contain fewer errors. For the Radiation Exposure Compensation  Program, these features allow program administrators to meet with  citizens, respond to questions about the program, conduct town hall  meetings, and assist in filling out claim forms. For the Energy Employees  Occupational Illness Compensation Program, town hall meetings have  provided information to more remote locations where individuals may not  have known they might have been exposed to radiation and, according to  the Department of Labor’s 2009 annual report, this outreach resulted in  86 new claims in fiscal year 2009. In addition, resource centers located  near major Department of Energy facilities helped claimants complete  necessary claim forms and gather documentation such as employment  verification to support their claims. In fiscal year 2009, this outreach  helped claimants file 9,935 claims. Further, the Energy Employees  Occupational Illness Compensation Program continues to assist  claimants by enhancing its database on the types of chemical and toxic  contaminants that existed at the major Department of Energy facilities,  easing claimants’ evidentiary burdens and speeding the claims process.
According to officials from the agencies that administer the alternative  programs for compensation we reviewed and our prior work, the eligibility  requirements of a given program may have an impact on the difficulty of  claimants trying to establish eligibility, the time needed to process claims,  and the cost of administering the program. The evidence needed by  claimants varies based on the criteria for each program, which are set out  in statutes and regulations. For example, under many compensation  programs, claimants must typically show a link between an environmental  exposure and subsequent adverse health conditions to be eligible.  However, the three programs we examined have certain presumptions  that alleviate the need for claimants to fully establish a causal link  between an environmental exposure and subsequent adverse health  condition. These presumptions address, among other things, locations at  which environmental exposures are presumed to have occurred, time  frames during which claimants present in certain locations are presumed  to have been exposed, and health conditions that are presumed to have  been caused by an exposure. According to officials from the agencies  that administer the alternative programs for compensation, although  presumptions may reduce the burden on the claimant they may  potentially increase costs. In addition, very specific presumptions can  reduce eligibility for individuals who do not meet established criteria but  who, in fact, developed adverse health conditions due to exposure, while  very broad presumptions may overstate the connection between an  exposure and adverse health conditions, allowing claimants who were not  harmed by the exposure to obtain benefits and potentially increasing the  cost of the program unnecessarily. The three alternative programs for  compensation that we reviewed further illustrate how eligibility  requirements may have an impact on the difficulty of claimants trying to  establish eligibility, the time needed to process claims, and the cost of  administering the program.
The Energy Employees Occupational Illness Compensation Program  provides compensation for several different types of claimants. Part B  provides compensation for, among others, employees of the  Department of Energy, its contractors or subcontractors, and atomic  weapons employers with radiation-induced cancer who developed the  cancer after working at a covered facility and whose cancer is  determined to be at least as likely as not related to the employment.  The Energy Employees Occupational Illness Compensation Program  relies on extensive medical and scientific processes that reconstruct  the radiation dose exposure by estimating the type and level of  radiation exposure to each affected organ to collect accurate evidence  for those claimants with a potential radiation-exposure related cancer,  which, based on previous GAO work, may increase the time and  administrative cost to adjudicate a claim. In 2010, GAO found that it  took 3 or more years to process claims that required a radiation dose  reconstruction, while those that did not require this reconstruction took  about a year to adjudicate. In addition, the direct administrative  costs for cases that require a dose reconstruction for potential  radiation-exposure related cancer, based on our 2010 report, are  estimated at about $20,000 per case, while the administrative costs of  other cases under the program ranged from $6,000-$8,000 per  case. However, in some cases in which it is not feasible to estimate  with sufficient accuracy the radiation dose received by employees at  Department of Energy facilities who were likely exposed to radiation— and there is a reasonable likelihood that such radiation dose may  have endangered employees’ health—the Energy Employees  Occupational Illness Compensation Program Act provides for the  addition of a class of those employees to the special exposure cohort.  Unlike claimants who are not members of the special exposure  cohort, members of the cohort who are diagnosed with any of the  cancers specified by Congress are not required to establish that the  cancer was “at least as likely as not” related to their employment. For  members of the cohort, this presumption reduces the evidence  necessary to meet eligibility requirements by removing the need to  establish causation between the exposure and the illness. According  to Department of Labor officials, for members of any of the more than  70 additional classes of employees added to the special exposure  cohort, the claim approval rate is 60 percent, compared to 34 percent  for claimants who are not in the special exposure cohort. Agency  officials told us that the special exposure cohort alleviates the need for  administrators to determine whether evidence supports the existence  of a link between the employment and the illness for each individual,  thus reducing administrative costs and the time needed for  adjudicating claims. However, these presumptions may overstate the  connection between an exposure and adverse health conditions and  potentially increase the cost of benefits provided in the program by  allowing claimants who were not harmed by the exposure to obtain  benefits.
