Defense Health Care: Improvements Needed in Occupational and Environmental Health Surveillance During Deployments to Address Immediate and Long-Term Health Issues
Released: 2005-07-19T00:00:00

Letter

Background

On March 19, 2003, the United States launched military operations in Iraq. As of the end of February 2005, an estimated 827,277 servicemembers had been deployed in support of OIF. Deployed servicemembers, such as those in OIF, are potentially subject to occupational and environmental hazards that can include exposure to harmful levels of environmental contaminants such as industrial toxic chemicals, chemical and biological warfare agents, and radiological and nuclear contaminants. Harmful levels include high- level exposures that result in immediate health effects. Health hazards may also include low-level exposures that could result in delayed or long- term health effects. Occupational and environmental health hazards may include contamination from the past use of a site, from battle damage, from stored stockpiles, from military use of hazardous materials, or from other sources.

Federal OEHS Policy

As a result of numerous investigations that found inadequate data on deployment occupational and environmental exposures to identify the potential causes of unexplained illnesses among veterans who served in the 1991 Persian Gulf War, the federal government has increased efforts to identify potential occupational and environmental hazards during deployments. In 1997, a Presidential Review Directive called for a report by the National Science and Technology Council to establish an interagency plan to improve the federal response to the health needs of veterans and their families related to the adverse effects of deployment. The Council published a report that set a goal for the federal government to develop the capability to collect and assess data associated with anticipated exposure during deployments. Additionally, the report called for the maintenance of the capability to identify and link exposure and health data by Social Security number and unit identification code. Also in 1997, Public Law 105- 85 included a provision recommending that DOD ensure the deployment of specialized units to theaters of operations to detect and monitor chemical, biological, and similar hazards. The Presidential Review Directive and the public law led to a number of DOD instructions, directives, and memoranda, which have guided the collection and reporting of deployment OEHS data. See table 1 for a list of selected DOD policies for collecting and reporting deployment OEHS data.

DOD Entities Involved with Setting and Implementing OEHS Policy

DHSD makes recommendations for DOD-wide policies on OEHS data collection and reporting during deployments to the Office of the Assistant Secretary of Defense for Health Affairs. DHSD is assisted by the Joint Environmental Surveillance Working Group, established in 1997, which serves as a coordinating body to develop and make recommendations for DOD-wide OEHS policy. The working group includes representatives from the Army, Navy, and Air Force health surveillance centers, the Joint Staff, other DOD entities, and VA.

Each service has a health surveillance center—CHPPM, the Navy Environmental Health Center, and the Air Force Institute for Operational Health—that provides training, technical guidance and assistance, analytical support, and support for preventive medicine units in theater in order to carry out deployment OEHS activities in accordance with DOD policy. In addition, these consulting centers have developed and adapted military exposure guidelines for deployment using existing national standards for human health exposure limits and technical monitoring procedures (e.g., standards of the U.S. Environmental Protection Agency and the National Institute for Occupational Safety and Health) and have worked with other agencies to develop new guidelines when none existed. (See fig. 1.)

Deployment OEHS Reports

DOD policies and military service guidelines require that the preventive medicine units of each military service be responsible for collecting and reporting deployment OEHS data. Deployment OEHS data are generally categorized into three types of reports: baseline, routine, or incident- driven.

Baseline reports generally include site surveys and assessments of occupational and environmental hazards prior to deployment of servicemembers and initial environmental health site assessments once servicemembers are deployed.

Routine reports record the results of regular monitoring of air, water, and soil, and of monitoring for known or possible hazards identified in the baseline assessment.

Incident-driven reports document exposure or outbreak investigations.

There are no DOD-wide requirements on the specific number or type of OEHS reports that must be created for each deployment location because reports generated for each reflect the specific occupational and environmental circumstances unique to that location. CHPPM officials said that reports generally reflect deployment OEHS activities that are limited to established sites such as base camps or forward operating bases; an exception is an investigation during an incident outside these locations. Constraints to conducting OEHS outside of bases include risks to servicemembers encountered while in combat and limits on the portability of OEHS equipment. In addition, DHSD officials said that preventive medicine units might not be aware of every potential health hazard and therefore might be unable to conduct appropriate OEHS activities.

OEHS Reporting and Archiving Activities during Deployment

According to DOD policy, various entities must submit their completed OEHS reports to CHPPM during a deployment. The deployed military services have preventive medicine units that submit OEHS reports to their command surgeons who review all reports and ensure that they are sent to a centralized archive that is maintained by CHPPM. Alternatively, preventive medicine units can be authorized to submit OEHS reports directly to CHPPM for archiving. (See fig. 2.)

According to DOD policy, baseline and routine reports should be submitted within 30 days of report completion. Initial incident-driven reports should be submitted within 7 days of an incident or outbreak. Interim and final reports for an incident should be submitted within 7 days of report completion. In addition, the preventive medicine units are required to provide quarterly lists of all completed deployment OEHS reports to the command surgeons. The command surgeons review these lists, merge them, and send CHPPM a quarterly consolidated list of all the deployment OEHS reports it should have received.

To assess the completeness of its centralized OEHS archive, CHPPM develops a quarterly summary report that identifies the number of baseline, routine, and incident-driven reports that have been submitted for all bases in a command. Additionally, this report summarizes the status of OEHS report submissions by comparing the reports CHPPM received with the quarterly consolidated lists from the command surgeons that outline each of the OEHS reports that have been completed. For OIF, CHPPM is required to provide a quarterly summary report to the commander of U.S. Central Command on the deployed military services’ compliance with deployment OEHS reporting requirements.

