Many Persian Gulf War veterans have complained of illnesses since the war’s end in 1991. Over 100,000 of the approximately 700,000 Gulf War veterans have participated in health examination programs established by the Department of Defense (DOD) and the Department of Veterans Affairs (VA). Many of those examined reported health complaints, including fatigue, muscle and joint pain, gastrointestinal problems, headaches, depression, neurologic and neurocognitive impairments, memory loss, shortness of breath, and sleep disturbances. Many veterans claim that their medical symptoms, some of them debilitating in nature, were not present before their service in the Persian Gulf War. Some veterans suspect that their health problems may be linked to chemical or biological warfare agents that Iraq may have used during the Gulf War. Various organizations have researched the causes of Gulf War illnesses—the source of much controversy over the past 7 years. By the end of 1996, DOD and the VA together had funded 82 research projects related to Gulf War illnesses. Despite these efforts, it remains unclear why some Gulf War veterans became ill following their service in the Persian Gulf War. It also remains unclear whether the rates of reported illnesses for veterans that deployed to the Gulf are higher overall than the rates for those that did not deploy or than the rates for the civilian or military population as a whole. Also unexplained are differences in the frequency of symptoms reported by reserve units and active duty units and any correlations between the location of units and the occurrence of particular illnesses. Research designed to answer these and many other Gulf War illnesses-related questions will not be completed for years. Of the 151 current federally sponsored research projects, less than 25 percent have been completed, and many are not scheduled for completion until after 2000. Prompted by the continuing controversy over Gulf War illnesses, President Clinton, in 1995, ordered DOD and other federal agencies to reexamine whether possible exposure to chemical or biological agents occurred during the Gulf War. In March 1995, the Deputy Secretary of Defense established the Persian Gulf Illnesses Investigation Team within the Office of the Assistant Secretary of Defense for Health Affairs to explore this question. The Investigation Team was established as DOD began to lose credibility among veterans and veterans’ groups in its efforts to determine the causes of Gulf War illnesses and to support the problems experienced by veterans. The 12-member team included intelligence officers, an Army Chemical Corps officer, a pilot, a chemist, a physician, and a criminal investigator. Beginning in 1991, senior Defense officials had taken the position, in testimony before the Congress and in press interviews, that Iraq did not use chemical or biological weapons during the Persian Gulf War and that no U.S. forces were exposed to chemical or biological agents. DOD officials maintained this position as late as 1994. This position came under attack because both U.S. and foreign detection teams had reported that chemical warfare agents were present on the battlefield. In 1995 and 1996, Central Intelligence Agency and U.N. reports established that during the Gulf War, Iraq had stored rockets filled with sarin, a deadly chemical warfare agent, at an ammunition storage site located at Khamisiyah, Iraq, about 60 miles from Kuwait’s border. In June 1996, DOD announced that U.S. troops at Khamisiyah in March 1991 were likely to have destroyed a bunker of rockets containing chemical agents. By July 1997, DOD acknowledged that U.S. troops near Khamisiyah may have unknowingly been exposed to low levels of sarin when they used demolitions to destroy these rockets. In the midst of this controversy, DOD became dissatisfied with the results of the Investigation Team’s efforts. The Investigation Team did not have the resources needed to accomplish its mission. For example, it was unable to follow up on more than 1,200 toll-free calls received on DOD’s hot line with Gulf War veterans. In addition, its operation was criticized in the December 1996 report by the Presidential Advisory Committee on Gulf War Veterans’ Illnesses. The report cited, for example, the Investigation Team’s failure to take advantage of its unique access to classified and routine military records to fully investigate and help answer the public’s questions about veterans’ possible exposure to chemical and biological warfare agents. A DOD team asked by the Deputy Secretary of Defense to evaluate DOD’s responses to Gulf War illnesses concluded that DOD’s work in this area needed a broader focus, a strategy for systematically examining the various theories concerning the nature and causes of Gulf War illnesses, and a method of effectively communicating DOD’s findings to U.S. veterans and the public. On November 12, 1996, the Deputy Secretary of Defense established the Office of the Special Assistant for Gulf War Illnesses (OSAGWI). The goal of restoring public confidence in DOD shaped the mission and organizational focus of OSAGWI. OSAGWI’s mission was broadly defined as ensuring that (1) veterans of the Gulf War are appropriately cared for, (2) DOD is doing everything possible to understand and explain Gulf War illnesses, and (3) DOD puts into place all required military doctrine and personnel and medical policies and procedures to minimize any future problems from exposure to chemical and biological warfare agents and other environmental hazards. Although OSAGWI’s mission statement charges it with ensuring that veterans are appropriately cared for, specific responsibility for providing health care to servicemembers still on active duty and for conducting the health research program continues to reside with the Office of the Assistant Secretary of Defense for Health Affairs. Similarly, VA remains the primary health care provider for those who have left military service. OSAGWI officials told us, however, that they assist servicemembers and veterans with health care matters related to Gulf War illnesses by providing them with referrals to sources of health care or helping them with the registration and examination processes associated with DOD’s Comprehensive Clinical Evaluation Program or the VA’s Persian Gulf Registry. OSAGWI also works with the Assistant Secretary of Defense for Reserve Affairs to (1) help ensure that reservists receive all entitled benefits and (2) recommend changes to legislation or rules where needed. At the time of our review, OSAGWI believed that its core activity involved investigating and reporting on incidents of possible exposure to chemical and biological warfare agents and investigating related military operations during the Gulf War. After OSAGWI has completed its investigation of an incident, the investigator writes a summation document called a case narrative. The purpose of OSAGWI’s case narratives is essentially to get all of the facts before the American people about what OSAGWI has learned from its investigation of an incident. The case narrative, a document updated as new evidence becomes known, is to contain all important investigative facts and OSAGWI’s assessment—in terms of “definitely,” “likely,” “indeterminate,” “unlikely,” or “definitely not”—of the likelihood that servicemembers were exposed to chemical or biological warfare agents. The standard OSAGWI used for its assessments was whether all available facts would lead a reasonable person to conclude that a chemical or biological warfare agent was or was not present. As of January 1, 1999, OSAGWI had published a total of 19 reports—13 case narratives, 2 environmental exposure reports, and 4 information papers. At that time OSAGWI also had 27 active investigations under way. Appendix III lists OSAGWI reports and their dates of publication as well as OSAGWI’s active investigations. On July 8, 1997, the Ranking Minority Member of the House Committee on Veterans Affairs asked us to examine OSAGWI operations. Specifically, we were asked to (1) describe DOD’s progress in establishing an organization to address Gulf War illnesses issues and (2) evaluate the thoroughness of OSAGWI’s investigations into and reporting on veterans’ potential exposure to chemical or biological agents during the Gulf War. We did not review OSAGWI activities to coordinate and monitor research on the causes of Gulf War illnesses because this subject is addressed by other reviews. To determine DOD’s progress in establishing an organization to address Gulf War illnesses issues, we obtained briefings from OSAGWI officials covering the range of activities performed to fulfill their mission objectives and reviewed associated documentation. OSAGWI had issued eight case narratives at the time we began our review. It pursued these eight cases first because they involved incidents that were the most prominent and controversial at the time. To evaluate the thoroughness of OSAGWI’s investigations and reporting on veterans’ possible exposures to chemical or biological warfare agents, we reviewed six of these eight case narratives. The case narratives we selected for review were (1) “Reported Mustard Agent Exposure”; (2) “U.S. Marine Corps Minefield Breaching”; (3) “Fox Detections in an Ammunition Supply Point (ASP) Orchard”; (4) “Al Jubayl, Saudi Arabia”; (5) “Al Jaber Air Base”; and (6) “Reported Detection of Chemical Agent, Camp Monterey, Kuwait.” We did not review the case narrative about the alleged exposure to chemical warfare agents at Khamisiyah, Iraq, because it was already being heavily reviewed by other organizations, such as the Presidential Advisory Committee on Gulf War Veterans’ Illnesses and the Senate Committee on Veterans Affairs’ Special Investigation Unit. We also did not review the “Possible Chemical Agent on SCUD Missile Sample” case narrative because it appeared to be less controversial than the other case narratives. In reviewing each case narrative, we generally used as criteria OSAGWI’s methodology, which had itself been derived from the United Nations and other international community protocols for investigating chemical warfare incidents. This methodology included (1) substantiating the incident by searching for documentation from operational, intelligence, and