Chemical and Biological Defense: DOD and VA Need to Improve Efforts to Identify and Notify Individuals Potentially Exposed during Chemical and Biological Tests
Published: 2008-02-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Tens of thousands of military personnel and civilians were potentially exposed to chemical or biological substances through Department of Defense (DOD) tests since World War II. DOD conducted some of these tests as part of its Project 112 test program, while others were conducted as separate efforts. GAO was asked to (1) assess DOD's efforts to identify individuals who were potentially exposed during Project 112 tests, (2) evaluate DOD's current effort to identify individuals who were potentially exposed during tests conducted outside of Project 112, and (3) determine the extent to which DOD and the Department of Veterans Affairs (VA) have taken action to notify individuals who might have been exposed during chemical and biological tests. GAO analyzed documents and interviewed officials from DOD, VA, the Department of Labor, and a veterans service organization.
section_title: What GAO Found
paragraphs: Since 2003, DOD has stopped actively searching for individuals who were potentially exposed to chemical or biological substances during Project 112 tests, but did not provide a sound and documented basis for that decision. In 2003, DOD reported it had identified 5,842 servicemembers and estimated 350 civilians as having been potentially exposed during Project 112, and indicated that DOD would cease actively searching for additional individuals. However, in 2004, GAO reported that DOD did not exhaust all possible sources of information and recommended that DOD determine the feasibility of identifying additional individuals. In response to GAO's recommendation, DOD determined continuing an active search for individuals had reached the point of diminishing returns, and reaffirmed its decision to cease active searches. This decision was not supported by an objective analysis of the potential costs and benefits of continuing the effort, nor could DOD provide any documented criteria from which it made its determination. Since June 2003, however, non-DOD sources--including the Institute of Medicine--have identified approximately 600 additional names of individuals who were potentially exposed during Project 112. Until DOD provides a more objective analysis of the costs and benefits of actively searching for Project 112 participants, DOD's efforts may continue to be questioned. DOD has taken action to identify individuals who were potentially exposed during tests outside of Project 112, but GAO identified four shortcomings in DOD's current effort. First, DOD's effort lacks clear and consistent objectives, scope of work, and information needs that would set the parameters for its efforts. Second, DOD has not provided adequate oversight to guide this effort. Third, DOD has not fully leveraged information obtained from previous research efforts that identified exposed individuals. Fourth, DOD's effort lacks transparency since it has not kept Congress and veterans service organizations fully informed of the progress and results of its efforts. Until DOD addresses these limitations, Congress, veterans, and the American public can not be assured that DOD's current effort is reasonable and effective. DOD and VA have had limited success in notifying individuals potentially exposed during tests both within and outside Project 112. DOD has a process to share the names of identified servicemembers with VA; however, DOD has delayed regular updates to VA because of a number of factors, such as competing priorities. Furthermore, although VA has a process for notifying potentially exposed veterans, it was not using certain available resources to obtain contact information to notify veterans or to help determine whether they were deceased. Moreover, DOD had not taken any action with the civilian names, focusing instead on veterans since the primary impetus for the research has been requests from VA. DOD has refrained from taking action on civilians in part because it lacks specific guidance that defines the requirements to notify civilians. Until these issues are addressed, some identified veterans and civilians will remain unaware of their potential exposure.

section_title: Letter
paragraphs: As we have previously reported, since World War II, tens of thousands of  military personnel and civilians have been involved in classified human  experimentation and were potentially exposed to chemical and biological  substances through tests conducted or sponsored by the Department of  Defense (DOD). Some of these tests and experiments involved the  intentional exposure of people to hazardous substances such as blister  and nerve agents, biological agents, lysergic acid diethylamide (LSD), and  phencyclidine (PCP). In some cases, healthy adults, psychiatric patients,  and prison inmates were used in these tests and experiments. According to  a 1994 staff report to the Senate Committee on Veterans Affairs, in some  instances, servicemembers who consented to serve as human subjects  found themselves participating in experiments quite different from those  described at the time they volunteered. These tests and experiments were  conducted to support weapon development programs, identify methods to  protect the health of military personnel against a variety of diseases and  combat conditions, and analyze U.S. defense vulnerabilities. From 1962  through 1974, DOD conducted a series of classified ship-based and land- based chemical and biological warfare tests involving military and civilian  personnel as well as, in some cases, foreign personnel observers—both  military and civilian. These tests were called Project 112 because in 1962 it  was the 112th project of 150 delineated by the Secretary of Defense  involving the classified testing of chemical and biological agents.
Precise information on the number of tests, experiments, and participants  is not available, and the exact numbers will never be known. However, as  a result of questions raised by members of Congress and veterans since  1993, DOD has undertaken three major initiatives to identify individuals  potentially exposed to chemical or biological substances during tests it  has sponsored or conducted. First, from 1993 to 1997, the former Office of  the Assistant Secretary of Defense for Force Manpower and Personnel  within the Office of the Under Secretary of Defense (OUSD) for Personnel  and Readiness (P&R) participated in a working group with the military  services and the Department of Veterans Affairs (VA) in response to a  January 1993 Institute of Medicine report on the exposure of individuals  to mustard agents and lewisite. The working group identified  approximately 6,400 servicemembers and civilians who were exposed to  mustard agents and other chemical substances.
Second, in August 2000, the acting Secretary of Veterans Affairs wrote a  letter to the Secretary of Defense requesting assistance in obtaining  information about a series of then-classified chemical and biological tests  under DOD’s Project 112 program. In response to this request and  subsequent congressional direction in the Bob Stump National Defense  Authorization Act for Fiscal Year 2003, the Office of the Assistant  Secretary of Defense (OASD) for Health Affairs (HA) within OUSD (P&R)  conducted an internal DOD investigation into Project 112. In a resulting  report issued in 2003, DOD identified 5,842 servicemembers and estimated  that 350 civilians had been potentially exposed during Project 112 tests.  We subsequently evaluated DOD’s efforts, and in May 2004, we reported  that DOD appeared to have accurately identified all major chemical and  biological tests associated with Project 112, but that there likely were  servicemembers and civilian personnel potentially exposed to substances  who had not been identified for various reasons.
Third, and in further response to congressional direction in the Defense  Authorization Act for FY 2003, the Office of the Special Assistant for  Chemical and Biological Defense and Chemical Demilitarization Programs  (hereafter referred to as the chemical and biological defense office) within  the OUSD for Acquisition, Technology, and Logistics (AT&L) issued a task  order to a contractor in September 2004 to identify servicemembers and  civilian personnel who might have been exposed to chemical and  biological substances outside of Project 112 tests. The research being  done as a result of this task order is ongoing as of December 2007.
For this review, you asked us to examine DOD’s current effort to identify  and notify individuals who were potentially exposed during chemical and  biological tests conducted or sponsored by DOD, including tests  conducted as a part of DOD’s Project 112 program and tests conducted  outside of Project 112. Accordingly, this report (1) assesses DOD’s efforts  since 2003 to identify individuals who were potentially exposed during  chemical or biological tests conducted during Project 112, (2) evaluates  DOD’s current effort to identify individuals who were potentially exposed  during chemical or biological tests conducted outside of Project 112, and  (3) determines the extent to which DOD and VA have taken action to  notify individuals who might have been exposed during chemical and  biological tests.