In order to receive benefits under the Black Lung Program, claimants  must generally show that the miner has or had pneumoconiosis, the  pneumoconiosis resulted in total disability or death, and that the  pneumoconiosis arose, at least in part, out of coal mine employment.  The requirement to establish causation between the coal mine  employment and the adverse health condition may increase the  difficulty for claimants trying to establish eligibility. For example, prior  GAO work has shown that few claimants have been able to meet the  program’s evidentiary requirements set by law. In 2008, 87 percent  of claims within the Black Lung Program were denied, with over 60  percent of the claims denied during the initial adjudication because  claimants could not prove that they had pneumoconiosis or that  pneumoconiosis had caused disability or death. The Black Lung  Program has some presumptions, set out in statute, that ease this  requirement for claimants who worked at a coal mine. However,  some of these presumptions are rebuttable, and according to agency  officials, can still be refuted by the mine operator.
Claimants seeking compensation under the Radiation Exposure  Compensation Program must show that they were exposed to  radiation from atmospheric nuclear testing or as a result of their  employment in the uranium mining industry, and that they developed  a related adverse health condition, specified in law or regulation.  These claimants are not required to establish causation between the  exposure and the adverse health condition. According to a  Department of Justice report, the Radiation Exposure Compensation  Program was designed to utilize existing records so that claims could  be resolved in a reliable, objective, and nonadversarial manner, with  little administrative cost to the program or person filing the claim. For  example, residents who lived downwind of atmospheric nuclear  weapons tests may use a record for ownership of a home to show that  they were present in a location during a specific time frame to meet  the qualifications of the program. While this approach may be  beneficial for administrators and claimants, the officials from the  agencies that administer the compensation programs told us that not  requiring the establishment of causation using scientific evidence  potentially diminishes the accuracy of decisions for claims, and may  increase the number of claimants who were not harmed by the  exposure but are approved for benefits. A study by the National  Academy of Sciences emphasizes this by concluding that eligibility for  the Radiation Exposure Compensation Program should be based on a  more scientific approach that emphasizes a “probability of causation”  model that uses a mathematical formula to determine whether  radiation exposure is likely the cause of an individual’s cancer.
The frequencies and types of payment provided vary among alternative  programs for compensation, and may impact the administrative costs of  compensation programs. For example, the Energy Employees  Occupational Illness Compensation Program Act and the Radiation  Exposure Compensation Act provide lump sum payments in varying  amounts, while the Black Lung Program provides monthly payments. The  Energy Employees Occupational Illness Compensation Program and the  Black Lung Program also provide compensation for some medical  expenses, and the Black Lung Program provides, in some cases,  payment of claimants’ attorney fees. According to Departments of Labor  and Justice officials who administer these programs, the frequency and  type of payments a program provides impacts administrative costs of the  program. For example, although a lump sum benefit payment has low  administrative costs since it is a one-time payment, some officials noted  that there may be moral implications with lump sum payments especially  in cases where the claimant may misallocate their lump sum award and  need to pursue benefits from other federal programs such as Social  Security Disability Insurance. Conversely, although monthly payments  may cost more in the longer term compared to lump sum payments,  especially if an adverse health condition must be periodically monitored  through the program in order to establish continued eligibility, a monthly  or periodic payment, on the other hand, would provide a steady stream of  income to the claimant but may also cost more to administer since the  funding agency must process payments on a monthly basis.
section_title: Conclusions
paragraphs: In the most recent Defense Installations Strategic Plan, DOD states its  goals of providing effective, safe, and environmentally sound living and  working places in support of DOD missions. However, limitations in some  of the existing policies targeting such areas as environmental restoration  complicate DOD’s efforts to consistently address environmental  exposures for individuals living or working on its installations. DOD only  recently revised its policy on health surveillance to include dependents  when collecting data that could improve its ability to address health risks  that may have resulted from environmental exposures. However, this  policy does not apply retroactively to past events such as those at Camp  Lejeune.