environmental logs; (2) documenting the medical reports related to the incident; (3) interviewing appropriate people; (4) obtaining information available to external organizations; and (5) assessing the results. We also used the criterion that the case narrative should accurately and fully disclose all materially significant information relevant to the investigation of the incident in order to avoid any appearance that OSAGWI was selectively reporting what had actually happened. We initially traced each statement in the published case narrative to its underlying supporting document to identify the accuracy and completeness of the text in the narrative. For those statements missing adequate supporting documentation, we requested that OSAGWI provide us with the appropriate documentation. We also reviewed additional documentation collected by the OSAGWI investigators in performing the investigation, even though some of this documentation might not have been cited in the published narrative. We looked for any inconsistencies in information that was not addressed in the published narrative. In addition, for the selected case narratives, we contacted 71 individuals interviewed by OSAGWI that were key sources of information and requested that they verify the accuracy and completeness of both the OSAGWI case narrative and the OSAGWI write-up of the investigator’s discussions. We also contacted some key participants not originally interviewed by OSAGWI to determine whether other relevant information was available that might affect OSAGWI’s assessment of possible exposures to chemical warfare agents. Finally, we contacted several Gulf War veterans organizations, including the following: the American Legion; the Disabled American Veterans; the Veterans of Foreign Wars; the National Gulf War Resource Center; GulfWatch; the Desert Storm Justice Foundation; the Operation Desert Storm/Shield Association; the Gulf War Veterans of Long Island, New York; and the Chronic Illnesses Net for Persian Gulf Veterans. We asked them to provide us with any information they had that refuted or added to the OSAGWI information. We did not systematically approach veterans’ groups to obtain their assessments of overall OSAGWI effectiveness because this was beyond the scope of our review. To further verify the case narratives, we interviewed officials and obtained pertinent documentary evidence from officials at the following locations: OSAGWI, located in Falls Church, Virginia; the U.S. Army Chemical and Biological Defense Command at Aberdeen, Maryland; the U.S. Army Chemical Center and School at Ft. McClellan, Alabama; the Office of the Surgeon General of the Navy, Washington, D.C.; the Naval Health Research Center, San Diego, California; the Department of Veterans Affairs, Washington, D.C.; the Deployment Surveillance Team, which operates the Comprehensive Clinical Evaluation Program, Falls Church, Virginia; and the U.S. Army Gulf War Declassification Project, Falls Church, Virginia. We conducted our review from September 1997 to January 1999 in accordance with generally accepted government auditing standards. In the face of severe criticism by veterans, veterans groups, and others of its handling of Gulf War illnesses issues, DOD committed additional resources to its efforts to determine the cause of veterans’ health problems. With greater resources and a much broader mandate than its predecessor, OSAGWI has made significant progress in reestablishing communications between DOD and veterans. In addition, OSAGWI is actively engaged in identifying improvements DOD needs to make to protect servicemembers on contaminated battlefields. DOD is investing significantly more resources for OSAGWI’s investigations and outreach efforts than it did for the Persian Gulf Illnesses Investigation Team. In 1996, the Investigation Team operated with a staff of 12 persons and a budget of $4.1 million. In contrast, as of October 9, 1998, OSAGWI had a staff of about 200 persons and a fiscal year 1998 budget of $29.4 million. In addition, OSAGWI was given much broader authority than the Investigation Team. Finally, OSAGWI reports directly to the Deputy Secretary of Defense; the Investigation Team reported to the Assistant Secretary of Defense for Health Affairs. OSAGWI officials said that with an adequate budget and sufficient operating authority within DOD, they were generally unconstrained in their efforts to pursue OSAGWI’s mandate. According to these officials, OSAGWI’s operations have been fully funded, and OSAGWI has had largely unrestricted access to personnel, files, and other data necessary for its work. For example, OSAGWI has had full access to classified information from the military services and intelligence agency sources. To date, OSAGWI has over 12 million pages of classified information in its computerized database and approximately 500,000 additional pages of classified data in hard-copy format. The Special Assistant (the head of OSAGWI) has been free to staff OSAGWI according to his needs. This authority has made it possible for him to obtain the expertise needed for OSAGWI’s investigations. From the start, OSAGWI management decided to make extensive use of contractors to quickly obtain personnel with specific expertise and maintain the flexibility to change the mix of staffing as needed. By October 9, 1998, 173 (87 percent) of OSAGWI’s personnel were contractor employees. As needed, OSAGWI has obtained specialized expertise from individuals in various governmental agencies, such as the Central Intelligence Agency, the Defense Intelligence Agency, and the Army’s Chemical and Biological Defense Command. OSAGWI also has the authority to contract with private organizations to perform specialized functions. A key element of OSAGWI’s attempt to regain credibility with veterans, veterans’ organizations, and the public was to improve communications with them. OSAGWI recognized that major improvements were needed from earlier DOD efforts to listen to veterans’ concerns and incorporate the information they provided into DOD’s investigations and help provide health referral services to veterans. Our review confirmed that OSAGWI has made significant progress in establishing communications with veterans and others. OSAGWI established an E-mail address and encouraged veterans and others to use both this and the DOD toll-free hotline to communicate with OSAGWI regarding Gulf War illnesses issues. Within the first year of operation, it received almost 1,200 letters and 2,700 E-mail messages. OSAGWI staff contacted over 3,900 veterans through personal telephone calls, which included the vast majority of the Investigation Team backlog of unanswered calls from 1,200 veterans. According to OSAGWI, as of January 1, 1999, it had received 2,850 letters and 4,906 E-mail messages and answered 2,803 and 4,866, respectively. OSAGWI used a staff specifically trained to deal with Gulf War veterans’ concerns, obtain information from veterans, provide information about OSAGWI activities, and make referrals for those needing medical support from DOD or VA. OSAGWI uses a variety of methods to disseminate information on its operations. For example, it uses a Web site called GulfLINK on which it publishes its case narrative reports, information papers, and much of the supporting documentation used in its investigations. OSAGWI reports that this site typically receives over 60,000 inquiries each week. OSAGWI also publishes a bimonthly newsletter called GulfNEWS. Over 12,000 individuals receive the newsletter. OSAGWI’s leadership and staff have met with veterans at 18 town hall meetings and made appearances at 41 national veterans conventions. In addition, OSAGWI officials frequently meet with veterans and military service organizations to discuss Gulf War illnesses topics of interest to them. Finally, OSAGWI communicates directly with veterans that are affected by its investigations. After OSAGWI completes an investigation and publishes the corresponding case narrative, it sends to each affected veteran a letter that contains a synopsis of the investigation’s results. For example, following its investigation of the potential chemical warfare agent exposure in Khamisiyah, Iraq, OSAGWI sent letters to 97,837 veterans concerning the possibility that they might have been exposed to low levels of sarin, a chemical warfare agent. According to OSAGWI officials, OSAGWI must go beyond investigating and reporting on possible veterans’ exposures to chemical or biological warfare agents and identify ways to better protect servicemembers from nontraditional battlefield threats. From its investigations and reports on possible veterans’ exposures to chemical, biological, or environmental agents, OSAGWI has identified force protection issues that need improvement. These lessons learned generally fall into the following three categories: how to build trust and confidence in DOD, how to better account for what happened on the battlefield, and how to better protect servicemembers on the battlefield. Specific examples of the lessons learned include the need for institutionalizing a veterans’ outreach capability after OSAGWI is disestablished; improving systems for tracking troop movements during a conflict so that accurate data is available to show where individuals or units were located on the battlefield at any point in time; improving wartime records development and post-war records management systems and addressing issues such as the lack of a uniform records management program for joint commands; improving chemical and biological warfare agent detection equipment to make it less prone to false alarms and requiring doctrinal changes to collect and retain detector-produced printouts of detections; implementing techniques to better safeguard the health of deployed troops, such as deploying forward field laboratories early and taking samples to determine whether contamination may have occurred subsequent to the use of depleted uranium ammunition; and improving and implementing depleted uranium training programs. OSAGWI is presently working with DOD agencies to implement the lessons learned. Discussions by the Special Assistant with the Director of the Joint Staff and the military service Chiefs of Staff resulted in revised Joint Staff