Uses of Deployment OEHS Reports

During deployments, military commanders can use deployment OEHS reports completed and maintained by preventive medicine units to identify occupational and environmental health hazards and to help guide their risk management decision making. Commanders use an operational risk management process to estimate health risks based on both the severity of the risks to servicemembers and the likelihood of encountering specific hazards. The operational risk management process, which varies slightly across the services, includes risk assessment, including hazard identification, to describe and measure the potential hazards at a location; risk control and mitigation activities intended to reduce potential risk communication efforts to make servicemembers aware of possible exposures, any risks to health that the exposures may pose, the countermeasures to be employed to mitigate exposure or disease, and any necessary medical measures or follow-up required during or after the deployment.

Commanders balance the risk to servicemembers of encountering occupational and environmental health hazards while deployed, even following mitigation efforts, against the need to accomplish specific mission requirements.

Along with health encounter and servicemember location data, archived deployment OEHS reports are needed by researchers to conduct epidemiologic studies on the long-term health issues of deployed servicemembers. These data are needed, for example, by VA, which in 2002 expanded the scope of its health research to include research on the potential long-term health effects of hazardous military deployments on servicemembers. In a letter to the Secretary of Defense in 2003, VA said it was important for DOD to collect adequate health and exposure data from deployed servicemembers to ensure VA’s ability to provide veterans’ health care and disability compensation. VA noted in the letter that much of the controversy over the health problems of veterans who fought in the 1991 Persian Gulf War could have been avoided had more extensive surveillance data been collected. VA asked in the letter that it be allowed access to any unclassified data collected during deployments on the possible exposure of servicemembers to environmental hazards of all kinds.

Deployed Military Services Use Varying Approaches to Collect OEHS Data and Have Not Submitted All OEHS Reports for OIF

The deployed military services generally have collected and reported OEHS data for OIF, as required by DOD policy. However, the deployed military services have not used all of the same OEHS data collection standards and practices, because each service has its own authority to implement broad DOD policies. To increase data collection uniformity, the Joint Environmental Surveillance Working Group has made some progress in devising cross-service standards and practices for some OEHS activities. In addition, the deployed military services have not submitted all of the OEHS reports they have completed for OIF to CHPPM’s centralized archive, as required by DOD policy. However, CHPPM officials said that they could not measure the magnitude of noncompliance because they have not received all of the required quarterly consolidated lists of OEHS reports that have been completed. To improve OEHS reporting compliance, DOD officials said they were revising an existing policy to add additional and more specific OEHS requirements.

Data Collection Standards and Practices Vary by Service, Although Preliminary Efforts Are Under Way to Increase Uniformity

OEHS data collection standards and practices have varied among the military services because each service has its own authority to implement broad DOD policies and the services have taken somewhat different approaches. For example, although one water monitoring standard has been adopted by all military services, the services have different standards for both air and soil monitoring. As a result, for similar OEHS events, preventive medicine units may collect and report different types of data. Each military service’s OEHS practices for implementing data collection standards also have differed, due to the varying levels of training and expertise among the service’s preventive medicine units. For example, CHPPM officials said that Air Force and Navy preventive medicine units had more specialized personnel with a narrower focus on specific OEHS activities than Army preventive medicine units, which included more generalist personnel who conducted a broader range of OEHS activities. Air Force preventive medicine units generally have included a flight surgeon, a public health officer, and bioenvironmental engineers. Navy preventive medicine units generally have included a preventive medicine physician, an industrial hygienist, a microbiologist, and an entomologist. In contrast, Army preventive medicine unit personnel generally have consisted of environmental science officers and technicians.

DOD officials also said other issues could contribute to differences in data collected during OIF. DHSD officials said that variation in OEHS data collection practices could occur as a result of resource limitations during a deployment. For example, some preventive medicine units may not be fully staffed at some bases. A Navy official also said that OEHS data collection can vary as different commanders set guidelines for implementing OEHS activities in the deployment theater.

To increase the uniformity of OEHS standards and practices for deployments, the military services have made some progress—particularly in the last 2 years—through their collaboration as members of the Joint Environmental Surveillance Working Group. For example, the working group has developed a uniform standard, which has been adopted by all the military services, for conducting environmental health site assessments, which are a type of baseline OEHS report. These assessments have been used in OIF to evaluate potential environmental exposures that could have an impact on the health of deployed servicemembers and determine the types of routine OEHS monitoring that should be conducted. Also, within the working group, three subgroups—laboratory, field water, and equipment—have been formed to foster the exchange of information among the military services in developing uniform joint OEHS standards and practices for deployments. For example, DHSD officials said the equipment subgroup has been working collaboratively to determine the best OEHS instruments to use for a particular type of location in a deployment. Another effort by the working group included devising a joint standard for the amount of OEHS data needed to sufficiently determine the severity of potential health hazards at a site. However, DOD officials estimated in late 2004 that it would take 2 years or more for this standard to be completed and approved.

Deployed Military Services Have Not Submitted All Required OEHS Reports for OIF, and the Magnitude of Noncompliance Is Unknown

The deployed military services have not submitted all the OEHS reports that the preventive medicine units completed during OIF to CHPPM for archiving, according to CHPPM officials. Since January 2004, CHPPM has compiled four summary reports that included data on the number of OEHS reports submitted to CHPPM’s archive for OIF. However, these summary reports have not provided information on the actual magnitude of noncompliance with report submission requirements because CHPPM has not received all consolidated lists of completed OEHS reports that should be submitted quarterly. These consolidated lists were intended to provide a key inventory of all OEHS reports that had been completed during OIF. Because there are no requirements on the specific number or type of OEHS reports that must be created for each base, the quarterly consolidated lists are CHPPM’s only means of assessing compliance with OEHS report submission requirements. Our analysis of data supporting the four summary reports found that, overall, 239 of the 277 bases had at least one OEHS baseline (139) or routine (211) report submitted to CHPPM’s centralized archive through December 2004.