To evaluate DOD’s efforts to identify all individuals who were potentially  exposed to chemical or biological substances during Project 112 tests and  tests outside of Project 112, we interviewed and obtained documentation  from cognizant DOD, Institute of Medicine, and contractor officials. To  determine how potentially exposed individuals were identified, we visited  record repository sites where contractors were conducting research and  observed their research and documentation process. To determine the  extent to which DOD and VA have taken action to notify servicemembers  who might have been exposed during chemical and biological tests, we  met with DOD officials to discuss their efforts to provide names of  identified servicemembers to VA and with VA officials to describe VA’s  notification process. We evaluated the reliability of DOD’s and VA’s  databases containing the names of individuals potentially exposed during  chemical and biological tests and found that there were potential  problems with the quality and reliability of the information. Although we  determined that the information was sufficiently reliable for the purposes  of our review, this report discusses weaknesses with DOD’s information,  and our recommendation to address them. Consequently, the number of  individuals whom we report as having been identified and notified is based  on information from DOD’s and VA’s databases and is approximate. We  also met with representatives from a veterans service organization to gain  their perspectives on DOD and VA efforts to identify and notify veterans  potentially exposed to chemical and biological substances during DOD  tests. Because DOD identified civilians who might have been exposed to  chemical or biological substances, we also met with DOD and Department  of Labor officials to ascertain their roles and responsibilities in notifying  such civilians. Additional information on our scope and methodology  appears in appendix I. We conducted this performance audit from June  2007 to February 2008 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.
subsections: section_title: Background
paragraphs: On January 6, 1993, the Institute of Medicine published a report that  discussed secret U.S. chemical weapons programs during World War II.  The report found that an estimated 60,000 military personnel participated  as human experimental subjects in tests of exposure to mustard agents  and lewisite and unknown numbers of additional servicemembers may  have been exposed to these substances through their participation in the  production, transportation, and/or storage of these chemical substances.  On February 18, 1993, we issued a report that found VA lacked information  about individuals who were exposed during secret DOD chemical tests.  After Members of Congress, the President of the United States, and the  Secretary of Defense exchanged a series of letters about this issue in 1993,  the Deputy Secretary of Defense issued an agencywide memo that  released all individuals from any nondisclosure restrictions that might  have been placed on them, tasked the secretaries of the military  departments to undertake efforts to declassify and provide to VA as soon  as possible information about individuals who were potentially exposed,  and directed OUSD (P&R) to establish a task force to monitor the status of  DOD’s efforts. As a result, OUSD (P&R), the military services, and VA  developed the Chemical Weapons Exposure Study Task Force to identify  DOD personnel exposed to chemical substances during testing, training,  transport, production, and storage. By conducting site visits and other  research efforts, the task force identified approximately 6,400  servicemembers and civilians who were potentially exposed to mustard,  lewisite, and other chemical substances. The office created a database  with information about these individuals (hereafter referred to as OUSD  (P&R) database) and, according to OUSD (P&R), sent certificates of  commendation to more than 700 individuals for whom it could find  contact information. In addition to its own research, OUSD (P&R), on  behalf of the task force, issued a task order for a contractor to analyze,  extract, and develop a database of information on all volunteers and/or  other subjects potentially exposed to live chemical or biological  substances. The contractor developed a database and issued a series of  reports that identified the locations of human exposures to chemical  substances, including those resulting from tests and a variety of other  activities such as transportation, production, storage, and disposal.  Congress continued to look into this issue during 1994 through a series of  hearings and a staff report that was prepared for the U.S. Senate’s  Committee on Veteran Affairs.
The issue of servicemembers being used as human subjects during DOD’s  chemical and biological tests received high-level attention again in 2000,  when the acting Secretary of Veterans Affairs wrote a letter to the  Secretary of Defense requesting assistance in obtaining information about  a series of then-classified chemical and biological tests under DOD’s  Project 112 program. OASD (HA) officials consequently initiated some  actions to identify potentially exposed individuals. Subsequently, DOD,  VA, and Congress exchanged a series of correspondence about the need to  identify individuals who were potentially exposed during these tests.  Eventually, the Defense Authorization Act for FY 2003 required DOD to  submit to Congress and the Secretary of Veterans Affairs a comprehensive  plan for the review, declassification, and submittal to VA of all DOD  records and information on Project 112 that are relevant to the provision  of benefits by the Secretary of Veterans Affairs to members of the armed  forces who participated in that project. During this effort, DOD identified  5,842 servicemembers and estimated that 350 civilians had been  potentially exposed during Project 112 tests, and this information was  entered into a Project 112 database. The act further required the  Comptroller General to evaluate the plan and its implementation.
The Defense Authorization Act for FY 2003 also required DOD to work  with veterans and veterans service organizations to identify DOD projects  or tests outside of Project 112 that may have exposed members of the  armed forces to chemical or biological substances. In June 2004, we  reported that DOD had not yet begun its investigation to identify such  projects or tests and recommended that the Secretary of Defense direct  the appropriate office(s) to finalize and implement a plan for identifying  DOD projects and tests conducted outside of Project 112 that might have  exposed servicemembers to chemical or biological substances and ensure  that the plan addresses the scope, reporting requirements, milestones, and  responsibilities for those involved in completing this effort. According to  an OASD (HA) official, OASD (HA) made an informal agreement with  OUSD (AT&L) to undertake this effort since OASD (HA) did not have the  resources to conduct an investigation itself or to fund a contractor to do  the research. In September 2004, OUSD (AT&L)’s chemical and biological  defense office issued a task order to fulfill this provision of the legislation.  The research being done as a result of this task order is ongoing as of  December 2007.
section_title: DOD’s Decision to Stop Actively Searching for Project 112 Individuals Was Not Based on a Sound and Documented Cost-Benefit Analysis
paragraphs: In June 2003, after having identified several thousand servicemembers and  hundreds of civilians as having been potentially exposed to chemical or  biological substances during Project 112, DOD stopped actively searching  for additional individuals.  According to a knowledgeable DOD official,  this decision was made without a sound and documented cost-benefit  analysis. The Defense Authorization Act for FY 2003 required DOD to  review records and information necessary to identify members of the  armed forces who were or may have been exposed to chemical or  biological substances as a result of Project 112. Subsequently, in June  2003, DOD issued a report to Congress that stated that 5,842  servicemembers and an estimated 350 civilians might have been exposed  during Project 112 tests. The report also indicated that DOD had ceased its  active search for individuals potentially exposed during Project 112 tests  and that it would investigate any new information that may be presented  as well as share any additional or changed information with VA and the  public.