policy concerning record-keeping by joint commands. OSAGWI was also instrumental in developing a DOD-initiated requirement for the military services to review their depleted uranium training programs. We did not review what impact OSAGWI’s lessons learned have had toward making changes within DOD. Until recently, OSAGWI had no office for monitoring and measuring the extent to which OSAGWI lessons learned were being acted upon. In October 1998, the Special Assistant created a new OSAGWI directorate to focus attention on ensuring that lessons learned are effectively communicated to and implemented by the responsible DOD agencies. We reviewed six of the eight case narratives OSAGWI had published at the time we began our review to evaluate the thoroughness and accuracy of OSAGWI’s investigations. OSAGWI generally followed its investigation methodology and used appropriate investigative procedures and techniques. However, we found significant weaknesses in the scope and quality of OSAGWI’s investigations for three of the six cases: the Reported Exposure to Mustard Agent, the Marine Minefield Breaching, and the Al Jubayl, Saudi Arabia, case narratives. Also, OSAGWI did not use DOD or Department of Veterans Affairs medical databases on Gulf War illnesses in conducting any of the six investigations. Despite the weaknesses we noted, in all but one case—the Marine Minefield Breaching case—we found no basis to question OSAGWI’s determinations of the likelihood that chemical warfare agents were present. Except for failing to take advantage of the VA and DOD medical databases, we did not find significant weaknesses in the remaining three cases: the Camp Monterey, the Al Jaber Airfield, and the ASP Orchard case narratives. In investigating these cases, OSAGWI followed its methodology, identified and interviewed important witnesses, appropriately used information from other key sources, included all important information in the case narratives, and accurately presented the information found. These investigations were performed in a generally thorough manner, and the evidence collected by OSAGWI supported its assessments. OSAGWI officials told us that they have revised their internal review processes for conducting and reporting investigations. They said that (1) improvements to these processes have evolved since the publication of the six case narratives we reviewed, (2) some of the process revisions were influenced by the findings we reported as our review progressed, and (3) enhancements to their processes would considerably minimize the recurrence of similar weaknesses in future case narratives. Our review of the six selected case narratives disclosed some weaknesses in the investigations and in the accuracy and completeness of OSAGWI’s reporting. OSAGWI’s investigations were usually conducted in accordance with the established methodology. OSAGWI also generally identified and interviewed the appropriate witnesses, obtained relevant evidence and information, accurately documented witness testimonies, and otherwise generally used appropriate investigative techniques and procedures. However, we found that three of the six selected case narratives still contained significant investigative and reporting problems. The types of problems varied. In three of the six case narratives, we found investigative problems such as failures to (1) follow up with appropriate individuals to confirm key evidence, (2) identify or ensure the validity of key physical evidence, (3) include important information, and (4) interview key witnesses. Following is a more detailed description of the three case narratives containing most of these weaknesses. This case narrative addresses the reported exposure of an individual soldier to mustard agent while he was exploring an Iraqi bunker. OSAGWI assessed this incident as a “likely” exposure. OSAGWI’s assessment of this case has been highly controversial. Some veterans organizations and others believe that the evidence presented in OSAGWI’s case narrative and the Army’s presentation of the Purple Heart medal to this soldier for his injuries warranted an assessment of “definite” exposure. However, we found that this case was affected by many investigative and evidentiary problems. Some of these are more closely associated with shortcomings in DOD procedural practices during the Gulf War than with how OSAGWI did its investigation. Despite the problems identified, we believe that OSAGWI’s original assessment of “likely” exposure remains appropriate for this case. According to OSAGWI’s case narrative, the soldier (an Army armored cavalry scout) was exploring enemy bunkers in southeastern Iraq near Kuwait’s border on March 1, 1991. He entered one bunker through a tight passageway and twice brushed against the bunker’s doorway and wall. About 8 hours later, he began to experience a stinging pain on the skin of his left upper arm. Three hours later, blisters had formed there. About 15 hours after the exposure, the company medic checked the soldier’s blisters and suspected a heater burn. Eight hours later, after more blisters had formed on the soldier’s arm, aid station medical personnel suspected he might be a casualty of blister agent, treated him, and evacuated him to the company support battalion. There, an Army physician photographed the blisters and confirmed the diagnosis of exposure to a blister agent. An Army chemical officer also observed the soldier’s blisters and examined his clothing. He observed a wet spot on the soldier’s coveralls. The officer took the coveralls to a Fox vehicle for testing. From its tests on March 2, 1991, the Fox vehicle reportedly confirmed the presence of a mustard chemical warfare agent. After this positive test, the soldier’s coveralls were buried at the scene in Iraq as contaminated waste. On March 3, 1991, a senior medical officer (a physician and an expert in chemical warfare agents who was also at the time the Commander of the U.S. Army Medical Research Institute of Chemical Defense) examined the soldier’s blisters and concluded that they had been caused by exposure to a liquid mustard agent. This officer based his diagnosis largely on (1) the latent period of 8 hours between exposure and the first symptoms, which is characteristic of mustard exposure and (2) the absence of any other known chemical compounds present on the battlefield that have this characteristic. On March 4, 1991, following an order from chemical officers at the division level to confirm the positive results from the first day of Fox vehicle testing, tests on the soldier’s flak vest were performed by two Fox vehicles—apparently because the vest had not been buried along with the coveralls. Initially, both Fox vehicles registered the potential presence of chemical warfare agents, but only one was apparently able to confirm the presence of mustard agent. At the bunker complex where the soldier was injured, a Fox vehicle also initially detected a chemical warfare agent but was unable to confirm the presence of mustard or any other chemical warfare agent. The case narrative reported that an in-theater analysis of the soldier’s urine tested positive for thiodiglycol, a breakdown product of mustard agent. It also reported that a second urinalysis was performed by the U.S. Army Medical Research Institute of Chemical Defense at Aberdeen Proving Ground, Maryland. This analysis found no evidence of thiodiglycol. Clothing samples were also sent to the U.S. Army Chemical Research, Development and Engineering Center for analysis. Tests of these items also revealed no evidence of any chemical warfare agent. However, the negative test results from one of the urinalyses were not considered unusual due to the low level of the exposure. OSAGWI based its assessment of “likely” exposure primarily on the following factors: (1) the medical assessments of two physicians who examined the soldier—a senior medical officer and a physician who had recently been trained to identify chemical warfare agent injuries; (2) the latent period of 8 hours between the soldier’s exposure and his first symptoms, which is consistent with exposure to mustard agent; and (3) the positive detections of mustard agent made in-theater from analyses of the soldier’s clothing and urine. We agree with OSAGWI’s assessment that exposure to a chemical agent was “likely.” However, we found several investigative procedural problems with this case, primarily concerning insufficient follow-up with witnesses, failure to interview key officials about tests conducted on the soldier’s clothing, and uncertainties about the identity and validity of key physical evidence sent to the United States for testing. First, information we discovered causes us to question the existence of the soldier’s positive in-theater urinalysis for mustard agent. OSAGWI based the existence of this test on an Army Central Command message reporting a positive in-theater test for thiodiglycol. However, OSAGWI was unable to find any documented test results from this urinalysis, and OSAGWI investigators did not perform sufficient follow-up with the involved individuals to verify that this test had actually taken place. In discussing what OSAGWI knew about the positive in-theater urinalysis, we learned that OSAGWI had not interviewed either the senior medical officer or the officer who wrote the message describing the positive in-theater analysis during its investigation. Instead OSAGWI relied upon the senior medical officer’s testimony to the Presidential Advisory Committee, his medical journal article, and his review of OSAGWI’s draft case narrative. However, this procedure failed to identify important information. In early 1998, our subsequent interviews with the senior medical officer and OSAGWI’s interviews with him revealed that he was unaware of the existence of any in-theater urinalysis involving the soldier. He also stated that, because of his position in the theater as the head of a team of scientists responsible for assessing any chemical casualties, he would have known about the existence of any positive urinalysis performed there. We then contacted the officer who had written the Army Central Command message and asked him about his basis for reporting the positive urinalysis. He told us that his message was based on 3rd Armored Division