DOD officials suggested several obstacles that may have hindered OEHS reporting compliance during OIF. For example, CHPPM officials said there are other, higher priority operational demands that commanders must address during a deployment, so OEHS report submission may be a lower priority. In addition, CHPPM officials said that some of the deployed military services’ preventive medicine units might not understand the types of OEHS reports to be submitted or might view them as an additional paperwork burden. CHPPM and other DOD officials added that some preventive medicine units might have limited access to communication equipment to send reports to CHPPM for archiving. CHPPM officials also said that while they had the sole archiving responsibility, CHPPM did not have the authority to enforce OEHS reporting compliance for OIF; this authority rests with the Joint Staff and the commander in charge of the deployment.

DOD has several efforts under way to improve OEHS reporting compliance. CHPPM officials said they have increased communication with deployed preventive medicine units and have facilitated coordination among each service’s preventive medicine units prior to deployment. CHPPM has also conducted additional OEHS training for some preventive medicine units prior to deployment, including both refresher courses and information about potential hazards specific to the locations where the units were being deployed. In addition, DHSD officials said they were revising an existing policy (DOD Instruction 6490.3; see table 1) to add additional and more specific OEHS requirements. However, at the time of our review, a draft of the revision had not been released and, therefore, specific details about these revisions were not available.

Progress Made in Using OEHS Reports to Address Immediate Health Risks, Though Limitations Remain for Addressing Both Immediate and Long-term Health Issues

DOD has made progress using OEHS reports to address immediate health risks during OIF, but limitations remain in employing these reports to address both immediate and long-term health issues. During OIF, OEHS reports have been used as part of operational risk management activities intended to assess, mitigate, and communicate to servicemembers any potential hazards at a location. While there have been no systematic efforts by DOD or the military services to establish a system to monitor the implementation of OEHS risk management activities, DHSD officials said relatively low rates of disease and nonbattle injury in OIF were considered an indication of OEHS effectiveness. In addition, DOD’s centralized archive of OEHS reports for OIF is limited in its ability to provide information on the potential long-term health effects related to occupational and environmental exposures for several reasons, including limited access to most OEHS reports because of security classification, incomplete data on servicemembers’ deployment locations, and the lack of a comprehensive federal research plan incorporating the use of archived OEHS reports.

Progress Made in Using Deployment OEHS Data and Reports in Risk Management, but DOD Does Not Monitor Implementation of These Efforts

To identify and reduce the risk of immediate health hazards in OIF, all of the military services have used preventive medicine units’ OEHS data and reports in an operational risk management process. A DOD official said that while DOD had begun to implement risk management to address occupational and environmental hazards in other recent deployments, OIF was the first major deployment to apply this process throughout the deployed military services’ day-to-day activities, beginning at the start of the operation. The operational risk management process includes risk assessments of deployment locations, risk mitigation activities to limit potential exposures, and risk communication to servicemembers and commanders about potential hazards.

Risk Assessments. Preventive medicine units from each of the services have generally used OEHS information and reports to develop risk assessments that characterized known or potential hazards when new bases were opened in OIF. CHPPM’s formal risk assessments have also been summarized or updated to include the findings of baseline and routine OEHS monitoring conducted while bases are occupied by servicemembers, CHPPM officials said. During deployments, commanders have used risk assessments to balance the identified risk of occupational and environmental health hazards, and other operational risks, with mission requirements. Alternatively, some preventive medicine units have addressed hazards identified through risk assessments without initially involving a commander. A Navy official said that, for example, if a preventive medicine unit found elevated bacteria levels when monitoring a drinking water purification system, the unit would likely order that the system be shut down and corrected and then notify the commander of the action in a summary report of OEHS activities. Generally, OEHS risk assessments for OIF have involved analysis of the results of air, water, or soil monitoring. CHPPM officials said that most risk assessments that they have received characterized locations in OIF as having a low risk of posing health hazards to servicemembers.

Risk Control and Mitigation. Using risk assessment findings, preventive medicine units have recommended risk control and mitigation activities to commanders that were intended to reduce potential exposures at specific locations. For OIF, risk control and mitigation recommendations at bases have included such actions as modifying work schedules, requiring individuals to wear protective equipment, and increasing sampling to assess any changes and improve confidence in the accuracy of the risk estimate.

Risk Communication. Risk assessment findings have also been used in risk communication efforts, such as providing access to information on a Web site or conducting health briefings to make servicemembers aware of occupational and environmental health risks during a deployment and the recommended efforts to control or mitigate those risks, including the need for medical follow-up. Many of the risk assessments for OIF we reviewed recommended that health risks be communicated to servicemembers.

The experience at Port Shuaiba, Kuwait, provides an illustration of the risk management process. Officials determined that Port Shuaiba, which had a moderate risk rating in numerous OEHS risk assessments, had the highest assessed risk for potential environmental exposures identified in OIF. The site is a deepwater port used for bringing in heavy equipment in support of OIF, and a large number of servicemembers have been permanently or temporarily stationed at this site. CHPPM officials said reported concerns about air quality problems, such as sulfur dioxide emissions and windblown dust and sand particles, and the concentration of a large number of industrial facilities at Port Shuaiba led to this risk characterization as a result of multiple OEHS risk assessments conducted before and during OIF. Risk mitigation recommendations that have been implemented at Port Shuaiba include increasing air monitoring to continuous, 24-hour sampling; implementing the use of standard protective equipment, such as goggles and face kerchiefs; and using dust suppression measures, such as laying gravel over the entire location to reduce dust. CHPPM officials said they were uncertain whether some other risk mitigation recommendations for Port Shuaiba had been implemented, such as requiring servicemembers to stay inside buildings or tents as much as possible when air pollution levels are high or increasing the number of servicemembers available for operations to reduce the duration of shifts. On the basis of recommendations from the risk assessments, military officials have been attempting to transfer the activities at Port Shuaiba to a nearby port that does not have industrial facilities, but servicemembers have continued to live and work at the site, though in greatly reduced numbers, CHPPM officials said. CHPPM officials said they have recommended extensive risk communication activities at Port Shuaiba, including providing information to servicemembers in town hall meetings and through posters and handouts in dining facilities. In addition, CHPPM officials said they have worked with commanders to allow CHPPM to provide briefings about the identified and potential health hazards as soon as new military units arrive at Port Shuaiba.