In 2004, we reported that DOD performed a reasonable investigation of  servicemembers who were potentially exposed to the substances used  during Project 112 tests. However, we found that DOD had not exhausted  all possibilities for identifying additional servicemembers and civilian  personnel who had been potentially exposed. Therefore, we recommended  that DOD determine the feasibility of addressing these unresolved issues.  In response to our recommendation, DOD determined continuing an active  search for individuals had reached the point of diminishing returns, and  reaffirmed its decision to cease active searches. This decision was not  supported by any objective analysis of the potential costs and benefits of  continuing the effort. Instead, this decision was made by officials in OASD  (HA) who had a working knowledge of Project 112 tests and the contents  of chemical and biological test record repositories. These officials  concluded that the record repositories that had been searched contained  the majority of Project 112 documents; therefore, they believed that the  bulk of exposures related to Project 112 tests had already been identified.  Furthermore, the officials decided that the application of resources  necessary to continue searching for Project 112 exposures would result in  a diminishing return on their investment. The Office of Management and  Budget has stated that a good cost-benefit analysis should include a  statement of the assumptions, the rationale behind them, and a review of  their strengths and weaknesses. This could include a full accounting of  information known, related costs, benefits, and challenges of continuing to  search for additional Project 112 participants. Moreover, our prior work  has shown that there are elements integral to a sound cost-benefit  analysis. For example, the analysis should include a thorough evaluation  of the social benefits and costs of investments, identify objectives to  ensure a clear understanding of the desired outcome, and include a list of  the relevant impacts to ensure that all aspects are considered. DOD could  not provide us with a quantitative analysis based on objective data or any  documented criteria because OASD (HA) was not required to provide any  support or basis for the decision.
Since DOD’s June 2003 report to Congress and its decision to cease  actively searching for additional exposures, additional individuals who  may have been exposed as a result of Project 112 tests have been  identified through various non-DOD sources, as shown in table 1. For  example, the Institute of Medicine conducted a study on the long-term  health effects of participation in the shipboard hazard and defense tests  that were conducted as a subset of Project 112.  This study identified 394  individuals who had been potentially exposed and who were previously  unknown to DOD. According to DOD and Institute of Medicine officials,  the additional names were discovered when the Institute of Medicine  applied a more inclusive methodology in its research. In addition, our  previous work in 2004 reported that DOD did not exhaust all possible  sources of information during its investigation of Project 112 and our own  research for that report resulted in the identification of 39 additional  potentially exposed servicemembers. For example, DOD had limited  success in identifying exposures during land-based tests because it was  unable to find documentation, and it did not specifically search for  individual civilian personnel in its investigation because it considered  them to be outside of its scope. Furthermore, DOD officials have told us  that veterans who participated in Project 112 tests have contacted DOD on  their own initiative in search of information and documentation related to  their exposures, which has resulted in 165 additional veterans being  identified as having been potentially exposed during these tests.
DOD’s current effort to identify individuals who may have been exposed to  chemical or biological substances during activities outside of Project 112,  discussed in the following section of this report, has also resulted in the  discovery of information related to Project 112 tests. Specifically, the DOD  contractor has found evidence that individuals who DOD already knew  were potentially exposed to substances during at least one known Project  112 test were also potentially exposed during other Project 112 tests.
In light of the increasing number of individuals who have been identified  since DOD ceased actively searching, until DOD makes a sound and  documented decision regarding the cost and benefits of actively searching  for individuals potentially exposed during Project 112 tests, Congress and  veterans may continue to question the completeness and accuracy of  DOD’s effort.
section_title: DOD’s Effort to Identify Individuals Potentially Exposed during Non-Project 112 Tests Has Several Shortcomings
paragraphs: Although DOD has taken action to identify individuals who were  potentially exposed during chemical or biological tests outside of Project  112, we identified several shortcomings in the current effort. Specifically,  we found that DOD’s approach was hampered by (1) a lack of clear and  consistent objectives, scope of work, and information needs; (2)  management and oversight weaknesses; (3) a limited use of the work of  other entities that previously identified exposed individuals; and (4) a lack  of transparency in DOD’s efforts.
subsections: section_title: DOD Issued a Task Order to Identify Individuals Potentially Exposed during Tests Conducted Outside of Project 112
paragraphs: In response to the Defense Authorization Act for FY 2003 and our May  2004 recommendation that DOD finalize and implement a plan to identify  individuals who were potentially exposed during tests conducted outside  of Project 112, DOD issued a task order in September 2004. The task order  identified four sets of tasks that the contractor was to undertake to  accomplish the task order’s objectives within 3 years—perform literature  searches, conduct and review on-site data collections, data mine existing  databases, and augment a database maintained by the contractor. The  contractor has issued monthly reports on its work to OUSD (AT&L)’s  chemical and biological defense office, which indicate that the contractor  has taken action on each of these tasks. OUSD (AT&L)’s chemical and  biological defense office and the contractor have agreed that the on-site  reviews will be conducted at a total of 18 sites that were identified and  prioritized based on established criteria, such as relevance and number of  documents expected to be present. As of October 2007, the contractor has  completed on-site data collection at 5 of these 18 sites, and as of  December 2007 was collecting data at 3 additional sites.
During its site visits, the contractor’s staff searches a variety of documents  for information that pertains to human exposure to chemical or biological  substances. The documents that are identified as having relevant  information are then scanned into an electronic file and the information  from those documents—such as the individual’s name, the substance to  which the subject was exposed, and the activity that resulted in the  exposure—is entered into a database. The contractor conducts a quality  assurance review before this information is delivered to OASD (HA)  officials. OASD (HA) officials told us that they perform a detailed review  of this information, query the contractor to resolve errors or  inconsistencies, and make modifications to the information provided by  the contractor if they have received or read other information that they  believe could add contextual sophistication. Once OASD (HA) officials  complete their review of the information, it is added to the DOD chemical  and biological test database that they maintain (hereafter referred to as  the OUSD (AT&L) task order database). While the database information is  not provided to OUSD (AT&L)’s chemical and biological defense office,  the contractor’s monthly report to this office includes the number of  identified individuals that the contractor has provided to OASD (HA).
The task order identified specific locations for the contractor to review  and was supposed to be completed in September 2007; however, the  contractor was unable to complete its work within the 3-year schedule and  has subsequently received a 3-year extension. This task order is valued at  almost $4.5 million, and the estimated value of the extension is between  $2.5 million and $3.7 million. Based on the project’s June 2007 concept of  operations plan, which DOD developed as a result of this review, the  contractor is expected to meet the project’s objectives and complete  collection and analysis of information obtained from 18 data collection  sites by September 2010. Since the remaining sites have been prioritized  based on expected level of information and other criteria, DOD officials  believe that the remaining data collection efforts could be completed more  quickly.
section_title: DOD’s Current Effort Lacks Clear and Consistent Objectives, Scope of Work, and Information Needs
paragraphs: DOD’s current effort to identify individuals potentially exposed to  chemical or biological substances lacks clear and consistent objectives,  scope of work, and information needs, which affects DOD’s ability to  know whether it has accomplished the project’s goals. First, the objectives  of DOD’s current effort are inconsistent. The Defense Authorization Act  for FY 2003, which was the genesis for DOD’s current effort, directed the  Secretary of Defense to identify DOD projects or tests outside of Project  112 that may have exposed members of the armed forces to chemical or  biological substances. However, the focus of the current effort has  expanded to include other exposures, including those resulting from  immunizations, transportation, storage, and occupational accidents. This  occurred because the documents that are guiding this effort, including the  project’s September 2004 statement of work and its June 2007 concept of  operations plan, have been used interchangeably to define the scope of the  work.