reports that the senior medical officer had found thiodiglycol in the soldier’s urine specimen. The available evidence is thus contradictory and insufficient to establish that this test actually occurred. Second, the results of the tests conducted on March 2, 1991 (the first day of testing), for mustard agent on the soldier’s clothing cannot be confirmed with the available documentation, and OSAGWI did not interview some key officials involved in the case about the tests. According to the Commander of the Fox vehicle involved, the Fox tests on the soldier’s clothing conducted on March 2, 1991, indicated the presence of blister agent on the soldier’s coveralls. However, the Fox printout of the test results was apparently lost. We located and interviewed the Fox test operator involved, who told us that several tests were conducted on the soldier’s clothing that day and that there was one positive confirmation for mustard agent. During our review, OSAGWI found a printout from one of these tests in its files, but it was negative for chemical agent. We noted that this printout had not been logged into OSAGWI’s document receipt system. We also noted that OSAGWI had never interviewed the Fox vehicle Commander in person or the operator who conducted the tests. OSAGWI relied upon information provided by E-mail from the Commander of the Fox vehicles involved because he was then stationed in Germany and could not easily be interviewed in person. OSAGWI said it did not interview the test operator because it could not locate him. On the second day of Fox testing, the Fox Commander returned with both the original and a second Fox vehicle to confirm the positive test results from the first day of Fox testing of the soldier’s clothing. One of the Fox vehicles was unable to confirm the presence of mustard agent on the soldier’s flak vest because of a high concentration of oil products on the vest. The other Fox vehicle, whose detailed confirmatory procedure was videotaped by a crewmember but for which the printout is unavailable, did show the presence of mustard agent. DOD sent the printout from the original Fox vehicle and the videotape from the second one to the U.S. Army Chemical and Biological Defense Command at Aberdeen Proving Ground, Maryland, for analysis. A Command expert found that the surviving printout did not confirm the presence of chemical warfare agent when the detailed confirmatory procedure was performed. However, after examining the printout and viewing the videotape, this official concluded that the incident had involved an actual mustard agent detection. We found other procedural discrepancies that raise questions regarding this case. First, DOD did not adequately identify or ensure the validity of important physical evidence. We noticed a difference between the inventory of items that the Commander of the Fox vehicles had reportedly packaged for shipment back to the United States for analysis and the items that were received at the U.S. Army Chemical Research, Development and Engineering Center. The Commander reported on his inventory list that he did not include samples from the soldier’s coveralls since they were unavailable; however, the Center’s inventory showed receipt of such samples. When we interviewed the Commander, he told us that he believed the sample material was in fact from the Commander’s own protective suit that he wore during the Fox vehicle testing. These discrepancies raise the possibility that either someone recovered the soldier’s coveralls and then repackaged the contents for shipment to the United States or that at least some of the clothing sent back to the United States for testing was not the soldier’s. The circumstances surrounding the testing of the soldier’s clothing in-theater thus remain unclear. It is impossible to determine whether the samples are actually from this soldier. In discussing the investigative weaknesses we found, the OSAGWI lead investigator told us that this investigation had begun under the Investigation Team before OSAGWI was established and that the case was carried over to OSAGWI. She said that the case’s outcome appeared to be obvious on the surface—particularly since the soldier had received a medical diagnosis indicating exposure to mustard agent. She said that the investigation process at OSAGWI has matured since this case narrative was published. She also said that OSAGWI would do more cross-checking of the facts if this investigation were being done today. Despite the investigation’s shortcomings, we believe that OSAGWI’s assessment of “likely” exposure to a chemical warfare agent in this case is reasonable. The senior medical officer’s clinical diagnosis that the soldier’s injuries were caused by exposure to mustard agent is significant in that this expert in chemical warfare agents made his assessment contemporaneously at the time of the injury and continues to believe that the latent period of 8 hours from exposure to the first symptoms supports his diagnosis. In addition, an expert at the U.S. Army Chemical and Biological Defense Command, after reviewing the Fox vehicle printout and viewing a videotape of another Fox vehicle conducting tests, concluded that this incident involved a valid detection of mustard agent. However, we believe the lack of confirmation of exposure through urinalysis or retained confirmatory printouts from the Fox vehicles involved prevents OSAGWI’s exposure assessment in this case from being classified as “definitely.” This case narrative addresses reports that U.S. Marines might have been exposed to chemical warfare agents while breaching minefield barriers on the first day of Operation Desert Storm’s ground war. OSAGWI concluded that the presence of chemical warfare agents was “unlikely” during this incident, in part because it found that no mechanism was present for delivering such agents. However, we found that OSAGWI overlooked information indicating that a means for delivering chemical warfare agents might have been present, and that the case narrative does not include other relevant information indicating that chemical warfare agents might have been present. We believe that these shortcomings are sufficient to cause a reasonable person to question OSAGWI’s assessment. On February 24, 1991, the first day of Operation Desert Storm’s ground war, Marine Corps forces breached two rows of minefields that stretched for miles near the border between Saudi Arabia and Kuwait. As they passed through the first row of minefields, two Fox vehicles (one assigned to units of the 1st Marine Division and another assigned to the 2nd Marine Division) indicated potential detections of chemical agents. The detection by the 1st Division’s Fox vehicle was described as a trace detection of such a small magnitude that no official report of the detection was made and no Fox printout was kept to document the detection. OSAGWI concluded that the presence of chemical warfare agents in the 1st Division area was “unlikely.” The detection by the 2nd Division’s Fox vehicle, however, indicated the potential presence of mustard, sarin, and lewisite—all chemical warfare agents. In this instance, the Fox vehicle printouts were kept, but because of the hostile environment, the Fox vehicle was not stopped to perform a more detailed confirmation procedure to conclusively determine whether chemical warfare agents were present. One possible chemical warfare agent injury was reported during the breaching: a 2nd Division Marine riding in an amphibious assault vehicle at the time of the detection claimed his hands were burned, presumably by a chemical warfare agent, as he closed the vehicle hatch after hearing the Fox vehicle alert by radio. However, the validity of this reported injury was controversial. Some witnesses supported the Marine’s claim that his hands were blistered, but the examining physician stated that the Marine had no injury of any kind. In investigating the breaching incident, OSAGWI interviewed key participants in the breaching operations, including members of the Fox vehicle crews, chemical warfare specialists, some unit commanders, the Marine who claimed to have been injured, other Marines from the injured man’s unit, and the medical personnel who examined him. The investigators also reviewed unit logs and other pertinent documentation, including classified data, and consulted with Fox vehicle and chemical weapons technical experts. On the basis of reviews of the 2nd Division Fox vehicles’ printouts by three different laboratories, OSAGWI concluded that the Fox vehicle detections were false alarms, probably caused by the high concentrations of smoke from oil well fires and petroleum particles in the atmosphere. OSAGWI further indicated that except for the possible injury to one Marine, no other troops reported claimed chemical warfare agent injuries. In its overall assessment of the incident, OSAGWI stated that the presence of chemical warfare agent was “unlikely.” In supporting its assessment, OSAGWI stated that since no chemical land mines were ever found in Kuwait and since no artillery fire was encountered by the Marines who breached the first row of mines, there was no delivery mechanism for chemical warfare agents. OSAGWI overlooked a key piece of evidence and did not report other significant information in its case narrative. OSAGWI concluded that the Marines had encountered no Iraqi artillery fire as they moved through the first row of Iraqi minefields. This conclusion was based on comments made by the commanding officer and others of the Marine company that carried out the minefield breach where the 2nd Division Fox vehicle reported the presence of a chemical warfare agent. However, our review of OSAGWI files disclosed a Marine Corps unit log entry indicating that Iraqi artillery and mortar fire was present during the first minefield breach. The OSAGWI investigator told us that he had inadvertently overlooked this information during his investigation. We also interviewed Marines who told us that Iraqi artillery and mortar fire was present as they passed through the first minefield. Consequently, we believe a delivery mechanism for chemical warfare agent may have been present. Also, the timing of events was significant. For example, the log entry indicating that enemy artillery