DOD does not fully track the status of its responses to recommendations  and findings of significant risk from the Agency for Toxic Substances and  Disease Registry’s public health assessments. In addition, the current  process does not ensure that status information on recommendations is  provided to or documented by the lead agent’s office, as prescribed in the  guidelines referenced in the memorandum of understanding between the  two agencies. As such, DOD cannot ensure that it has taken timely and  appropriate responses to all public health risks. Furthermore, because  DOD does not have a policy establishing when it is appropriate for  installations to request public health assessments or follow-up work  beyond the initial assessment of proposed National Priorities List sites by  the Agency for Toxic Substances and Disease Registry, DOD could be  missing opportunities to identify and resolve concerns about some health  threats. While DOD officials told us that cleanup laws do not require  identification of individuals potentially affected by past exposures, events  like the contamination at Camp Lejeune indicate a need for some  guidance on whether, when, and how to respond to health concerns  raised about such individuals.
section_title: Recommendations for Executive Action
paragraphs: To ensure that DOD meets its goal of providing effective, safe, and  environmentally sound living and working places, and to assess potential  gaps in policy coverage for individuals living or working on its installations  who are exposed to environmental hazards, the Secretary of Defense  should direct the Under Secretary of Defense for Acquisition, Technology,  and Logistics to take the following three actions:  (1) Establish procedures to comprehensively track and document the  status and nature of DOD responses to Agency for Toxic Substances and  Disease Registry recommendations and findings of significant risk to  ensure that DOD and its components monitor the status of these  recommendations and findings of significant risk and respond in a timely  manner. These procedures should be reflected in an updated  memorandum of understanding prepared in collaboration with the Agency  for Toxic Substances and Disease Registry, and could include revisions  to the agencies’ joint guidelines or other mechanisms.  (2) Establish a policy that identifies when installations should consider  requesting public health assessments in addition to the initial  assessments at National Priorities List sites.  (3) Provide guidance on what actions, if any, DOD should take to identify  and address possible health risks faced by individuals from past  exposures at military installations.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided copies of this report for review and comment to the  Departments of Defense, Veterans Affairs, Health and Human Services,  Labor, and Justice. The Departments of Defense, Veterans Affairs, and  Health and Human Services provided written comment letters; all of the  departments provided technical comments which we have incorporated  as appropriate. The Departments of Defense’s, Veterans Affairs’, and  Health and Human Services’ written comment letters are reprinted in  appendices IV, V, and VI, respectively. The Department of Veterans  Affairs supported the recommendations, stating that “the Department of  Defense’s adoption of the report recommendations would likely lead to  prompt provision of additional information on exposures, and ultimately  help veterans and others potentially exposed.” The Department of Health  and Human Services expressed its support for the first recommendation  indicating that it would be available to collaborate with DOD to update the  current memorandum of understanding. In its comments, DOD partially  concurred with our first recommendation and did not concur with our  second and third recommendations. We continue to believe our  recommendations remain valid, as discussed in the report.
DOD partially concurred with our first recommendation––to establish  procedures to comprehensively track and document the status and nature  of DOD responses to public health recommendations and reflect these  procedures in an updated memorandum of understanding. Specifically:
DOD stated that it will review its procedures for tracking DOD’s  responses to Agency for Toxic Substances and Disease Registry  recommendations and, if needed, make the appropriate changes  to its tracking system. As noted in our report, the tracking system  data provided to GAO indicated that DOD did not have information  on the status of DOD’s response to 80 percent of the  recommendations. Therefore, we believe DOD needs to make  improvements to its tracking system. Without these improvements,  DOD is missing opportunities to ensure that vital public health  issues are adequately addressed.
In regards to the memorandum of understanding, DOD stated that  changes are not necessary. We disagree. The current  memorandum of understanding does not expressly call for  tracking recommendations, which we believe is an important  coordination activity. As we note in our report, the memorandum  of understanding does refer to DOD guidelines for tracking  recommendations, but these have not been updated in 17 years.  Moreover, these guidelines are not being followed, as our report  shows and DOD officials acknowledged. These guidelines called  for regular updates and an annual report on the status of  recommendations and public health actions at each site. On the  other hand, the Agency for Toxic Substances and Disease  Registry officials told us that updating the memorandum of  understanding with DOD, to address tracking recommendations  would be useful. Given that DOD is not following the tracking  procedures in its existing guidelines and overlooking the status of  80 percent of the recommendations, we believe that the  memorandum of understanding should be revised to expressly  address tracking responsibilities to help ensure that identified  public health risks are addressed.
DOD did not concur with our second recommendation––to establish a  policy that identifies when installations should consider requesting public  health assessments in addition to the initial assessments at National  Priorities List sites. DOD stated that its agrees that there should be  policies in place to guide decisions on soliciting public health  assessments, but believes the appropriate policies and responsibilities  are already in place. We disagree with DOD for several reasons:
First, DOD states that additional public health assessments  conducted by the Agency for Toxic Substances and Disease  Registry would duplicate the risk assessments conducted by DOD  and others, which it believes are more comprehensive. We believe  DOD’s comments overlook the important distinctions between the  two assessments. Risk assessments are intended to enable the  selection of cleanup remedies to reduce or eliminate current and  future exposures, but these risk assessments generally do not  include epidemiology or assessments of health risk to populations  from current, future, and past exposures, as the public health  assessments do––a fact which DOD officials acknowledged.  Thus, these assessments have distinct purposes and scopes.