We identified a difference of opinion between DOD and VA regarding the  overall focus of the contractor’s research efforts. Officials in OUSD  (AT&L)’s chemical and biological defense office stated that they believe  the contractor should focus only on identifying participants in DOD tests  since the Defense Authorization Act for FY 2003 was the genesis of this  task order, and they believe that the primary interest is in individuals who  were not aware of their exposures or are unable to report their exposures  due to the classified nature of the tests. They also believe that individuals  accidentally exposed at a work location might be protected under  occupational health regulations and statutes. However, VA officials stated  that they would prefer that DOD provide information on all exposures,  including those not associated with DOD tests, since VA is responsible for  adjudicating all claims by servicemembers, regardless of how they were  exposed. The contractor conducting the search has included all types of  exposures in its research, which according to DOD and contractor officials  is based on VA’s stated preferences.
Second, the scope of DOD’s current effort is unclear. Specifically, while  the Defense Authorization Act for FY 2003 directed DOD to identify only  members of the armed forces, the task order’s 2004 statement of work and  the June 2007 concept of operations plan state that the objective of the  project is to collect information on all servicemembers and civilian  personnel who might have been exposed from 1946 to present. However,  DOD’s current effort has not included an active search of civilian  personnel. Instead, at the direction of DOD, the contractor is collecting  information on civilians who may have been exposed to chemical or  biological substances when it comes across those names while searching  for servicemembers. DOD officials stated that they focused their efforts on  servicemembers because VA has actively requested information about  servicemembers from DOD for years and the department has not received  any inquiries about the civilians. At the time of our review, the contractor  had collected information on approximately 700 civilian personnel who  were potentially exposed to chemical or biological substances.
Third, the amount and type of information that the contractor needs to  collect for this effort has been expanded from the original task order  requirement. The task order specifies that the information to be collected  should identify potential human exposure events, the names of test  programs, chemical and biological substances involved, and the names of  volunteers or participants. However, DOD has expanded the information  that the contractor should collect, which may be lengthening the time for  the contractor to complete its work. For example, in February 2007,  officials from one of the repository sites provided the contractor a CD with  names and exposure information for 2,300 individuals who were exposed  to a series of biological tests at Fort Detrick, Maryland, known as  Operation Whitecoat. However, as of October 2007, the contractor had not  provided DOD with these names because it was adding information, such  as the test objective and summary, and exposure and treatment  information. Since most of these 2,300 individuals had been previously  aware of their exposures due to Fort Detrick’s independent outreach  efforts, a DOD official who has worked with these individuals has stated  that it is unclear how much additional information the contractor needs to  collect about this group. While OASD (HA) officials have said that the  additional information has been helpful for their needs, they and VA  officials have also acknowledged that the identity of the chemical or  biological substance to which an individual was potentially exposed is the  most pertinent information.
Without consistent guidance about the objectives, scope of work, and  information necessary to meet DOD’s goals and objectives, DOD’s current  effort might not produce the desired results. After discussing this issue  with DOD officials, in December 2007 officials in OUSD (AT&L)’s chemical  and biological defense office stated that they plan to revise the task order’s  statement of work, concept of operations plan, and a DOD implementation  plan to clarify the scope of work and the focus of the research to  servicemembers—the original focus as identified in the Defense  Authorization Act for FY 2003.
section_title: DOD’s Current Effort Has Lacked Adequate Oversight
paragraphs: Until recently, DOD’s current effort has lacked adequate oversight of the  contractor activities and results. We have previously reported that  providing effective oversight is essential and, at times, DOD’s oversight  was wanting, as it did not always task personnel with oversight duties or  establish clear lines of accountability. While OUSD (AT&L)’s chemical  and biological defense office established three different points of contact  throughout the life of the task order who participated in meetings when  the work started in 2004 and assisted the contractor undertaking the effort  in accessing repository sites when requested, these points of contact were  not performing active oversight activities nor were they designated as the  project manager for this effort. During our review, officials in OUSD  (AT&L)’s chemical and biological defense office realized that their  predecessors had not selected a project manager and selected one of the  office’s civilian employees to oversee the effort.
We also found that DOD had not visited any of the repository sites where  the contractor had proposed or completed its research to ensure that the  work was effectively and efficiently meeting the task order’s objectives.  We visited the three repository sites where the contractor was conducting  its work during our review. At one location, a knowledgeable DOD official  expressed concerns to us that the contractor’s presence and research in  one of the site’s libraries might not be needed. However, since officials in  OUSD (AT&L)’s chemical and biological defense office had not visited the  site or met with site officials, they were unaware of these concerns and  therefore were unable to decide whether the contractor should be  conducting work at that particular site or whether the research funds and  time should be spent at a site that they believe might provide more  relevant information.
In addition, until June 2007, OUSD (AT&L)’s chemical and biological  defense office had not regularly evaluated the effectiveness or efficiency  of the contractor’s work. For example, at the time of our review, officials  in OUSD (AT&L)’s chemical and biological office told us that they did not  know the extent to which each of the task order’s four tasks was meeting  its objective to identify servicemembers and civilians who were potentially  exposed to chemical or biological substances during testing and other  activities. Therefore, DOD was not in a position to determine whether the  task order needed to be modified to focus DOD’s resources and the  contractor’s research efforts to those tasks that will best meet its  objectives.
Further, while the contractor had implemented its own quality  assurance/quality control process that was approved by OUSD (AT&L)’s  chemical and biological defense office, the office had not taken any action  to independently assess the accuracy and characterization of the  information that the contractor was providing to the OASD (HA), which  maintains DOD’s databases of potentially exposed individuals. As a result,  officials in OUSD (AT&L)’s chemical and biological defense office, who  are responsible for overseeing the contractor’s efforts, have limited  knowledge about the accuracy and characterization of the information  that was being collected.
Review and assessment of the contractor-provided data by the project  manager are important because we identified potential problems with the  accuracy of that information. For example, our work indicated that there  are discrepancies between the number of individuals reported by the  contractor in its monthly reports to OUSD (AT&L)’s chemical and  biological office and the number of individuals that exist in OASD (HA)’s  database that could not be adequately explained. In addition, at the time of  our review, the characterization in the contractor’s monthly reports  provided to OUSD (AT&L)’s chemical and biological defense office that all  of these individuals were potentially exposed during chemical or  biological tests gave the wrong impression to the project manager. For  example, while the contractor has characterized the individuals it has  identified as having been involved in DOD’s chemical and biological  “tests”, an unknown number of these exposures resulted from  immunizations, transportation, occupational, and storage accidents. This  number also includes individuals who might have been associated with the  tests but who were not exposed to any substances, such as those who  participated in physical exercises to test the durability of chemical and  biological suits or who could have been part of a test control group. OASD  (HA) officials were able to identify at least 1,800 names in the database  that were not exposed to any substances, which leaves about 7,100 names  in the database that have been potentially exposed to chemical or  biological substances, as shown in table 2. DOD and contractor officials  stated that they have included these names in the database so that they  could appropriately respond to these individuals’ concerns if they contact  DOD or VA. Specifically, according to DOD, including these names in the  database enables the department to refute any claims by individuals who  participated in tests where they were not exposed to any chemical or  biological substances.