was encountered was made around 6:15 a.m. on February 24, 1991. The Fox vehicle detection was made at 6:22 a.m. of that same day. The Marine who claimed to be injured was riding in an amphibious assault vehicle that was following the Fox vehicle. He said his injury occurred just after he heard the Fox vehicle’s report of the chemical warfare agent detection over the radio. We also learned that the Commander of the 2nd Division’s Fox vehicle told OSAGWI investigators that chemical detection paper taped to the outside of the Fox vehicle was noted to have changed colors after passing through the first minefield (indicating possible contact with a chemical agent). However, this information was not reported in OSAGWI’s narrative. The OSAGWI investigator said that this information was omitted because technical experts had told him that the detection paper could change colors because of the heavy concentrations of petroleum products in the air coming from the oil well fires the Iraqis had set. Furthermore, as mentioned in the case narrative, three different laboratories had reviewed the Fox vehicle printout and concluded that the detections were probably false alarms. The narrative did not point out, however, that one of the three laboratories had also said that it could not rule out the possibility of the presence of a chemical warfare agent. Finally, a classified document in OSAGWI’s files contained intelligence evidence not included in the narrative that could support the possibility of an Iraqi chemical attack. This information, some of which has since been declassified, refers to a report indicating the end of a chemical attack on February 24, 1991, the same date as this incident. OSAGWI was aware of this information, but because of its vagueness, unknown origin, fragmentary nature, and time of report (about 4 hours after the breaching event), it was not given much weight during OSAGWI’s analysis. We agree that the potential impact of this evidence is unclear. However, when combined with the other information we have cited, it provides additional cause for further investigation by OSAGWI, regardless of its potential for association with this case. We believe that OSAGWI’s assessment of “unlikely” in this case is subject to question. While the information we found does not conclusively prove that chemical warfare agents were present, it does increase the potential that some might have been present. In our opinion, the weaknesses we found in this case narrative are sufficient to warrant OSAGWI’s reconsideration of its assessment. We discussed our findings with OSAGWI investigators and officials, and they agreed that this information needs to be evaluated. OSAGWI officials told us they would include this information in their follow-up investigation of the minefield breaching incident and would address the questions we raised. Regarding this case narrative about three significant events occurring in the Al Jubayl area during the Persian Gulf War, OSAGWI concluded that the presence of chemical warfare agents was “unlikely” for one of the events and “definitely did not occur” in the remaining two. We believe that the available evidence generally supports OSAGWI’s assessment, but OSAGWI is still performing work regarding alternate explanations for some events affecting this case. However, we also found that OSAGWI did not include important information in this case narrative regarding the unusually high levels of post-war veterans’ complaints of medical symptoms they associated with the incidents involved in this case. Furthermore, OSAGWI did not adequately identify and coordinate some of this information that could potentially provide evidence to help resolve research questions concerning whether there is a correlation between high levels of reported Gulf War illnesses symptoms and duty during the Gulf War at Al Jubayl. Al Jubayl is the largest of eight planned industrial cities in Saudi Arabia. It consists of an industrial zone and port facilities, as well as residential and other noncommercial areas. The Al Jubayl area was developed during the early 1980s along what was then essentially undeveloped coast line and was designed to take advantage of Saudi Arabia’s vast oil resources. Al Jubayl played a crucial role during the Gulf War—many U.S. and coalition military units either passed through or were stationed there. OSAGWI’s case narrative addresses three separate events that allegedly involved exposure to chemical agents in the Al Jubayl area: the “loud noise” event and alerts on January 19 through 21, 1991; an Iraqi SCUD missile attack on February 16, 1991; and a noxious fumes event on March 19, 1991, which some U.S. military personnel claim caused them to experience medical problems and turned portions of the T-shirts they were wearing from brown to purple. The need for OSAGWI to investigate these events was underscored by concerns about Gulf War illnesses expressed in a May 1994 report of the U.S. Senate’s Banking, Housing, and Urban Affairs Committee (known as the Riegle Committee) by veterans of Naval Mobile Construction Battalion 24 (NMCB-24). NMCB-24 was a reserve “Seabee” or military construction battalion of 724 enlisted persons and 24 officers. During Operation Desert Shield/Desert Storm, NMCB-24 was stationed alongside NMCB-40, an active duty “Seabee” battalion. Both units occupied Camp 13, a housing and billeting area located in the Al Jubayl industrial zone that was commanded by the senior officer of NMCB-40. OSAGWI found that the “loud noise” event actually referred to several loud explosive-like noises and related events occurring between January 19 and 21, 1991. As stated in the OSAGWI narrative and confirmed by our review, early on January 19, a very loud noise like an explosion was heard throughout the Al Jubayl area. Units in the area subsequently reported additional explosions, went on alert, and conducted tests for the presence of a chemical warfare agent. A variety of confusing and contradictory actions subsequently occurred. All NMCB-24 tests for chemical warfare agent were officially reported as negative, but one member of this unit alleged that he had obtained positive test results for a chemical warfare agent in two of three attempts. British units in the vicinity initially reported positive tests for a chemical warfare agent, but detection teams sent to investigate these reports were unable to confirm any such agents. Some eyewitnesses from NMCB-24 reported a large fireball that illuminated the sky and medical symptoms such as runny noses, burning sensations, blisters, and numbness. They stated that those experiencing symptoms reported for medical attention within the next few days. However, other NMCB-24 personnel said that although they were unprotected during these events, they experienced no such symptoms. After reviewing NMCB-24’s medical logs, neither OSAGWI nor we found any records indicating that medical attention for these symptoms was sought on or shortly after January 19, 1991. OSAGWI and our interviews with the NMCB-24 Commander, medical personnel, and senior noncommissioned officers similarly revealed no evidence that any medical attention was sought. OSAGWI found, and we confirmed, that many coalition aircraft were engaged in the air war on the day in question, and Air Force records show that two coalition aircraft flew over the Al Jubayl area at supersonic speed during the early hours of January 19, 1991. OSAGWI concluded that the loud noise and related events were due to sonic booms from these aircraft. It also concluded that the presence of chemical or biological warfare agents was “unlikely” because (1) DOD records show that no SCUD missiles were launched toward Saudi Arabia by Iraq on January 19, (2) no verifiable tests in the Al Jubayl area were positive for chemical warfare agents, and (3) no records were found of any individual receiving treatment for symptoms associated with exposure to chemical or biological warfare agents. On January 20-21, 1991, air raid sirens and explosions were heard again in the Al Jubayl area, but available records reviewed by OSAGWI, and checked by us, indicated that chemical detection tests were again negative. OSAGWI again concluded that the presence of chemical or biological warfare agents was “unlikely” because (1) records show a SCUD missile aimed at Dhahran was intercepted and destroyed at high altitude by a Patriot air defense missile at approximately the same time as this incident, (2) there is no record of an impact site in the Al Jubayl area, and (3) no records were found of anyone receiving medical treatment for symptoms associated with exposure to chemical or biological warfare agents. A second possible exposure of veterans to chemical and biological warfare agents in the Al Jubayl area occurred as the result of an Iraqi SCUD missile attack early in the morning of February 16, 1991. The OSAGWI narrative explains that U.S. national sensors detected this missile early in flight and provided warning of the launch. The missile landed in the waters of Al Jubayl harbor, and the site of impact was quickly found and marked by Coast Guard and Navy boat crews. Later that day, a Navy explosive ordnance disposal team surveyed the marked area with an underwater television system and located missile debris on the harbor’s bottom. Divers confirmed that the missile had broken apart and that the site contained an intact SCUD warhead, guidance section, rocket motor, and miscellaneous components. Recovery of the smaller SCUD components began on February 19 and concluded with the warhead on March 2. During the recovery operation, tests were conducted, but no evidence was found indicating the presence of chemical or biological agents. The Joint Captured Material Exploitation Center then took custody of the SCUD components, which were subsequently shipped to the Army Missile Command in Huntsville, Alabama. The Command’s evaluation of the recovered SCUD missile components confirmed that the warhead did not contain chemical or biological warfare agent. Some eyewitnesses to this event reported that the SCUD missile was intercepted and shot down by a Patriot missile and during this process could have dispersed chemical or biological warfare agents over Al Jubayl. A Patriot battery was defending Al Jubayl at