While risk management activities have become more widespread in OIF compared with previous deployments, DOD officials have not conducted systematic monitoring of deployed military services’ efforts to conduct OEHS risk management activities. As of March 2005, neither DOD nor the military services had established a system to examine whether required risk assessments had been conducted, or to record and track resulting recommendations for risk mitigation or risk communication activities. In the absence of a systematic monitoring process, CHPPM officials said they conducted ad hoc reviews of implementation of risk management recommendations for sites where continued, widespread OEHS monitoring has occurred, such as at Port Shuaiba and other locations with elevated risks. DHSD officials said they have initiated planning for a comprehensive quality assurance program for deployment health that would address OEHS risk management, but the program was still under development.

DHSD and military service officials said that developing a monitoring system for risk management activities would face several challenges. In response to recommendations for risk mitigation and risk communication activities, commanders may have issued written orders and guidance that were not always stored in a centralized, permanent database that could be used to track risk management activities. Additionally, DHSD officials told us that risk management decisions have sometimes been recorded in commanders’ personal journals or diaries, rather than issued as orders that could be stored in a centralized, permanent database.

In lieu of a monitoring system, DHSD officials said the rates of disease and nonbattle injury in OIF are considered by DOD as a general measure or indicator of OEHS effectiveness. As of January 2005, OIF had a 4 percent total disease and nonbattle injury rate—in other words, an average of 4 percent of servicemembers deployed in support of OIF had been seen by medical units for an injury or illness in any given week. This rate is the lowest DOD has ever documented for a major deployment, according to DHSD officials. For example, the total disease and nonbattle injury rate for the 1991 Gulf War was about 6.5 percent, and the total rate for Operation Enduring Freedom in Central Asia has been about 5 percent. However, while this indicator provides general information on servicemembers’ health status, it is not directly linked to specific OEHS activities and therefore is not a clear measure of their effectiveness.

Access to Most Archived OEHS Reports Is Limited by Security Classification

Access to archived OEHS reports by VA, medical professionals, and interested researchers has been limited by the security classification of most OEHS reports. Typically, OEHS reports are classified if the specific location where monitoring activities occur is identified. VA officials said they would like to have access to OEHS reports in order to ensure appropriate postwar health care and disability compensation for veterans, and to assist in future research studies. However, VA officials said that they did not expect access to OEHS reports to improve until OIF has ended because of security concerns.

Although access to OEHS reports has been restricted, VA officials said they have tried to anticipate likely occupational and environmental health concerns for OIF based on experience from the 1991 Persian Gulf War and on CHPPM’s research on the medical and environmental health conditions that exist or might develop in the region. Using this information, VA has developed study guides for physicians on such topics as health effects from radiation and traumatic brain injury and also has written letters for OIF veterans about these issues.

DOD has begun reviewing classification policies for OEHS reports, as required by the Ronald W. Reagan National Defense Authorization Act for Fiscal Year 2005. A DHSD official said that DOD’s newly created Joint Medical Readiness Oversight Committee is expected to review ways to reduce or limit the classification of data, including data that are potentially useful for monitoring and assessing the health of servicemembers who have been exposed to occupational or environmental hazards during deployments.

Difficulties Exist in Linking Archived OEHS Reports to Individual Servicemembers, but Some Efforts Are Under Way to Include Information in Medical Records

Linking OEHS reports from the archive to individual servicemembers will be difficult because DOD’s centralized tracking database for recording servicemembers’ deployment locations currently does not contain complete or comparable data. In May 1997, we reported that the ability to track the movement of individual servicemembers within the theater is important for accurately identifying exposures of servicemembers to health hazards. However, DMDC’s centralized database has continued to experience problems in obtaining complete, comparable data from the services on the location of servicemembers during deployments, as required by DOD policies. DMDC officials said the military services had not reported location data for all servicemembers for OIF. As of October 2004, the Army, Air Force, and Marine Corps each had submitted location data for approximately 80 percent of their deployed servicemembers, and the Navy had submitted location data for about 60 percent of its deployed servicemembers. Additionally, the specificity of location data has varied by service. For example, the Marine Corps has provided location of servicemembers only by country, whereas each of the other military services has provided more detailed location information for some of their servicemembers, such as base camp name or grid coordinate locations. Furthermore, the military services did not begin providing detailed location data until OIF had been ongoing for several months.

DHSD officials said they have been revising an existing policy to provide additional requirements for location data that are collected by the military services, such as a daily location record with grid coordinates or latitude and longitude coordinates for all servicemembers. Though the revised policy has not been published, as of May 2005 the Army and the Marine Corps had implemented a new joint location database in support of OIF that addresses these revisions.

During OIF, some efforts have been made to include information about specific incidents of potential and actual exposure to occupational or environmental health hazards in the medical records of servicemembers who may be affected. According to DOD officials, after preventive medicine units have investigated incidents involving potential exposure, they generally have developed narrative summaries of events and the results of any medical procedures for inclusion in affected servicemembers’ medical records. Additionally, rosters were generally developed of servicemembers directly affected and of servicemembers who did not have any acute symptoms but were in the vicinity of the incident. For example, in investigating an incident involving a chemical agent used in an improvised explosive device, CHPPM officials said that two soldiers who were directly involved were treated at a medical clinic, and their treatment and the exposure were recorded in their medical records. Although 31 servicemembers who were providing security in the area were asymptomatic, doctors were documenting this potential exposure in their medical records.

