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

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