the time. However, OSAGWI found and we confirmed that this battery was not operational for maintenance reasons at the time of the attack and therefore was not able to engage the SCUD. OSAGWI concluded in its case narrative that while an Iraqi SCUD missile had hit the waters of Al Jubayl harbor, it had not detonated, had caused no damage or injuries, had tested negative for chemical warfare agents, and therefore was definitely not armed with chemical warfare agents. The third known possibility of exposure to chemical agents at Al Jubayl occurred on March 19, 1991, when personnel from NMCB-24 were exposed to unidentified airborne noxious fumes. These fumes affected nine persons working in three separate groups. They experienced acute symptoms such as burning throats, eyes, and noses and difficulty in breathing. In addition, portions of the brown T-shirts being worn by these individuals turned purple, as did some of the individuals’ combat boots. Seven persons composing two of the groups immediately sought medical attention and returned to work with no further symptoms after showering and changing clothes. The two persons in the third group did not seek medical assistance and continued to work. The nine persons involved stated that they had experienced a choking sensation when a noxious cloud enveloped them. None saw the origin of the cloud, but all believed it had come from one of the industrial plants located nearby. Evidence collected by OSAGWI regarding the source of the noxious fumes was inconclusive. One eyewitness of the event said that he had seen purple dust falling in the area that was coming from a smokestack at a nearby fertilizer plant. The Navy’s Environmental and Preventive Medicine Unit No. 2 (EPMU-2) conducted an environmental/occupational hazard investigation and site visit to Al Jubayl in 1994. The resulting EPMU-2 study did not determine the source of the irritant. It noted, however, that the camp was located in a heavily industrialized area and that emissions from a petrochemical plant or from a spill within the camp’s motor park could have been the source of the irritant. The T-shirts and the boots that changed color were given to unnamed U.S. military and Saudi officials. However, the chain of custody cannot be identified, and no reports have been found other than an informal telephone call to NMCB-24 shortly after the incident indicating that “there was nothing to worry about.” The U.S. Army Material Test Directorate and the Natick Research Development and Engineering Center later conducted tests on the type of military T-shirts involved. The Natick tests showed that these T-shirts do turn purple when exposed to acids such as sulfuric (battery) acid or oxides from nitric acid. OSAGWI concluded that chemical warfare agents were definitely not involved in the purple T-shirt event. OSAGWI reached this conclusion because (1) the event occurred after the cessation of Gulf War hostilities, (2) there was no record of hostile attack during the time period of the event, and (3) the types of medical problems affecting the individuals involved and their rapid recovery are not consistent with exposure to chemical warfare agents. As a result of our review of evidence, procedures, and other information obtained from OSAGWI and other sources regarding the Al Jubayl case narrative, we generally concur that OSAGWI’s assessments of whether chemical warfare agents were present are reasonable. The evidence generally supports OSAGWI’s assessment that chemical warfare agents were “definitely not” involved in the SCUD missile and purple T-shirt events. The loud noise incident involved some contradictions in evidence or testimony that we could not resolve, but our work confirmed the credibility of the vast majority of the evidence used by OSAGWI. We noted the existence of another potential explanation of some of the events involved in the loud noise incident. Some documents and other evidence we acquired from a veterans’ organization indicate that an Iraqi aircraft or a patrol boat might have been involved in an attempted chemical attack on Al Jubayl at the time of this incident. OSAGWI is currently investigating this version of events. However, pending the outcome of this continuing investigation, we believe that the currently available evidence still provides a reasonable level of support for OSAGWI’s conclusion that exposure to chemical warfare agents was “unlikely” in this incident. Although we concur with OSAGWI’s assessments in the Al Jubayl case, we believe that the case narrative is not complete and could be misleading because it does not mention the fact that many members of NMCB-24 have reported unusually high levels of health problems since their service in the Persian Gulf War. We also found that OSAGWI had not coordinated some information developed during this investigation with the Naval Health Research Center for inclusion in its Gulf War illnesses research on Seabees. OSAGWI’s Al Jubayl case narrative states that the methodology it used was designed to investigate reports of exposure to chemical warfare agents and to determine whether chemical weapons were used. OSAGWI officials told us that in this case they had expanded their methodology to include a considerable amount of information in the narrative regarding environmental cleanliness factors affecting the Al Jubayl area. They said they had done this in an effort to better explain the circumstances of the case because some veterans had expressed concern over the hazardous materials they could have been exposed to while they were in Al Jubayl. The narrative thus contained much information explaining that (1) Saudi environmental protection standards were equivalent to those of the U.S. Environmental Protection Agency, (2) these standards were monitored and maintained by the Saudis throughout Operation Desert Storm/Desert Shield, and (3) Saudi monitoring records indicate no detections that normal standards were exceeded on the date of the purple T-shirt incident. The environmental data included in the narrative, much of which was obtained by EPMU-2, thus indicated that Al Jubayl was no worse or better than comparable industrialized sites in the United States. We concur that OSAGWI’s decision to expand its stated methodology in order to include this information was appropriate. As indicated at the beginning of the narrative, OSAGWI’s charge is to investigate all possible causes of Gulf War illnesses. However, most of the information presented in this case narrative leads the reader to conclude that exposure to either chemical warfare agents or other chemical agents at Al Jubayl was “unlikely” and probably did not involve a health threat in the limited incident involving the purple T-shirts. The narrative mentions that some NMCB-24 veterans testified before the Congress (the Riegle Commission) but does not state why. The narrative text also contains no information regarding significant DOD actions taken to address the high incidence of post-war health problems reported by members of NMCB-24. DOD has long been aware of health problems reported by NMCB-24. In 1992, DOD began to identify clusters of military personnel who were complaining of medical symptoms they attributed to their Gulf War service. As a result, DOD initiated two field investigations. One of these, performed at the request of the Navy Surgeon General, was a study of illnesses reported by members and former members of NMCB-24 conducted during 1993-94 by the same unit (EPMU-2) that conducted the Al Jubayl environmental study. EPMU-2 personnel visited 6 of NMCB-24’s 12 detachments during this period, conducted a questionnaire study, performed medical examinations, reviewed military and other medical records, interviewed veterans and family members, and otherwise attempted to identify prevalent symptoms experienced by the members of NMCB-24 and diagnoses of their illnesses. Much of the information they collected was computerized and used to produce a series of tables and other statistical data relevant to Gulf War illnesses issues and included in EPMU-2’s final report. This report contained the following conclusions: A significant number of NMCB-24 veterans of the Gulf War have experienced an array of nonspecific symptoms since returning from the Persian Gulf. More than 41 percent of the veterans from three of the six detachments experienced 10 or more symptoms. No common syndrome or diagnosis was identified in these veterans. The diagnoses identified were the same as those that might be expected in a group of the same age that had not served in the Persian Gulf War. More research was needed. Our review of OSAGWI’s files, our visit to EPMU-2, our interviews of current and former EPMU-2 officials, and our review of all remaining EPMU-2 documentation related to this study revealed additional information. For example, 44 of the 67 witnesses OSAGWI interviewed regarding the facts of the loud noise incident are now reporting health problems they attribute to their service during the Persian Gulf War. A former EPMU-2 physician directly involved in the EPMU-2 study told us that while he had no factual baseline for comparison, it appeared to him that the frequency of symptoms found in NMCB-24 veterans was greater than the frequency to be expected in the general population. This observation, along with the high symptom rates, was one of the reasons the EPMU-2 report recommended more research. NMCB-24 veterans have been involved in testimony before the Congress regarding health problems they attribute to their service in the Persian Gulf War, and the Naval Health Research Center in San Diego, California, is currently performing a major, multiyear, Gulf War illnesses-related epidemiological study involving the vast majority of the Navy’s Seabees. NMCB-24 veterans have also been the subject of several additional research studies related to Gulf War illnesses. OSAGWI was aware of the existence of the EPMU-2 medical study and had a copy on file that was originally obtained by its predecessor, the Persian Gulf Illnesses Investigation Team, in 1996. However, no OSAGWI investigators visited EPMU-2 to review files regarding this study. No information regarding this study, the Naval Health Research Center research project, or other epidemiological studies or