In addition, the military services have taken some steps to include summaries of potential exposures to occupational and environmental health hazards in the medical records of servicemembers deployed to specific locations. The Air Force has created summaries of these hazards at deployed air bases and has required that these be placed in the medical records of all Air Force servicemembers stationed at these bases. (See app. II for an example.) However, Air Force officials said no follow-up activities have been conducted specifically to determine whether all Air Force servicemembers have had the summaries placed in their medical records. In addition, the Army and Navy jointly created a summary of potential exposure for the medical records of servicemembers stationed at Port Shuaiba. Since December 2004, port officials have made efforts to make the summary available to servicemembers stationed at Port Shuaiba so that these servicemembers can include the summary in their medical records. However, there has been no effort to retroactively include the summary in the medical records of servicemembers stationed at the port prior to that time.

No Federal Research Plan Exists for Using OEHS Reports to Follow the Health of OIF Servicemembers over Time

According to DOD and VA officials, no federal research plan that includes the use of archived OEHS reports has been developed to evaluate the long- term health of servicemembers deployed in support of OIF, including the effects of potential exposure to occupational or environmental hazards. In February 1998 we noted that the federal government lacked a proactive strategy to conduct research into Gulf War veterans’ health problems and suggested that delays in planning complicated researchers’ tasks by limiting opportunities to collect critical data. However, the Deployment Health Working Group, a federal interagency body responsible for coordinating research on all hazardous deployments, recently began discussions on the first steps needed to develop a research plan for OIF. At its January 2005 meeting, the working group tasked its research subcommittee to develop a complete list of research projects currently under way that may be related to OIF. VA officials noted that because OIF is ongoing, the working group would have to determine how to address a study population that changes as the number of servicemembers deployed in support of OIF changes.

Although no coordinated federal research plan has been developed, there are some separate federal research studies under way that may follow the health of OIF servicemembers. For example, in 2000 VA and DOD collaborated to develop the Millennium Cohort study, a 21-year longitudinal study evaluating the health of both deployed and nondeployed military personnel throughout their military careers and after leaving military service. According to the principal investigator, the Millennium Cohort study was designed to examine the health effects of specific deployments if enough servicemembers in that deployment enrolled in the study. However, the principal investigator said that as of February 2005 researchers had not identified how many servicemembers deployed in support of OIF had enrolled in the study. Additionally, a VA researcher has received funding to study mortality rates among OIF servicemembers. According to the researcher, if occupational and environmental data are available, the study will include the evaluation of mortality outcomes in relation to potential exposure for OIF servicemembers.

Conclusions

Since the 1991 Persian Gulf War, DOD has made progress in improving occupational and environmental health data collection through its development of a militarywide health surveillance framework for use during deployments. However, these efforts still could be strengthened. OEHS data that the deployed military services have collected during OIF may not always be comparable because of variations among the services’ data collection standards and practices. As a result of these variations, the amount and comprehensiveness of data for servicemembers from one military service may be more extensive than for servicemembers from another service. Additionally, the deployed military services’ uncertain compliance with OEHS report submission requirements casts doubts on the completeness of CHPPM’s OEHS archive. These data shortcomings, in conjunction with the incomplete data in DOD’s centralized tracking database of servicemembers’ deployment locations, limit CHPPM’s ability to respond to requests for OEHS information about possible exposure to occupational and environmental health hazards of those who are serving or have served in OIF. Other limitations may also impede the comprehensiveness of the archived OEHS reports, including the inability to collect OEHS data outside of base camps and a lack of knowledge of all potential health hazards. Nonetheless, these limitations do not outweigh the need to collect data on known or expected hazards in order to make every effort to address potential health issues. DHSD officials have said they are revising an existing policy on OEHS data collection and reporting to add additional and more specific OEHS requirements. However, unless the military services take measures to direct those responsible for OEHS activities to proactively implement the new requirements, the services’ efforts to collect and report OEHS data may not improve.

DOD’s risk management efforts during OIF represent a positive step in helping to mitigate potential environmental and occupational risks of deployment. But the effects of such efforts are unknown without systematic monitoring of the deployed military services’ implementation activities. Rates of disease and nonbattle injury have been used as an overall surrogate outcome measure for risk management in OIF, but DOD and the military services currently are unable to ascertain how and to what extent risk management efforts have contributed to the relatively low disease and nonbattle injury rate for OIF.

Although OEHS reports alone are not sufficient to identify the causes of potential long-term health effects in deployed servicemembers, they are an integral component of research to evaluate the long-term health of deployed servicemembers. However, efforts by a joint DOD and VA working group to develop a federal research plan for OIF that would include examining the effects of potential exposure to occupational and environmental health hazards have just begun, despite similarities in deployment location to the 1991 Persian Gulf War. Unless DOD addresses OEHS data collection and reporting weaknesses and develops a federal research plan for OIF with VA, the departments ultimately may face the same criticisms they faced following the first Gulf War over their inability to adequately address the long-term health issues of servicemembers.

Recommendations for Executive Action

We are making recommendations aimed at improving the collection and reporting of OEHS data during deployments and improving OEHS risk management. To improve the collection and reporting of OEHS data during deployments and the linking of OEHS reports to servicemembers, we recommend that the Secretary of Defense ensure that cross-service guidance is created to implement DOD’s policy, once that policy has been revised, which addresses improvements to conducting OEHS activities and to reporting the locations of servicemembers during deployment.

To improve the use of OEHS reports to address the immediate health risks of servicemembers during deployments, we recommend that the Secretary of Defense ensure that the military services jointly establish and implement procedures to evaluate the effectiveness of risk management efforts.