Second, DOD states that supplementary policy for additional  public health assessments for DOD cleanup sites is not needed,  but did not elaborate on the reasons why. In the course of  conducting a DOD cleanup program, installations may become  aware of past exposures––such as at Tyndall Air Force Base or  Camp Lejeune––years after an initial health assessment was  developed. In fact, site characterization and restoration activities  may take many years, and new health risks may be discovered  during this process. However, without this guidance, it is unclear  when it is appropriate to request a new health assessment.
Third, DOD states that its current policies require the assessment  of health risks to servicemembers and their dependents living on  its installations; however, until DOD’s February 2012 revised  directive, it was unclear when and if health surveillance data were  collected for servicemembers’ dependents. As we said in the  report, it is too soon to determine whether the implementation of  this directive will include all individuals living or working on DOD  installations––particularly servicemembers’ dependents living on  overseas installations. As such, policies beyond the general  directive are needed to ensure appropriate data are collected that  might support a public health assessment when necessary.
Finally, DOD states that assessments at Naval Air Station Atsugi,  Japan, and Naval Air Station Fallon, Nevada, were initiated based  on health concerns raised by military families living on these  installations. However, in our view, these examples highlight  DOD’s reactive––rather than proactive––approach to responding  to health concerns.  In the case of air pollution at Atsugi, no DOD  policy existed to guide the Navy on their approach to conducting  environmental surveillance, medical testing, or notification of the  potentially exposed dependents. As a result, it took several years  for DOD to complete a risk assessment and notify  servicemembers and their dependents about the long-term health  effects. It took at least 13 years after the initial complaints for DOD  and the U.S. government to get the Japanese government to  close the incinerator that contributed to the air pollution. Policies to  guide decisions on soliciting public health assessments could  accelerate DOD’s response to future public health concerns.
DOD did not concur with our third recommendation––to provide guidance  on actions to identify and address possible health risks faced by  individuals from past exposures at military installations. DOD stated that it  follows federal law, and its current guidance and policy are adequate for  reasonably anticipated actions. We disagree for two reasons:
The experiences at Atsugi Naval Air Station and Camp Lejeune  demonstrate that DOD’s current guidance and policy are not  adequate to encompass situations that have potentially severe  health implications, which DOD has already encountered in the  past. At Atsugi, an off-base incinerator in Japan released toxic  fumes that drifted onto the naval base and may have exposed  over 25,000 individuals on the installation to toxic air contaminants  from 1985 through 2001, according to the Department of Veterans  Affairs, despite individual complaints starting around 1988. At  Camp Lejeune, potential exposure to volatile organic compounds  in drinking water has resulted in administrative claims by  servicemembers against the U.S. government totaling billions of  dollars in potential damages for health conditions alleged to have  resulted from exposure to contaminated water. In these examples,  no current DOD policy or guidance was available to provide focus  and direction in how officials should address past exposures. We  continue to believe that these experiences could inform new  policies by DOD to provide guidance to the services and their  installations on how to manage situations that encounter similar  challenges in the future, while maintaining appropriate flexibility.
DOD stated that its cleanup policy is adequate because the  Comprehensive Environmental Response, Compensation, and  Liability Act does not require responsible parties to identify  individuals who may have been exposed to contamination in the  past. We agree that the act does not generally require responsible  parties to identify exposed individuals, but that was not the basis  for our recommendation; moreover, DOD is not limited to meeting  the minimum requirements of federal law. GAO was mandated by  Congress to review the extent to which DOD has a standard  framework for responding to environmental hazards and possible  exposures, among other things, and to make recommendations  for any administrative action “that the Comptroller General deems   In determining  appropriate in the context of the assessment.”whether there is a standard framework, we found these gaps in  policy. In light of these gaps and our mandate, we believe it is  appropriate and have recommended that DOD develop guidance  to assist the services and their installations in these situations.  Further, we emphasize that our recommendation calls for  guidance, but leaves its substance—such as what actions, if any,  are appropriate—to DOD.