research on Gulf War illnesses was included in the case narrative. A high-ranking OSAGWI official told us that OSAGWI investigators had been instructed to consider such medical information as outside their charter for inclusion in the case narratives. This official said that they had been so instructed because this line of inquiry was more appropriately the responsibility of the Office of the Assistant Secretary of Defense for Health Affairs and because OSAGWI did not have the expertise to conduct or evaluate epidemiological studies such as the one performed by EPMU-2. We believe that much more information regarding the health complaints of NMCB-24 veterans should have been included in the case narrative. OSAGWI was aware of this information and could have included it without conducting or evaluating epidemiological studies. Including information developed by EPMU-2 regarding the environmental cleanliness of Al Jubayl but excluding EPMU-2’s report and other information specifically related to post-war health complaints by NMCB-24 veterans makes OSAGWI vulnerable to an appearance of bias. Such omissions tend to reinforce the beliefs of some that DOD is inappropriately withholding information. We also found that some information developed by OSAGWI might have significantly added to what is known about Gulf War illnesses issues involving NMCB-24 had OSAGWI coordinated the information with the Naval Health Research Center for use in its currently ongoing Seabee epidemiological study. For example, as determined by OSAGWI and reported in the Al Jubayl case narrative, both NMCB-24 and NMCB-40 were located at Camp 13 during Operations Desert Shield and Desert Storm. Complaints by NMCB veterans regarding post-war medical problems they attribute to Persian Gulf service are well known, having been the subject of several congressional hearings, various research efforts, and other activities addressing Gulf War illnesses issues. An OSAGWI official told us that interviews with selected NMCB-40 personnel indicated that personnel from this unit were not experiencing health problems of the same nature and extent as those reported by NMCB-24 veterans. Since NMCB-24 and NMCB-40 occupied the same camp at Al Jubayl, we believe that a determination of whether NMCB-40 veterans are encountering medical problems similar to those being reported by NMCB-24 veterans would be of considerable interest to those concerned with resolving Gulf War illnesses issues. The Naval Health Research Center study is obtaining for analysis a wide range of Gulf War illnesses-related information from current and former Seabees and plans to perform a multifaceted analysis of the information collected. In August 1998, Naval Health Research Center officials told us they had coordinated with OSAGWI officials regarding the Seabee study on several occasions but that OSAGWI officials had not informed them of the relationship between NMCB-24 and NMCB-40. The study’s methodology therefore did not include plans to specifically compare Gulf War illnesses information obtained from veterans of these two units. They acknowledged, however, that such comparisons could be conducted and that they might provide useful information. They said they would be willing to discuss adding such comparisons if OSAGWI officials requested that they do so. We believe such comparisons, especially regarding the extent and nature of post-war medical symptoms, might provide information important to OSAGWI’s investigation and reporting of Gulf War illnesses issues involving the Al Jubayl and other case narratives. OSAGWI officials agreed that the Al Jubayl case narrative needed to be modified to acknowledge the high rate of symptoms reported by members of NMCB-24 and that they would modify the case narrative accordingly. They also told us they would coordinate with the Naval Health Research Center regarding new information that might be developed through comparisons of NMCB-24 and NMCB-40 data in the Naval Health Research Center Seabee study. DOD and the VA maintain databases that contain self-reported health information and clinical information on thousands of Gulf War veterans. Some of these veterans may have symptoms associated with Gulf War illnesses. Although OSAGWI’s methodology calls for the use of the DOD and VA databases in its investigations, we found it did not access them for the six case narratives selected for our review. Therefore, OSAGWI missed an opportunity to determine whether individuals involved in possible exposure incidents were also reporting symptoms in the databases. Information thus obtained could provide leads to help scope and guide the nature of the investigation and potentially could be combined with other evidence and research efforts conducted by DOD and others to help evaluate whether chemical warfare agents might have been present. In response to the complaints of many military personnel that returned from the Gulf War with health problems they believed were related to their deployment, DOD and VA created programs to track the health of Gulf War veterans. Information collected in these programs is stored in databases that describe the health status of a large group of Gulf War veterans who have undergone a standardized examination process to document their health. The multiphase Comprehensive Clinical Evaluation Program (CCEP) was implemented by DOD in June 1994 to provide a systematic clinical evaluation for the diagnosis and treatment of active duty military personnel who have medical complaints they believe could be related to their service in the Persian Gulf. Phase I of the CCEP consists of a medical history, physical examinations, and laboratory tests that are comparable to an evaluation conducted during an inpatient internal medicine hospital admission. CCEP participants are evaluated by a primary care physician at their local medical treatment facility and receive specialty consultations if deemed appropriate. The primary care physician may refer patients to phase II for further specialty consultations depending on the clinical findings of phase I. Phase II evaluations consist of targeted, symptom-specific examinations; laboratory tests; and consultations. During this phase, potential causes of unexplained illnesses are assessed, including infectious agents, environmental exposures, psychological factors, and vaccines. DOD maintains a database that summarizes the clinical evaluations of CCEP participants. The database shows self-reported complaints and symptoms from everyone and physician diagnoses for examined participants. In addition, the database shows unit assignments, medical complaints, diagnoses, and possible exposures of individuals who were part of units during the Gulf War that may have come in contact with chemical warfare agents or other environmental hazards. As of October 31, 1998, the CCEP database contained health information on 34,963 service members who had received clinical evaluations as a part of the program. The VA’s Persian Gulf Registry (VA Registry) was established in 1992. Any Gulf War veteran may participate in the registry, even if that person has no current health complaints. Like the CCEP, the registry consists of a two-phase examination process. During phase I, the veteran completes a standardized questionnaire on exposures during the Gulf War and health complaints and undergoes a physical examination with laboratory testing. Veterans who have health problems that remain undiagnosed after phase I are referred to more extensive phase II medical evaluations. VA maintains a database that summarizes the results of clinical evaluations of registry participants. It contains information on symptoms and complaints self-reported by veterans and diagnosed by physicians. It also contains information on exposures, birth defects, and undiagnosed illnesses. Like the DOD database, the registry database also contains information on which units the participants were assigned to during the Gulf War. As of July 31,1998, the VA Registry contained information on the health conditions of 70,051 Gulf War veterans who had physical examinations under the VA program. Each of the case narratives selected for our review describes possible chemical exposure incidents that involve individuals acting alone or as a part of larger units. Many of these individuals may have enrolled in either the CCEP or the VA Registry. OSAGWI could use this data to identify whether individuals involved in the incidents described in the case narratives might be experiencing health problems. Several of the case narratives included in our review describe events that could have been the subject of further analysis using the CCEP and VA Registry. For example, OSAGWI’s ASP Orchard case narrative describes chemical warfare agent alarms at an ammunition storage facility near an orchard outside Kuwait City, Kuwait. OSAGWI collected information from many of the personnel that inspected this facility and from a variety of other sources, such as the Central Intelligence Agency and the Defense Intelligence Agency. OSAGWI concluded that the alarms were false and that chemical warfare agents probably had not been stored at this facility. However, for the six case narratives we reviewed, OSAGWI investigators did not query the CCEP or the VA Registry in an attempt to determine whether any of the several personnel that inspected the site or any of the hundreds of other personnel encamped nearby had enrolled and had reported or been diagnosed with health problems. Although it would not be definitive, unusually high levels of participation accompanied by the reporting of certain health problems and possible exposures might have led OSAGWI to investigate further. Performing this investigative step would serve to enhance the credibility of OSAGWI’s case narratives and would confirm OSAGWI’s intention to investigate these events leaving no stone unturned. We noted that OSAGWI’s investigative methodology includes the use of the CCEP and the VA registry and that OSAGWI had used such an analysis in investigating the Khamisiyah incident and in developing its Depleted Uranium environmental exposure report issued on August 4, 1998. For example, in performing the investigation on depleted uranium, OSAGWI investigators queried the CCEP to determine