To better anticipate and understand the potential long-term health effects of deployment in support of OIF, we recommend that the Secretary of Defense and the Secretary of Veterans Affairs work together to develop a federal research plan to follow the health of these servicemembers that would include the use of archived OEHS reports.

Agency Comments and Our Evaluation

We requested comments on a draft of this report from DOD and VA. Both agencies provided written comments that are reprinted in appendixes III and IV. DOD also provided technical comments that we incorporated where appropriate.

In commenting on this draft, DOD did not concur with our recommendation that the military services jointly develop implementation guidance for DOD’s policy on OEHS during deployments, once that policy has been revised. However, DOD stated that officials are planning steps that will meet the intent of our recommendation to improve the collection and reporting of OEHS data during deployments. DHSD officials stated that cross-service implementation guidance for the revised policy on deployment OEHS would be developed by the Joint Staff instead of by the individual military services, as we originally recommended. We believe that the development of cross-service implementation guidance is a critical element needed to improve OEHS data collection and reporting during deployments, regardless of the entity responsible for developing this guidance. Therefore, we modified the wording of our recommendation to clarify our intent that joint guidance be developed.

DOD partially concurred with our recommendation that the military services jointly establish and implement procedures to evaluate the effectiveness of risk management efforts. DOD stated that OEHS reports would be of no value for “immediate” health risks, except for incident- driven reports, and assumed that we were referring to health risks that may occur once servicemembers return from a deployment. However, our findings describe the OEHS operational risk management process that is specifically conducted during a deployment, including risk assessment, risk mitigation, and risk communication activities that are used to identify and reduce the risk of immediate health hazards. Additionally, DOD stated that it has procedures in place to evaluate OEHS risk management through a jointly established and implemented lessons learned process. Because the lessons learned process was not raised by agency officials during our review, we did not determine whether it would systematically monitor or evaluate the effectiveness of OEHS risk management activities. However, in further discussions, DHSD officials told us that they were not aware of any lessons learned reports related to OEHS risk management for OIF.

DOD partially concurs with our recommendation that DOD and VA work together to develop a federal research plan to follow the health of servicemembers deployed in support of OIF that would include the use of archived OEHS reports. Although DOD states that it agrees with the importance of following the health of its servicemembers, its response focuses on initiatives for the electronic exchange of clinical health information with VA. In further discussions, DHSD officials explained that analysis of this clinical information could lead to the development of research hypotheses and, ultimately, research questions that would guide federal health research. Although DOD officials stated that they have not yet linked any occupational or environmental exposures to specific adverse health effects, there is no certainty that long-term health effects related to these types of exposures will not appear in veterans of OIF. Federal research has not clearly identified the causes of unexplained illnesses reported by servicemembers who served in the 1991 Persian Gulf War, and OIF servicemembers are serving in the same region for longer periods of time.

Separately, VA concurred with our recommendation to work jointly with DOD to develop a federal research plan to follow the health of OIF servicemembers. VA confirmed that the Deployment Health Working Group, which includes DOD officials, had initiated steps in January 2005 toward developing a comprehensive joint federal surveillance plan to evaluate the long-term health of servicemembers returning from both OIF and Operation Enduring Freedom (OEF). However, more importantly, the difference in VA and DOD’s responses to this recommendation illustrates a disconnect between each agency’s understanding of whether and how such a federal research plan should be established. Therefore, continued collaboration between the agencies to formulate a mutually agreeable process for proactively creating a federal research plan would be beneficial in facilitating both agencies’ ability to anticipate and understand the potential long-term health effects related to OIF deployment versus taking a more reactive stance in waiting to see what types of health problems may surface.

In its response, VA also contends that we overstate problems related to its ability to access DOD’s classified occupational and environmental health data. VA notes that it has staff with the necessary security clearances to examine classified OEHS reports, so that there is no barrier to access. However, during our review VA officials expressed concerns that they did not have OEHS data and that access to the data was difficult. Even if VA staff have security clearances that enable them to examine OEHS data, any materials that arise from the use of classified documents, such as research papers or other publications, would likely be restricted. Therefore, these results would have limited use, as they cannot be broadly shared with other researchers and the general public. Nonetheless, VA maintains that development of a systematic method to tabulate and organize the exposure data is needed, as is a complete roster of OIF and OEF veterans, pre- and post-deployment health screening data, and a complete roster of the most seriously injured veterans. We agree that a systematic method to organize and share OEHS data is important. This issue could be addressed within the efforts to develop a federal research plan.

As arranged with your office, unless you release its contents earlier, we plan no further distribution of this report until 30 days after its issuance date. At that time, we will send copies of this report to the Secretary of Defense and the Secretary of Veterans Affairs. We will also provide copies to others upon request. In addition, the report will be available at no charge on GAO’s Web site at http://www.gao.gov.

If you or your staff has any questions about this report, please call me at (202) 512-7119. Bonnie Anderson, Karen Doran, John Oh, Danielle Organek, and Roseanne Price also made key contributions to this report.

Scope and Methodology

To describe how the military services have implemented the Department of Defense’s (DOD) policies for collecting and reporting occupational and environmental health surveillance (OEHS) data for Operation Iraqi Freedom (OIF), we reviewed pertinent DOD policies and military services’ guidance that delineated the requirements for OEHS data collection and reporting. We interviewed officials at the Deployment Health Support Directorate (DHSD) and the Joint Staff to obtain a broad overview of DOD’s OEHS activities in OIF. We also interviewed officials at each of the military services’ health centers—the U.S. Army Center for Health Promotion and Preventive Medicine (CHPPM), the Navy Environmental Health Center, and the Air Force Institute for Operational Health—to obtain information about each service’s OEHS data collection standards and practices, training of preventive medicine units for OIF, obstacles that could hinder OEHS data collection and reporting, and efforts to improve reporting compliance. Additionally, we interviewed members of the Joint Environmental Surveillance Working Group to discuss the purpose and structure of the working group and efforts related to increasing the uniformity of OEHS standards and practices for deployments.