In its written comments on a draft of this report, the Department of  Veterans Affairs stated that environmental exposure data should be  available in service treatment records and that this information is vitally  important for the Department to adequately adjudicate claims based on  environmental exposures. Accordingly, the Department stated that DOD’s  adoption of our report recommendations would likely lead to the prompt  provision of additional information on exposures, and ultimately help  veterans and others potentially exposed. The Department of Veterans  Affairs’ written comments are reprinted in appendix V.
In its written comments on a draft of this report, the Department of Health  and Human Services stated that in regards to our first recommendation,  the Agency for Toxic Substances and Disease Registry would be  available for collaboration with DOD to update the current memorandum  of understanding that is in place regarding the Agency for Toxic  Substances and Disease Registry’s recommendations and findings for  significant risk. The Department of Health and Human Services’ written  comments are reprinted in appendix VI.
We are sending copies of this report to interested congressional  committees and the Secretaries of Defense, Labor, Veterans Affairs; the  Under Secretary of Defense for Acquisition, Technology, and Logistics;  the Attorney General; and the Director of the Centers for Disease Control  and Prevention. The report also is available at no charge on GAO’s  website at http://www.gao.gov.
If you or your staff have any questions concerning this report, you may  contact us at: Brian J. Lepore, (202) 512-4523 or leporeb@gao.gov or  David C. Trimble, (202) 512-9338 or trimbled@gao.gov. Contact points  for our Offices of Congressional Relations and Public Affairs may be  found on the last page of this report. Key contributors to this report are  listed in appendix VII.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: The objectives of our report were to determine (1) the extent to which the  Department of Defense (DOD) has policies for identifying and responding  to possible human exposures to environmental hazards on its  installations; (2) what programs currently exist to provide health care and  compensation to individuals for adverse health conditions resulting from  environmental exposures on military installations and any factors that  may affect these individuals’ access to health care or compensation; and  (3) the features of alternative federal programs that provide medical  benefits or compensation to large groups of individuals affected by a  specific environmental exposure, which may be considered as possible  options in the design of any future programs for individuals harmed by  environmental hazards.
To determine the extent to which DOD has policies for identifying and  responding to possible human exposures to environmental hazards on its  installations, we reviewed and analyzed relevant laws as well as DOD,  Environmental Protection Agency, and Agency for Toxic Substance and  Disease Registry guidance and other documentation to identify the extent  to which DOD identifies and responds to environmental exposures that  may pose a risk to human health. In conducting this analysis, we  catalogued DOD guidance and conducted content analysis to determine  the extent to which the guidance addressed environmental exposures on  military installations. Additionally, we conducted a literature search in  professional journals to identify DOD policies in responding to  environmental exposures. We also examined the database used to track  the Agency for Toxic Substances and Disease Registry’s public health  assessment recommendations and DOD’s implementation of those  recommendations. In addition, we interviewed DOD officials at the Office  of the Secretary of Defense and the various components, as well as  officials at the Environmental Protection Agency, the Agency for Toxic  Substances and Disease Registry, and some members of the Agency for  Toxic Substances and Disease Registry’s Community Assistance Panel  for Camp Lejeune. The Agency for Toxic Substances and Disease  Registry created the community assistance panel as the forum for the  Camp Lejeune community to voice concerns and provide input into future  health studies regarding the water contamination at Camp Lejeune. We  attended the July 2011 meeting of the Community Assistance Panel held  in Wilmington, North Carolina and also conducted site visits to Camp  Lejeune, North Carolina and Aberdeen Proving Ground, Maryland where  the Army, as DOD’s Executive Agent for interaction with the Agency for  Toxic Substances and Disease Registry, has its offices.
To determine what programs currently exist to provide health care and  compensation to individuals for adverse health conditions resulting from  environmental exposures on military installations and any factors that  may affect these individuals’ access to health care or compensation, we  reviewed and analyzed relevant laws and regulations, agency guidance,  scientific journals, and other documentation to identify the eligibility  requirements and determination procedures and extent of compensation  and medical benefits provided through various processes currently  available to different types of individuals (veterans and servicemembers  and current and former military dependents, federal civilian workers, and  contractors) possibly exposed to environmental hazards while working or  living on military installations. We reviewed the following programs: the  Federal Employee Compensation Act Program, Department of Defense’s  TRICARE, Department of Defense’s Disability Evaluation System,  Department of Veterans Affairs’ disability benefits and health care  benefits programs, State Workers’ Compensation Programs, the Defense  Base Act, and Federal Employee Health Benefits Program. We then  developed matrices comparing the eligibility requirements and  determination procedures of the various programs to identify what types  of individuals were eligible for the various programs and if there were any  gaps in coverage. We met agency officials from the Departments of  Defense, Veterans Affairs, Labor, and Justice, to obtain further insight  into the administration and eligibility requirements of the various  programs; find out the reasons for any gaps in coverage and what  challenges exist in obtaining benefits or compensation; and determine the  potential adverse effects any such gaps and challenges may have on  individuals exposed to environmental hazards. In addition, we interviewed  officials from each of the Army, Navy, and Air Force Judge Advocate  Offices to obtain information regarding environmental exposure tort  claims and the process for filing claims. To assess the reliability of claims  data obtained from the Department of the Navy and the Department of  Veterans Affairs, we interviewed agency officials regarding the processes  and procedures used to verify accurate data are maintained within the  databases. Although we did not independently validate the claims data,  we found these data to be sufficiently reliable for our purposes.