We identified a variety of factors affecting the ability of OUSD (AT&L)’s  chemical and biological defense office to provide oversight, including a  lack of consistent leadership, inadequate internal controls, a shortage of  personnel, and a lack of defined roles and responsibilities. For example,  the position that was identified as the office’s point of contact for the task  order is a 1-year position. Consequently, the contractor has had to work  with three different individuals during the first 3 years of the task order.  The official holding this position during our review requested and was  granted a 2-year extension in this position, and thus he has been able to  implement a number of internal controls to improve the oversight and  accountability of this project. In addition, until September 2007, the  respective roles and responsibilities of OUSD (AT&L)’s chemical and  biological defense office and OASD (HA) had not been clearly identified.  In September 2007, in response to our review, OUSD (AT&L)’s chemical  and biological defense office and OASD (HA) signed an implementation  plan that identified their respective roles and responsibilities.
section_title: DOD Did Not Fully Leverage the Work of Other Entities that Identified Exposed Individuals
paragraphs: In planning, executing, and evaluating DOD’s current effort, OUSD  (AT&L)’s chemical and biological defense office did not fully leverage the  work of other entities that had previously identified exposed individuals.  Multiple DOD and non-DOD organizations have conducted a variety of  independent efforts since the early 1990s, through which they have  identified thousands of individuals who were potentially exposed during  chemical or biological tests. These entities possess specific information  about the tests—to include the location of test records—and the personnel  conducting the work developed institutional knowledge. While OUSD  (AT&L)’s chemical and biological defense office leveraged Project 112  information from the OASD (HA), it did not leverage information available  from other DOD and non-DOD sources. For example, between 1993 and  1997, the joint DOD-VA task force identified approximately 6,400  individuals who were potentially exposed to sulfur mustard, lewisite, and  other chemical substances. OUSD (P&R) led the effort by using some of its  own personnel to conduct the research and visit several repository sites in  addition to issuing a task order for a contractor—the same contractor  DOD is currently using to research and identify tests and exposures—to  develop a database containing information on the location, chemicals  tested, and dates of the chemical weapons research program. During this  period, OUSD (P&R) personnel involved with the research became very  knowledgeable about the issues, collected boxes of information, and  issued various reports. OUSD (P&R) officials transferred the names of the  individuals who were identified to OASD (HA) officials in April 2005.  According to OUSD (P&R) officials, however, officials in OUSD (AT&L)’s  chemical and biological defense office had not met with any of the  personnel with institutional knowledge or examined any of the documents  that OUSD (P&R) still maintained. Since OUSD (P&R)’s reports identified  locations of exposures, officials in OUSD (AT&L)’s chemical and  biological defense office could have used this information as another  source to help validate and prioritize the repository sites proposed by the  contractor for its current effort, and to eliminate potential redundancy.
Furthermore, as a result of independent research efforts by the Institute of  Medicine about the health effects of DOD chemical tests using human  subjects, the organization developed a database that contained the names  and addresses of more than 4,000 servicemembers who were potentially  exposed to chemical substances during a series of tests at Edgewood,  Maryland. However, OUSD (AT&L)’s chemical and biological defense  office was not aware of this database since the office had not coordinated  with the organization. Institute of Medicine officials told us that they  believe the names and contact information in this database could help  DOD with its efforts since the names were collected from the same  locations where the contractor for DOD’s current effort is doing its  research. Subsequent to our September 2007 meeting with the Institute of  Medicine, its officials contacted OASD (HA) to establish the protocols to  transfer the names of identified individuals to DOD so that it can  determine whether these individuals are already included in any of DOD’s  databases. Without communicating and coordinating with DOD and non- DOD organizations that have previously conducted similar efforts, DOD’s  current effort will not be able to take advantage of existing information so  that it can focus its resources on the areas where information is missing.
section_title: DOD’s Current Effort Lacks Transparency
paragraphs: DOD’s current effort lacks transparency since it has not worked with  veterans, and it has not kept Congress and veterans service organizations  fully informed about the status of its efforts. Although DOD officials  conducted outreach to veterans during its Project 112 research effort and  the Defense Authorization Act for FY 2003 required DOD to work with  veterans and veterans service organizations to identify projects and tests  outside of Project 112 that may have exposed members of the armed  forces to chemical and biological substances, DOD has not included  veterans and veterans service organizations during its current effort. DOD  also has not kept Congress, veterans, and the public informed on the  status of its current effort as it did during its Project 112 investigation.  Specifically, in 2002, DOD established a public internet site to provide  interested persons with information on what happened during those tests  that might have affected the health of those who served. The internet site  included a status report on DOD’s efforts so that veterans and others could  monitor the progress, and it also contained reports, documents, and links  to related internet sites. The internet site, which was operated by OASD  (HA), has not been updated with information about DOD’s current effort  to identify individuals outside of Project 112. Representatives from a  veterans service organization that has pursued information regarding  DOD’s use of servicemembers as human subjects told us they were not  aware of DOD’s current effort and they believe DOD has not been  transparent and forthcoming with the information that it has obtained.  These officials stated that the continuous lack of collaboration and  transparency has negatively affected the level of trust veterans and the  veterans service organization have in DOD regarding its commitment to  fully identify and disclose information regarding these tests. The  representatives stated that it is imperative for DOD to be as transparent as  possible so that Congress, veterans, and the public have reason to believe  the cloak of secrecy regarding these tests has been lifted and individuals  who were potentially exposed could receive appropriate medical care and  benefits. DOD officials acknowledged the importance of keeping veterans  informed so that they know that these tests are no longer classified, they  are entitled to a medical screening for long-term health effects, and they  can assist in DOD’s efforts to identify other individuals who might have  been exposed. Until DOD is more transparent about its efforts to identify  individuals who were potentially exposed during these previously  classified tests, Congress, veterans, and the public could have reason to  believe that the cloak of secrecy has not been lifted and not realize the  reasonableness, effectiveness, success, and challenges of DOD’s current  effort.
section_title: DOD and VA Have Had Limited Success in Notifying Potentially Exposed Individuals
paragraphs: DOD and VA have had limited success in notifying individuals who were  potentially exposed to chemical and biological substances during Project  112 tests or testing that occurred outside of Project 112 due to several  factors. First, DOD has inconsistently transmitted information about  identified servicemembers to VA. Second, VA has not used all available  resources to obtain contact information for servicemembers who were  identified as having been potentially exposed. Finally, DOD has not taken  any actions to notify civilians who have been identified.