To determine if the military services were submitting OEHS reports to CHPPM’s centralized archive, we obtained and reviewed CHPPM’s quarterly summary reports, which provided the total number of bases that have submitted at least one report in each of the categories of baseline, routine, or incident-driven reports for the U.S. Central Command’s (CENTCOM) area of responsibility, details about consolidated lists of reports, and information about other OEHS reporting compliance issues. The summary reports did not show report submission by individual bases or, other than for the first summary report, separately identify OIF bases from all others in the CENTCOM area of responsibility. For each of the summary reports, CHPPM provided us with supporting documents that included lists of the bases specific to OIF and, for each base, whether it had submitted baseline, routine, or incident-driven reports. We attempted to include only unique OIF bases in our analysis; however, CHPPM officials told us that a few duplicate OIF bases may be included in our analysis due to reasons such as frequent base openings and closures and base name changes. We used these supporting documents to identify the number and percentage of bases with and without baseline or routine reports during the reporting periods. Incident-driven reports reflect OEHS investigations of unexpected incidents and would not be submitted to CHPPM’s archive according to any identified pattern. Therefore, we did not review the services’ submission of incident-driven reports. Because OEHS reports generally are classified, we did not report on the specifics contained in these reports.

We determined that the data from CHPPM’s OEHS archive were sufficiently reliable for the purposes of this report by (1) confirming the data included the elements that we requested and were consistent with provided documentation and (2) conducting detailed fact-finding interviews with CHPPM officials to understand how the data were obtained and to determine the limitations of the data. To characterize the OEHS reports for OIF submitted to CHPPM, we discussed the numbers of reports submitted and characterized the categories of reports using percentages. While the OEHS reports were contained in a computerized archive, there was no formal database in which the information from the reports could have been extracted into data fields. Instead, the archived reports were Microsoft Word documents, Microsoft Excel spreadsheets, Adobe Acrobat files, scanned images, or e-mail text that were organized by either military base or type of report. Therefore, there was no specific database with data fields that could be examined through a data reliability test.

To identify the efforts to use OEHS reports to address the more immediate health issues of servicemembers deployed in support of OIF, we reviewed DOD policies and documents describing the operational risk management process. Additionally, we reviewed 28 risk assessment reports and the risk mitigation efforts and risk communication activities that resulted from these assessments. We also reviewed and summarized risk management activities for Port Shuaiba, Kuwait. We interviewed officials from CHPPM responsible for OEHS risk management activities at Port Shuaiba and discussed quality assurance efforts related to these activities. We also interviewed officials from DHSD about additional OEHS-related quality assurance programs.

To identify the efforts under way to use OEHS reports to address the long- term health issues of servicemembers deployed in support of OIF, we interviewed Department of Veterans Affairs (VA) and DOD officials to examine access to OEHS reports and use of OEHS reports for VA, and reviewed laws relating to classification of documents. Additionally, we reviewed relevant VA documents to determine the ways in which VA can use OEHS reports and to determine its efforts to anticipate OEHS issues.

To determine the difficulties in linking OEHS reports to the individual records of servicemembers, we interviewed officials and military representatives at DOD’s Defense Manpower Data Center (DMDC) regarding the status of the Contingency Tracking System, a centralized tracking database to identify deployed servicemembers and track their movements within the theater of operations. To help identify problems with this system, we asked DMDC to provide information about the amount of location data submitted by each military service to this database. To assess the reliability of the data submitted by each military service, we (1) interviewed DMDC officials about limitations of the system and (2) confirmed that the data included the elements we requested and were consistent with provided documentation. We tested the data electronically to ensure that the numbers were accurately calculated. Given our research questions and discussions with DMCD officials regarding the centralized system, we determined that these data were reliable for our purposes.

We interviewed CHPPM officials to examine efforts to include information from investigations of potential exposures to occupational and environmental health hazards in servicemembers’ medical records, and reviewed summary documents related to potential occupational and environmental exposures. We also interviewed Army, Air Force, and Navy officials to discuss these summary documents and determine efforts in place to ensure that these documents were placed in the medical records. We also examined other documents, including DOD policies, federal laws, and interagency coordinating council meeting minutes relating to OEHS.

We interviewed DOD and VA officials to determine whether a federal research plan using OEHS reports had been developed to evaluate the long- term health of servicemembers deployed in support of OIF. We also reviewed documents, including the meeting minutes of an interagency group and documents relating to a current collaborative study between DOD and VA. We performed our work from September 2004 through June 2005 in accordance with generally accepted government auditing standards.

Example of an Occupational and Environmental Health Surveillance Summary Created by the Air Force during Operation Iraqi Freedom

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

ENVIRO NMENTAL/OCCUPAT IONAL HEAL TH WORK PLACE EXPOSURE DATA This a sse ssm ent covers individuals deployed to BAGHDAD AIR B ASE (BDAB), IRAQ for the time period 15 DEC 03 to 30 APR 2004.

Purpose: To comply with the deployment health surveillan ce requirements of Presidential Review Directive 5 and JCSM 0006-02, Updated Procedures for Deployment Health Surveillan ce and Readiness. CENTAF/SG officially sanctions use of this form and recommends it be maintained in the individual s permanent medical record with the DD Form 2796, Post Deployment Health Assessment, covering the same time period.

Camps Sather and Griffin, the primary AF locations on Baghdad International A irport (BIAP), were part of the Iraqi Military Training portion of BIAP. However, this specific area was not heavily used. The small Iraqi terminal on site was for military guests and distinguished visitors. Base housing and training was on the other side of the main road outside Camp Sather. While there is farming around BIAP, we are not aware of any specific farming activities within Camp Sather; however, there is evidence of flooded fields in/around Camp Griffin. We are als o not aware of any major spills within the BIAP AF cantonment. BDAB refers to both Camps Sather and Griffin.