To determine the features of alternative federal programs that provide  medical benefits or compensation to large groups of individuals affected  by a specific environmental exposure, which may be considered as  possible options in the design of any future programs for individuals  harmed by environmental hazards, we reviewed and analyzed relevant  laws and regulations, academic journals, external studies, and previous  GAO reports to identify alternative compensation programs that (1)  provided monetary compensation for specific adverse health conditions or  death and/or medical benefits, (2) provided compensation based on  exposure to a harmful contaminant in the environment, and (3) were  federal programs that covered U.S. citizens. Using these criteria, we  identified three programs: The Black Lung Program administered by the  Department of Labor, the Energy Employee Occupational Illness  Compensation Program administered by the Department of Labor, and  the Radiation Exposure Compensation Program administered by the  Department of Justice as the most comparable of environmental  exposure compensation programs. We identified one other environmental  exposure-related compensation program, the Marshall Islands Nuclear  Claims Tribunal, but did not include it our analysis because it does not  provide compensation to U.S. citizens. Although we collected and  reviewed information regarding other compensation programs such as the  Smallpox Vaccine Injury Compensation Program, the National Vaccine  Injury Compensation Program, and the September 11th Victim  Compensation Fund, we did not include these programs in our analysis  as they do not provide compensation for injuries caused by environmental  hazards. Both the Smallpox Vaccine Injury Compensation Program and  the National Vaccine Injury Compensation Program provide  compensation for injuries caused by vaccines and the September 11th  Victim Compensation Fund only provides compensation based on death  or injury caused by terrorist attacks. To identify and assess the features of  these alternative compensation programs, including the benefit and  challenges to the design of features, we reviewed prior GAO reports, met  with GAO experts who have reported on these programs, interviewed  agency officials with the Departments of Labor and Justice, and obtained  and reviewed documentation and claims data on the programs from  agency officials. To assess the reliability of claims data obtained by the  Departments of Labor and Justice, we interviewed agency officials and  received written documentation on internal control used by the agencies  and the processes and procedures used to verify accurate data are  maintained within the databases. Although we did not independently  validate the claims data, we found these data to be sufficiently reliable for  our purposes.
We conducted this performance audit between May 2011 and May 2012  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
section_title: Appendix II: Selected Contaminants That Have Been Found on Some Military Installations and Their Effect on Humans
paragraphs: The Department of Defense has 141 installations on the national priorities  list. In some cases, these installations and surrounding areas became  heavily contaminated due to storage and disposal of substances such as  solvents, machining oils, metalworking fluids, and metals. Many of these  contaminants, such as trichloroethylene, perchloroethylene, and vinyl  chloride, are known or suspected carcinogens. On some installations,  these contaminants have spread far beyond their points of origin because  they have been transported by wind currents or have leached into  groundwater supplies, resulting in potential environmental exposures.  Some of these contaminants include:
Perchlorate is a rocket fuel component and by-product of rocket and  missile testing and is also found in some fertilizers and fireworks.  Now ubiquitous in the environment, it has spread from numerous  manufacturing sites into drinking water systems and can also  accumulate in leafy food crops and fruit irrigated by perchlorate- contaminated water. According to the Agency for Toxic Substances  and Disease Registry, perchlorate’s main target for toxicity in humans  is the thyroid gland. In humans, perchlorate accumulates in the thyroid  gland and can block iodide transfer into the thyroid, resulting in iodine  deficiency and lower thyroid activity. The populations most sensitive to  perchlorate exposure are children and fetuses, as adequate iodide is  crucial for neurological development.
Trichloroethylene and Perchloroethylene are solvents that have  historically been used as metal degreasers and as ingredients in dry- cleaning spot removers, adhesives, paint removers, and typewriter  correction fluids. According to the Environmental Protection Agency,  exposure to trichloroethylene and perchloroethylene can result in  cardiac arrhythmia, liver damage, and possible kidney effects, as well  as an increased risk for a variety of cancers (esophagus, kidney,  bladder, lung, pancreas, and cervix). Trichloroethylene and  perchloroethylene degrade in groundwater over time to vinyl chloride.