subsections: section_title: DOD Has Inconsistently Transmitted Information to VA
paragraphs: While DOD and VA have a process in place to share the names of  servicemembers who are identified as having been potentially exposed to  chemical and biological substances, the transmission of information  between the two agencies has been inconsistent. To date, DOD has  provided information to VA as agreed upon through an informal  arrangement. Under the arrangement, DOD generally provides VA with the  servicemember’s name, as well as any information related to the potential  exposure that DOD uncovered during its investigation, such as the  chemical or biological substance that was used, the dosage of the chemical  or biological substance, and the date of the exposure. As of October 2007,  DOD had used this process to transmit to VA approximately 20,700 names  of servicemembers who had been potentially exposed to chemical or  biological substances. The informal arrangement between DOD and VA  did not establish a schedule for the exchange of information, so DOD  provides newly acquired exposure information to VA in batches of varying  size and at inconsistent intervals. When we began our work we found that  DOD had not provided VA with any updates after September 2006 even  though, as of June 2007, DOD had added approximately 1,800 additional  servicemember names to its chemical and biological exposure database.  Subsequent to our inquiries, however, DOD provided VA with an update in  September 2007. According to DOD officials, regular updates to VA have  been delayed because of a number of factors, including competing  priorities such as current military operations, lack of personnel, database  management issues, and lack of an impetus to take a proactive approach.  Although limited personnel and competing priorities might be valid issues,  until DOD provides regular updates of identified servicemembers to VA in  a timely manner, VA will be unable to notify identified veterans about their  potential exposure to chemical or biological substances.
section_title: VA Has Not Used Certain Available Resources to Notify Veterans
paragraphs: VA has not used certain available resources to obtain contact information  for and to notify veterans who were identified as having been potentially  exposed to chemical or biological substances. To notify veterans who  were potentially exposed to chemical or biological substances during DOD  tests, VA matches the list of potentially exposed veterans it obtains from  DOD against its own database of veterans to find either contact  information or a Social Security number. If no Social Security number is  located, VA matches the available veterans’ information to information  contained in the National Personnel Records Center. Once a Social  Security number is obtained, VA usually uses a private credit bureau and  on occasion has used the Internal Revenue Service database to obtain  contact information for the veteran. In responding to a draft of this report,  VA notes that it uses the credit bureau for a variety of reasons, including  its up-to-date data transmissions from the Social Security Administration,  expedience in responding, and general accuracy of information. As shown  in table 3, as of December 2007, VA had obtained contact information for  and sent notification letters to 48 percent of the names that DOD provided  to them and that they may be able to contact. VA officials noted that  while the total number of notification letters sent is 48 percent of the  number of names that DOD has provided to them and that they may be  able to contact, it represents all of the individuals for whom they were  able to obtain contact information.
A number of factors beyond VA’s control have impeded its ability to notify  veterans of their potential exposure to chemical or biological substances.
For example, some records have been lost or destroyed, and existing  documentation contains limited information and often does not identify  names of participants, while others were not turned in by the scientists  who were conducting the research. When the records can be found, they  do not necessarily identify the participants, but may instead refer to  control numbers that were issued to the participants, which cannot be  cross-referenced to other documents for identification. For those records  that do include identification of participants, the information may contain  only the participants’ initials, nicknames, or only first or last names. Also,  since a number of these records do not include the participant’s military  service number or social security number, it is difficult to determine the  exact identity of these individuals. Further, the contact information that  VA is able to obtain may not be accurate. For example, more than 860  notification letters have been returned as undeliverable to VA.
However, VA is not using other available resources to obtain contact  information to notify veterans. For example, while VA told us that it was  using a company that is able to provide current contact information as a  source, it had not coordinated with the Social Security Administration to  obtain contact information for veterans receiving social security benefits  or to identify deceased veterans using the agency’s death index and had  not regularly used the Internal Revenue Service’s information. VA officials  acknowledged that they had not directly used the death index and that a  memorandum of understanding with the Social Security Administration  might facilitate a new way to accomplish this. However, they noted the  credit bureau receives weekly updates from the Social Security  Administration’s death index. VA officials also acknowledged that it  planned to make more frequent use of IRS databases. Until VA implements  a more effective process to obtain contact information for veterans, some  veterans will remain unaware of their potential exposure or the availability  of health exams and the potential for benefits directly related to an  exposure.
section_title: DOD Has Not Notified Civilians Due in Part to a Lack of Specific Guidance
paragraphs: DOD has not taken any actions to notify civilians who have been identified  as having been potentially exposed during Project 112 tests and other  chemical and biological tests, due in part to a lack of specific guidance  defining the requirements to notify civilians. The Defense Authorization  Act for FY 2003 required DOD to identify its tests or projects that may  have exposed members of the armed forces to chemical or biological  substances, but did not specifically address civilian personnel who may  have been affected by these tests. However, in our 2004 report we  recommended that DOD address the appropriateness of and responsibility  for reporting new information, such as the identification of additional  potentially exposed servicemembers, civilian employees, contractors, and  foreign nationals who participated in the tests. In its response to our  report, DOD concurred with our recommendation and stated that it would  determine the appropriate reporting channels for civilian employees,  contractors, and foreign national participants who were identified as being  potentially exposed. However, DOD has not taken any action with the  approximately 1,900 civilian names that it maintains, as shown in table 4.  Instead, DOD has focused its efforts on the identification and notification  of servicemembers who were potentially exposed. DOD officials stated  that they have focused on identifying and notifying servicemembers since  the primary impetus for their efforts to identify and notify individuals who  may have been exposed has been requests for information from veterans  and VA.
OASD (HA) has not acted in part because it is unclear whether it is  required to notify civilians or transmit civilian exposure information to  another agency for notification. During our review, DOD and Department  of Labor officials stated that they were unaware of a requirement for them  to notify civilians of their potential exposure. However, our April 2005  report about civilian and contractor exposures to chemical substances in  Vietnam identified compensation programs that might be available for  civilians who were exposed during these chemical and biological tests if  they come forward and present evidence that they were potentially  exposed. Specifically, federal employees can file claims for workers  compensation with their employing agency, which refers the claims to the  Department of Labor under the Federal Employees Compensation Act.  Employees who work under contract to the U.S. government can file  workers compensation claims through their employers with the  employers’ insurance carrier. Without an effort to develop and provide  guidance for notifying civilians, those civilians who have been identified  may not be aware of their potential exposure.