SSN/ID NO.

REGISTER NO.

WARD NO.

Rank/Grade.)

CHRONOLOGICAL RECORD OF MEDICAL CARE STANDARD FORM 600 (REV. 6-97)

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

ENVIRO NMENTAL/OCCUPAT IONAL HEAL TH WORK PLACE EXPOSURE DATA (continued) medical record, individual reported no adverse contact (i.e. bites). Feral cats and dogs have als o been noted in the area. Rats and mice have been a nuisance; one rat bite was reported in the summer of 2003. 6. Waste Sites/Was te Disposal: Hazar dous waste storage on BDAB is limited to used and off-spec POL products, and small s pill cleanup residue. Currently, proper handling, storage, and disposal of industrial waste generated on base (mainly oil, fuel and hydraulic fluid) are strictly enforced. Airborne exposure to base personnel from stored waste is assessed as minimal to nonexistent. No obvious signs of significant past spills or tank leakage were noted when coalition forces occupied BIAP, although POL personnel did drain and remove several ex tant tanks. Trash and garbage are containerized and routinely collected by contractors. Latrines are pumped out by trucks and waste is disposed off-BIAP. 7. Nuclear, Biological or Chemical (NBC) Weapon Exposure: There has been no evidence of any use, storage, release, or ex posure of NBC agents to personnel at this site. 8. Agricultural Emissions: Surrounding land is moderately agricultural. Many farms are within 1-2 miles of the perimeter fence, with numerous potentially flooded fields for rice cultivation. Aerial photos previous to May 2003 revealed that much of BIAP, including parts of the AF cantonment, were rice cultivation areas. While we haven t witnessed any significant application, herbicide/pesticide use probably routinely occurs just outside the base. However, airborne exposure to base personnel is assessed as minimal to nonexistent. . Depleted Uranium (DU): DU is a component of some aircraft present and/or transient on/through BDAB. There is no evidence of DU munitions having been expended at BIAP. Therefore, there is no potential air borne exposure to DU. Exposure is classified as far below permissible exposure levels. 10. Hazardous Materia ls: There are only a few permanent structures on BDAB. Both lead-based paint and potential as bestos- containing material have been tentatively identified in various locations on BIAP; however, personnel are not performing activities that involve routine exposure, thereby minimizin g health risk. There were multiple sites where Iraqi hazar dous materials caches were located; however, personnel exposures were minimize d/eliminated by removing or limiting access to the materials .

Occupational Exposure Data and Risk Asse ssment: 1. Noise: Aircraft, aircraft ground equipment, generators and other equipment produce hazar dous noise. Workers routinely exposed to hazar dous noise are those working on or near the flight line and/or in selected industrial shops. These workers have comparable noise exposure at home station and are on the hearing conservation program. For all in dividuals, appropriate hearing protection is provided for protection again st hazar dous noise. Additionally, the whole of Camp Sather is within 300 yards of an extremely active flightline. 2. Heat Stress: Daily temperature range: Mar - Oct from 75 F to 125 F ; Nov - Feb from 55 F to 95 F. Personnel are continually educated on heat stress dangers, water intake and work/rest cycles. Unless separately documented, individual had no heat related injury. 3. Airborne Exposure to Chemical Hazards: Unless sp ecified in a duty-specific supplement, individual exposure to chemical inhalation is considered similar to duties performed at home station. On base industrial ac tivities include routine aircraft, equipment and installatio n maintenance. Generally, majority of the chemicals used on BDAB are oils, greases, lubricants, hydraulic fluids a nd fuel. Little to no corrosion control activities are performed and no solvent tanks exist on site. No industrial ac tivity is performed that generates, or has been expected to generate, airborne exposures above permissible exposure levels or medical action levels. 4. Chemical Contact and Eye Protection: Unless sp ecified in a job-specific supplement, individual exposure to chemical contact is considered similar to duties performed at home station. Workers are provided appropriate protective equipment (i.e. nitrile/rubber gloves, goggles, safety glasses and face s hields) when and where needed. 5. Radiation: Ionizing radiation is emitted from medical/dental x-ray and OSI operations, and low-level radioactive materials present in equipment such as chemical ag ent monitors and alar ms. No worker has been identified as exceed ing 10% of the 5 REM/year OSHA permissible exposure level. Radio frequency (RF) radiation is emitted from multiple radar systems and communication equipment. Systems are marked with warning signs and communication workers recei ve appropriate training. Unless otherwise documented, no worker has been identified as ex ceed ing RF-radiation permissible ex posure limits. Significant UV radiation from the sun is expected on exposed unprotected skin. BDAB personnel have been advised to minimize sun exposure through the use of sunscreen and wear of sleeves down. Additionally, BDAB is a high light level environment. Many cases of photosensitivity dermatitis were observed. Some were no doubt exacerbated by the use of doxycycline for malaria prophylaxis. Unless otherwise stated in medical record, individual reported no radiation/light related injuries. 6. Er gonomics: Individual exposure to ergonomic stress from job related duty is substantially similar to duties performed at home station, with potential moderate increase in lifting involved with unique deployment requirements such as erection of tents and shelters. Unless otherwise stated in medical record, individual reported no ergonomic stress related injuries. 7. Bloodborne Pathogens: Individual exposure to bloodborne pathogens from job related duty is considered similar to duties performed at home station. Applicable workers are provided appropriate protective equipment and have been placed on the bloodborne pathogen program. Unless otherwise stated elsewhere in the medical record, individual reported no significant unprotected ex posures.

Comments from the Department of Defense

Appendix IV