Vinyl chloride is a colorless gas with a sweet odor. Vinyl chloride is  used to manufacture numerous products in building construction, the  automotive industry, electrical wire insulation and cables, piping,  industrial and household equipment, and medical supplies, and is  depended upon heavily by the rubber, paper, and glass industries.  Vinyl chloride is a known human carcinogenic and, according to the  Environmental Protection Agency, long-term exposure to vinyl  chloride may lead to liver cancer.
Benzene is a colorless liquid with a sweet odor that is highly  flammable, evaporates in the air very quickly, and dissolves slightly in  water. Benzene is formed from both natural processes and human  activities. Natural sources of benzene include volcanoes and forest  fires. Benzene is a natural part of crude oil, gasoline, and cigarette  smoke. It is widely used in the United States. Some industries use  benzene to make other chemicals that are used to make plastics,  resins, and nylon and synthetic fibers. Benzene is also used to make  some types of lubricants, rubbers, dyes, detergents, drugs, and  pesticides. In humans, benzene causes cells not to work correctly.  For example, it can cause bone marrow not to produce enough red  blood cells, which can lead to anemia. Also, it can damage the  immune system by changing blood levels of antibodies and causing  the loss of white blood cells. The Department of Health and Human  Services has determined that benzene causes cancer in humans.
Lead is extensively used in ammunition and firearms and, as a result,  is prevalent in the soil of current and former firing ranges on many  military installations. Lead can affect almost every organ and system  in the body. The main target for lead toxicity is the nervous system,  both in adults and children. Exposure to high lead levels can severely  damage the brain and kidneys in adults or children.
section_title: Appendix III: Significant Health Studies and Notification Efforts Related to Contamination at Marine Corps Base Camp Lejeune
paragraphs: Appendix III: Significant Health Studies and  Notification Efforts Related to Contamination  at Marine Corps Base Camp Lejeune 1997 – An Agency for Toxic Substances and Disease Registry health assessment stated that exposure to volatile organic compounds in three  drinking water systems on base was a public health hazard. The Agency also stated that the exposures were not likely to cause health problems in  adults but recommended that studies be conducted to evaluate the risks of childhood cancer related to volatile organic compound exposure at Camp  Lejeune and noted that adverse pregnancy outcomes were also of concern.  1998 – An Agency for Toxic Substances and Disease Registry study found a statistically significant association between exposure and some adverse  pregnancy outcomes.  1999 – 2012 – An Agency for Toxic Substances and Disease Registry case-control study of specific birth defects and childhood cancers at Camp  Lejeune was initiated to evaluate whether in utero exposure and/or exposure during the first year of life to contaminated drinking water at the base  was associated with specific birth defects and childhood cancers. Agency for Toxic Substances and Disease Registry expects completion of the study  some time in 2012.  2005 – An expert panel reported on the Agency for Toxic Substances and Disease Registry’s computer models of past Camp Lejeune drinking water  systems. The Agency for Toxic Substances and Disease Registry said it accepted the panel’s recommendations for more rigorous record searches in  order to reconstruct events for the water modeling studies.  2007 – A Marine Corps online notification registration database and a new telephone line was activated to place former Camp Lejeune residents,  workers, and other interested parties on a contact list to receive results from research initiatives.  2008 – The National Defense Authorization Act for Fiscal Year 2008, Pub. L. No 110-181 § 315 required, among other things, that the Secretary of  the Navy make reasonable efforts to identify and notify directly certain individuals – those served by the contaminated water systems or civilian  employees in particular timeframes—who may have been exposed to the contaminated drinking water at Camp Lejeune.  2008 – A Marine Corps and Internal Revenue Service mailing was sent to about 150,000 individuals who resided or worked at Camp Lejeune during  the applicable timeframe encouraging individuals to join the contact list to be notified about research initiatives.  2009 – The Agency for Toxic Substances and Disease Registry said it withdrew its 1997 public health assessment after additional information  emerged related to exposures to volatile organic compounds in drinking water at Camp Lejeune. The public health agency said inaccuracies  regarding the exclusion of benzene in the 1997 assessment caused the withdrawal. The Agency for Toxic Substances and Disease Registry plans to  revise the public health assessment once a water modeling study is complete. In the meantime, the Agency for Toxic Substances and Disease  Registry said it stands behind the information related to the other nine exposure pathways.  2009 – The National Research Council completed a report in response to a request from the Navy, mandated by Congress (Pub. L. No. 109-364,  §318), to review evidence on whether adverse health outcomes are associated with past contamination of the water supply at Camp Lejeune. Among  other things, the National Research Council concluded that most questions about whether exposures at Camp Lejeune resulted in adverse health  effects cannot be answered definitively even with further scientific study.  2010 – The Agency for Toxic Substances and Disease Registry began conducting a mortality study looking at all causes of death, including cancers  and other fatal diseases to determine if there is a link between the death and exposure to contaminated drinking water at Camp Lejeune. The study  focuses on Marines who started active duty and DOD civilian employees who began work at Camp Lejeune between June 1975 and December 1985.  2011 – The Agency for Toxic Substances and Disease Registry launched a health survey of 300,000 Marine Corps personnel and civilians regarding  diseases that may be associated with chemical exposures in the drinking water, in response to a mandate in the 2008 National Defense Authorization  Act. This is the largest health survey ever conducted by the Agency for Toxic Substances and Disease Registry, which expects to release its findings  in 2014.