section_title: Conclusions
paragraphs: Since World War II, potentially tens of thousands of military personnel and  civilians have been exposed to chemical or biological substances during  previously classified DOD tests. As this population becomes older, it will  become more imperative for DOD and VA to identify and notify these  individuals in a timely manner because they might be eligible for health  care or other benefits. While DOD has concluded that continuing an active  search for individuals potentially exposed during Project 112 has reached  a point of diminishing returns, it has not conducted an informed cost- benefit analysis, which could guide DOD in identifying the extent to which  it might need to take additional actions. Without conducting a sound and  documented cost-benefit analysis that includes a full accounting of  information known and the challenges associated with continuing to  search for Project 112 participants, DOD will not be in a position to make  an informed and transparent decision about whether any of the remaining  investigative leads could result in meaningful opportunities to identify  additional potentially exposed individuals. Furthermore, until DOD  conducts such an analysis, Congress, veterans, and the public may  continue to question the completeness and accuracy of DOD’s efforts.  Moreover, while DOD has undertaken efforts to identify and notify  individuals who were potentially exposed during tests outside of Project  112, the department has not worked with veterans and veterans service  organizations during its current effort as required by the Defense  Authorization Act for FY 2003, and it has not coordinated its efforts with  other DOD and non-DOD organizations. Until DOD and VA undertake  more effective and efficient efforts to identify and notify potentially  exposed individuals—including consistent guidance about the scope of  work, such as clearly defined goals and objectives and agreement on the  type and amount of information that is necessary to collect; effective  internal controls and oversight practices; coordination with other entities  to leverage existing information; regular updates to VA; and utilization of  all available resources—Congress, veterans, and the public may continue  to question DOD and VA’s commitment to this effort. Furthermore, in the  absence of transparency about these previously classified tests and DOD’s  efforts to identify individuals who were potentially exposed, Congress,  veterans, and the public could have reason to believe that the cloak of  secrecy has not been lifted and may not understand the success and  challenges of DOD’s current effort. While DOD and VA have developed a  process for notifying servicemembers who were potentially exposed, it is  unclear whether DOD or any other agency, such as the Department of  Labor, is required to notify potentially exposed civilians who are  identified. Therefore, without specific guidance that defines the  requirements, roles and responsibilities, and mechanisms to notify  civilians who have been potentially exposed to chemical or biological  substances, these individuals might continue to be unaware of their  circumstances.
section_title: Matters for Congressional Consideration
paragraphs: We are suggesting the Congress consider the following two matters:    To provide greater transparency and resolve outstanding questions  related to DOD’s decision to cease actively searching for the  identification of individuals associated with Project 112, Congress  should consider requiring the Secretary of Defense to consult with and  address the concerns of VA, veterans, and veterans service  organizations; to conduct and document an analysis that includes a full  accounting of information known, and the related costs, benefits, and  challenges associated with continuing the search for additional Project  112 participants; and to provide Congress with the results of this  analysis.  Our draft report addressed this recommendation to the  Secretary of Defense; however, because DOD disagreed, we elevated  this to a matter for congressional consideration.
To ensure that civilians who were potentially exposed to chemical or  biological substances as a result of tests conducted or sponsored by  DOD are aware of their circumstances, Congress should consider  requiring the Secretary of Defense, in consultation with the Secretary  of Labor, to develop specific guidance that defines the requirements,  roles and responsibilities, and mechanisms to notify civilians who have  been potentially exposed to chemical or biological substances.
section_title: Recommendations for Executive Action
paragraphs: To ensure a sound and documented process for DOD’s decision regarding  the identification of individuals associated with Project 112, we  recommend that the Secretary of Defense direct the Office of the Under  Secretary of Defense for Personnel and Readiness to conduct and  document an analysis that includes a full accounting of information  known, and the related costs, benefits, and challenges associated with  continuing the search for additional Project 112 participants, and to  provide Congress with the results of this analysis. In developing the  analysis, DOD should consult with and address the identified concerns of  VA, veterans, and veterans service organizations.
To ensure that DOD’s current effort to identify individuals who were  potentially exposed during chemical and biological tests outside of Project  112 are more efficient, effective, and transparent, and to ensure that its  databases contain accurate information, we recommend that the Secretary  of Defense direct the Office of Under Secretary of Defense for Acquisition,  Technology, and Logistics to take the following four actions:  in coordination with the Office of the Under Secretary of Defense for  Personnel and Readiness and the Secretary of Veterans Affairs, modify  the guidance about the scope of work for its current effort, such as the  statement of work and concept of operations plan, to clearly define  consistent, reasonable, and acceptable goals and objectives, and the  type and amount of information that will need to be collected to meet  these goals and objectives;  implement effective internal controls and oversight practices, such as  periodic site visits, regular assessments of the contactor’s efforts, and  quality assurance reviews of the information provided by the  contractor;    coordinate and communicate with other entities that previously  identified exposed individuals to leverage existing information,  including institutional knowledge and documents; and    make its efforts transparent with regular updates to Congress, the  public, and veterans service organizations.
To ensure that DOD has taken appropriate action in its efforts to notify  servicemembers who were potentially exposed, we recommend that the  Secretary of Defense direct the Office of the Under Secretary of Defense  for Personnel and Readiness to take appropriate action to address the  factors—such as competing priorities and database management  weaknesses—affecting DOD’s ability to forward the names of potentially  exposed individuals to VA in a timely and effective manner.
To ensure that all veterans who have been identified as having been  potentially exposed to chemical or biological substances have been  notified, we recommend that the Secretary of Veterans Affairs take steps  to increase its use of available resources, such as the Internal Revenue  Service, to implement a more efficient and effective process for obtaining  contact information for living veterans.
section_title: Agencies’ Comments and Our Evaluation
paragraphs: We requested comments from DOD, VA, and the Department of Labor on a  draft copy of this report. DOD generally agreed with five  recommendations, but disagreed with the first recommendation to  conduct and document a cost-benefit analysis associated with continuing  the search for additional Project 112 participants, and to provide Congress  with the results of this analysis. VA agreed with one recommendation and  partially agreed with another recommendation that pertained to its  activities. The Department of Labor did not provide us any comments.  Because DOD disagreed with the recommendation to conduct and  document a cost-benefit analysis associated with continuing the search for  additional Project 112 participants and has not adequately addressed our  May 2004 recommendation to determine the feasibility of addressing  unresolved issues associated with Project 112, we added a Matter for  Congress to consider directing the Secretary of Defense to conduct such  an analysis.  DOD and VA also provided technical comments, which we  incorporated as appropriate. DOD’s and VA’s comments are reprinted in  appendices II and III, respectively.
DOD agreed to and has in some cases begun taking action to respond to  five of the recommendations. Specifically, DOD stated that it has already  coordinated on updating program goals and objectives for the  identification of individuals who were potentially exposed during chemical  and biological tests outside of Project 112 and is revising the statement of  work, implementation plan, and concept of operations to ensure  consistent guidance and deliverables. DOD also stated that it has taken  steps to increase oversight of the project and has established an  implementation plan with OASD (HA) delineating oversight  responsibilities. In addition, DOD stated that it will take steps to determine  if other organizations are conducting similar work to identify potentially  exposed individuals and will coordinate and leverage all available  information. The department also stated that it will expand its current  efforts to update the public and make efforts more transparent. Finally,  DOD and VA are in the process of discussing short-term and long-term  improvements necessary for improving the transfer of information to VA in  a timely and effective manner. We believe these are positive steps that,  when completed, will address the intent of our recommendations.