section_title: Appendix V: Comments from the Department of Veterans Affairs
section_title: Appendix VI: Comments from Department of Health and Human Services
section_title: Appendix VII: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Acknowledgments
paragraphs: In addition to the individuals named above, Diane Raynes (Assistant  Director), Mark J. Wielgoszynski (Assistant Director), Shawn Arbogast,  Elizabeth Beardsley, Marissa Dondoe, Laurie Ellington, Dani Greene,  Joanne Landesman, Nicholas McKay, Jennifer Neer, Alison O’Neill,  Daniel Semick, Amie Steele, and Nicole Willems made key contributions  to this report.
section_title: Related GAO Products
paragraphs: Hearing Loss Prevention: Improvements to DOD Hearing Conservation  Programs Could Lead to Better Outcomes. GAO-11-114. Washington,  D.C.: January 31, 2011.
Afghanistan and Iraq: DOD Should Improve Adherence to Its Guidance  on Open Pit Burning and Solid Waste Management. GAO-11-63.  Washington, D.C.: October 15, 2010.
Superfund: Interagency Agreements and Improved Project Management  Needed to Achieve Cleanup Progress at Key Defense Installations.  GAO-10-348. Washington, D.C.: July 15, 2010.
Agency for Toxic Substances and Disease Registry: Policies and  Procedures for Public Health Product Preparation Should Be  Strengthened. GAO-10-449. Washington, D.C.: April 30, 2010.
Energy Employees Compensation: Additional Oversight and  Transparency Would Improve Program’s Credibility. GAO-10-302.  Washington, D.C.: March 22, 2010.
Black Lung Benefits Program: Administrative and Structural Changes  Could Improve Miners’ Ability to Pursue Claims. GAO-10-7. Washington,  D.C.: October 30, 2009.
Superfund: Greater EPA Enforcement and Reporting are Needed to  Enhance Cleanup at DOD Sites. GAO-09-278. Washington, D.C.: March  13, 2009.
Radiation Exposure Compensation: Radiation Exposure Compensation  Act: Program Status. GAO-07-1037R. Washington, D.C.: September 7,  2007.
Environmental Contamination: Department of Defense Activities Related  to Trichloroethylene, Perchlorate, and Other Emerging Contaminants.  GAO-07-1042T. Washington, D.C.: July 12, 2007.
Defense Health Care: Issues Related to Past Drinking Water  Contamination at Marine Corps Base Camp Lejeune. GAO-07-933T.  Washington, D.C.: June 12, 2007.
Defense Health Care: Activities Related to Past Drinking Water  Contamination at Marine Corps Base Camp Lejeune. GAO-07-276.  Washington, D.C.: May 11, 2007.
Federal Compensation Programs: Perspectives on Four Programs.  GAO-06-230. Washington, D.C.: November 18 2005.
Defense Health Care: Improvements Needed in Occupational and  Environmental Health Surveillance during Deployment to Address  Immediate and Long-term Health Issues. GAO-05-632. Washington, D.C.:  July 14, 2005.
Perchlorate: A System to Track Sampling and Cleanup Results is  Needed. GAO-05-462. Washington, D.C.: May 20, 2005.
Agent Orange: Limited Information Is Available on the Number of Civilians  Exposed in Vietnam and Their Workers’ Compensation Claims.  GAO-05-371. Washington, D.C.: April 22, 2005.
Environmental Compliance: Better DOD Guidance Needed to Ensure  That the Most Important Activities Are Funded. GAO-03-639. Washington,  D.C.: June 17, 2003.