DOD did not agree with the first recommendation to conduct and  document an analysis that includes a full accounting of information  known, and the related costs, benefits, and challenges associated with  continuing the search for additional Project 112 participants, and to  provide Congress with the results of this analysis. DOD stated that it  believes it made a full accounting of its efforts available to Congress in  2003, that it has not received any credible leads that would allow DOD to  continue its research, and that it currently knows of no other investigative  leads that would meaningfully supplement what it believes to be a total  picture of Project 112. However, as discussed in our May 2004 report, we  identified a number of credible leads that could possibly result in  additional Project 112 information. In addition, as discussed in this report,  almost 600 additional individuals who were potentially exposed during  Project 112 (more than a 10 percent increase) have been identified by non- DOD sources since DOD’s 2003 report to Congress and its decision to  cease actively searching for additional exposures. In light of the increasing  number of individuals who have been identified since DOD provided its  report to Congress in 2003 and ceased its active search for additional  individuals, until the department provides a more substantive analysis that  supports its decision to cease active searches for additional individuals  potentially exposed during Project 112 tests, Congress and veterans may  continue to question the completeness and level of commitment to this  effort. Because DOD has disagreed with our recommendation and has not  adequately addressed our May 2004 recommendation to determine the  feasibility of addressing unresolved issues associated with Project 112, we  have added a Matter for Congress to consider directing the Secretary of  Defense to conduct such an analysis.
In response to our recommendations, VA agreed to work with DOD to  modify the guidance about the scope of work for its current effort to  clearly define consistent, reasonable, and acceptable goals and objectives;  and the types and amount of information that will need to be collected to  meet these goals and objectives.  VA also agreed to contact the Internal  Revenue Service to determine if a more timely response can be obtained  from them to assist VA in notifying individuals potentially exposed to  chemical or biological substances. We believe these steps are consistent  with the intent of our recommendations. However, VA disagreed with a  part of our recommendation that it needs to pursue information from the  Social Security Administration since the credit bureau that VA uses to  obtain contact information already receives the same information from the  Social Security Administration. Accordingly, we adjusted our  recommendation to the Secretary of Veterans Affairs so that it did not  refer to the Social Security Administration as another source of  information.
We are sending copies of this report to other interested congressional  committees, the Secretary of Defense, the Secretary of Veterans Affairs,  and the Secretary of Labor. We will also make copies available to others  upon request. In addition, the report will be available at no charge on the  GAO Web site at http://www.gao.gov.
If you have any questions about this report, please contact me at (202)   512-5431 or dagostinod@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made contributions to this report are listed  in appendix IV.
section_title: Appendix I: Scope and Methodology
paragraphs: To assess the Department of Defense’s (DOD) efforts since 2003 to  identify servicemembers and civilians who may have been exposed to  chemical or biological substances used during tests conducted under  Project 112, we reviewed and analyzed documents pertaining to Project  112, including DOD’s 2003 Report to Congress: Disclosure of Information  on Project 112 to the Department of Veterans Affairs. We interviewed  officials at the Office of the Secretary of Defense, Washington, D.C.,  including the Under Secretary of Defense for Acquisition, Technology, and  Logistics, and the Under Secretary for Personnel and Readiness. We also  interviewed officials at the Office of the Assistant Secretary of Defense for  Health Affairs who were responsible for conducting DOD’s investigation of  Project 112 tests and have been designated as the single point of contact  for providing information related to tests and potential exposures during  Project 112. We interviewed officials at the Institute of Medicine and  reviewed their 2007 report on the long-term health effects of participation  in the shipboard hazard and defense tests of Project 112. In addition, we  reviewed and analyzed our prior reports as well as reports of other  organizations to provide a historical and contextual framework for  evaluating DOD’s efforts.
To evaluate DOD’s current effort to identify servicemember and civilian  exposures that occurred during activities outside of Project 112 tests, we  reviewed and analyzed reports, briefings, and documents and interviewed  officials at the Office of the Secretary of Defense, Washington, D.C.,  including the Under Secretary of Defense for Acquisition, Technology, and  Logistics and the Under Secretary of Defense for Personnel and Readiness.  We also interviewed officials at the Office of the Assistant Secretary of  Defense for Health Affairs, who have been designated as the single point  of contact for providing information related to tests and potential  exposures outside of Project 112. In addition, we interviewed officials at  the U.S. Army Medical Research Institute of Infectious Diseases and the  U.S. Army Medical Research and Materiel Command, Fort Dietrich,  Maryland; the Department of Veterans Affairs, Washington, D.C.; the  Institute of Medicine, Washington, D.C.; the Vietnam Veterans of America,  Silver Spring, Maryland; and DOD’s contractor currently conducting  research to identify potential exposures that occurred outside of Project  112. We also evaluated DOD’s methodology for identifying  servicemembers and civilians who may have been exposed to chemical or  biological substances by observing the process the contractor uses to  conduct research at repositories containing documents related to  chemical and biological exposures from tests and other activities, such as  the transportation and storage of chemical and biological substances. We  interviewed officials and observed storage facilities at the three chemical  or biological substance exposure record repositories where the contractor  was currently conducting its work: Edgewood Chemical and Biological  Center Technical Library, Aberdeen Proving Grounds, Maryland; U.S.  Army Research, Development, and Engineering Command Historical  Office, Aberdeen Proving Grounds, Maryland; and U.S. Army Medical  Research Institute of Infectious Diseases Technical Library, Fort Detrick,  Maryland. In addition, we interviewed officials and observed the records  storage area at the U.S. Army Medical Research Institute of Infectious  Diseases Medical Records Office, Fort Detrick, Maryland, where  information about Operation Whitecoat is maintained. We also reviewed  DOD’s outreach efforts and the extent to which DOD coordinated with  other agencies that might have useful information, including the  Department of Veterans Affairs (VA), the Department of Labor, the  Institute of Medicine, and the Vietnam Veterans of America.
To evaluate VA’s process to notify servicemembers whom DOD has  determined may have been exposed to a chemical or biological substance,  we interviewed VA officials with the Veteran’s Benefit Administration,  Veteran’s Health Administration, and Office of Planning and Policy, and  gathered data concerning their success in making notifications. In  particular, we documented the number of servicemembers whose names  had been provided to VA by DOD, the extent to which notification letters  were sent, the extent to which veterans were deceased, and the number of  cases where sufficient documentation was not available to obtain contact  information to make notifications.
We assessed the reliability of DOD’s and VA’s data by interviewing agency  officials knowledgeable about the data and by reviewing existing  information about the data and the systems used to maintain and produce  them. Although we found that there were potential problems with the  quality and reliability of the information, we determined that the data were  sufficient for the purposes of this report.
We conducted this performance audit from June 2007 to February 2008 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: Comments from the Department of Defense
section_title: Appendix III: Comments from the Department of Veterans Affairs
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact named above, Robert L. Repasky (Assistant  Director), Tommy Baril, Renee S. Brown, Brian D. Pegram, Steven  Putansu, Terry L. Richardson, and Karen Thornton made key contributions  to this report.
section_title: Related GAO Products
paragraphs: 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.
Chemical And Biological Defense: DOD Needs to Continue to Collect and  Provide Information on Tests and Potentially Exposed Personnel. GAO- 04-410. Washington, D.C.: May 14, 2004.
Human Experimentation: An Overview on Cold War Era Programs.  GAO/T-NSIAD-94-266. Washington, D.C.: September 28, 1994.
Veterans Disability: Information From Military May Help VA Assess  Claims Related to Secret Tests. GAO/NSIAD-93-89. Washington, D.C.:  February 18, 1993.