whether an unusually high proportion of the participants involved in the case had experienced kidney damage—a possible medical effect of being exposed to depleted uranium. According to OSAGWI, the analysis showed that these CCEP participants did not suffer unusually high rates of kidney damage compared to the general U.S. population. Except for not using the DOD and VA medical databases, the Al Jaber Air Base, ASP Orchard, and Camp Monterey case narratives generally did not have the weaknesses we found in the other three cases. In investigating these cases, OSAGWI followed its methodology, identified and interviewed important witnesses, appropriately used information from other key sources, included all important information, and accurately presented the information found. These investigations were performed in a thorough manner, and the evidence collected by OSAGWI convincingly supported its assessments. The Camp Monterey case is a good example. In this case, soldiers of the 8th U.S. Army Infantry Division were moving wooden Iraqi crates containing metal canisters out of a building in a bivouac area north of Kuwait City, Kuwait, so that it could be used to house troops. One of the canisters broke open, spilling a white powder-like substance and causing several soldiers to become ill. At the request of the local commander, two Fox vehicles tested the spilled substance. Both Fox vehicles initially reported detections of sarin, a deadly nerve agent, and this apparently led to some initial reports that soldiers had been exposed to a nerve agent. Later, mass spectrometer tests by these Fox vehicles confirmed that the substance was actually a relatively harmless riot control agent rather than sarin. OSAGWI found, and we confirmed, that after interviewing the personnel present (including the Fox crews) and after reviewing Fox crew and laboratory analyses of the Fox printouts, the initial alarm for sarin was an error. Similarly, in both the Al Jaber and ASP Orchard cases, initial Fox alarms for persistent chemical warfare agent could not be confirmed in some instances even by repeated attempts by the same Fox vehicles. OSAGWI concluded, and we agreed, that had the chemical warfare agents been present, they would have been detected in the repeated tests. We believe that inadequate quality control procedures within OSAGWI contributed to the investigative and reporting problems discussed in this report. During our review of OSAGWI operations, we periodically briefed OSAGWI officials on the nature and types of weaknesses we had found and on our preliminary observations. OSAGWI officials agreed that they needed to improve their investigations and their reporting of the investigation results. They said that they have instituted several changes to their internal quality assurance practices that they believe will considerably strengthen their investigative and reporting processes. According to OSAGWI officials, their current investigative and reporting process has evolved over the 2 years since OSAGWI was established. Consequently, certain enhancements are now in place that were not present when the six case narratives we reviewed were published. More specifically, OSAGWI now requires its investigators to prepare a written investigation plan. The investigation plan must specify the information that will be obtained, the direction the investigation will take, and the schedule. The plan is expected to mirror the overall methodology adopted by the division within the Investigation and Analysis Directorate for its investigations. The division chief is to review the investigation plan and provide feedback to the investigator on the scope and direction of the investigation and the proposed schedule. Following approval of the plan by the division chief, the investigator can begin the investigation. Also, the process now includes a requirement for a team directional guidance meeting when the investigation is 50- to 75-percent complete. At this meeting, the investigator briefs a small group of analysts from within the investigator’s division on the investigation’s scope, direction, and findings to that point. The purpose of the meeting is to identify at an early stage any problems in the direction of the investigation and to identify any major information sources that are not being used. According to OSAGWI, each case investigation is now periodically reviewed by the Director of the Investigations and Analysis Directorate to allow the Director to adjust, as necessary, the scope of the investigation and the case narrative development. Furthermore, the peer review process for case narratives is now more robust because the peer review team, comprising experienced individuals, reviews the completed case narrative along with the source materials. The peer reviewers are responsible for ensuring that the text in the case narrative is supported by the source material and also for identifying portions of the text needing footnotes to source materials. In addition, an OSAGWI official said the internal review of case narratives by key individuals within the OSAGWI organization is more rigorous than it used to be. OSAGWI officials believe that these enhancements to their review processes will preclude the recurrence of the types of investigative and reporting weaknesses we found. The weaknesses in the scope and quality of OSAGWI’s investigations and in reporting the results of these investigations in the Reported Exposure to Mustard Agent, Marine Minefield Breaching, and Al Jubayl case narratives are significant; however, we agree with OSAGWI’s assessments of the likelihood of the presence of chemical warfare agents in all but the Marine Minefield Breaching case narrative. In our opinion, the lack of effective quality assurance policies and practices within OSAGWI contributed to the weaknesses we noted. A stronger quality control mechanism for its investigations would provide greater assurance that all relevant facts are included and that the information presented is accurately and properly sourced. More consistent use of some types of medical information would also strengthen the rigor of OSAGWI’s investigations. By querying available medical databases for all cases, OSAGWI investigators might have been able to better determine whether personnel at or near the sites of incidents had reported or been diagnosed with unusual health problems, thus helping indicate whether increased investigative efforts regarding the potential presence of chemical warfare agents or other environmental hazards in these incidents might be appropriate. OSAGWI’s changes to its internal review process appear to be positive steps in ensuring the quality of investigations and the related case narrative reports. Because OSAGWI initiated these changes after the case narratives we reviewed were published, we could not determine their effectiveness in ensuring the quality of OSAGWI investigations and reports. However, the procedures should incorporate two features to enhance the credibility of the review process. First, it is critical that those named to review OSAGWI’s investigations are independent of the team investigating the incidents to avoid the appearance of a conflict of interest. Second, it is important that the procedures in place lead reviewers to thoroughly check to ensure that all relevant information obtained by the investigation teams has been included in the case narrative reports, that all important leads have been pursued, and that the investigation team has reached conclusions that are fully substantiated by the facts. Information about the potential for differences in the occurrence of Gulf War illnesses symptoms between NMCB-24 and NMCB-40 developed during the Al Jubayl case investigation was not shared with the Naval Health Research Center for consideration for inclusion in its ongoing Gulf War illnesses research. We believe this information has potential for use in helping DOD evaluate issues related to the high levels of health problems reported by many of the Seabees stationed at Al Jubayl during the Gulf War. To ensure that OSAGWI’s case narratives contain all relevant facts, we recommend that the Secretary of Defense direct the Special Assistant for Gulf War Illnesses to revise the Marine Minefield Breaching, Exposure to Mustard Agent, and Al Jubayl, Saudi Arabia, case narratives to reflect the new and/or unreported information noted in our report and examine whether it should change its conclusion about the likelihood of the presence of chemical warfare agents in the Marine Minefield Breaching case from “unlikely” to “indeterminate” in light of the additional information now known about this case. To enhance the thoroughness of OSAGWI’s investigative and reporting practices, we recommend that the Secretary of Defense direct the Special Assistant for Gulf War Illnesses to use the DOD and VA Gulf War clinical databases to assist in designing the nature and scope of all OSAGWI investigations; include relevant medical information in its case narratives where it is needed to fully explain incidents of possible exposure to chemical agents or other potential causes of Gulf War illnesses; and ensure that its internal review procedures provide that (1) those reviewing an investigation and related report are independent of the team investigating the incident and (2) steps are in place that will lead the reviewers to thoroughly check that all relevant information obtained by the investigation teams has been included in the case narrative reports, all conclusions have been fully substantiated by the facts, and that all logical leads have been pursued. Because of the potential research value of information developed through OSAGWI investigations, we further recommend that OSAGWI contact the Naval Health Research Center regarding the usefulness and desirability of comparing data between the veterans of NMCB-24 and NMCB-40 for purposes such as helping to determine whether veterans of these two units are reporting the same types and numbers of symptoms. DOD generally concurred with a draft of this report, agreeing to revise the case narratives we reviewed to include new or unreported data, and to reassess case narrative findings based upon any new evidence. In particular, DOD agreed to update the Marine Minefield Breaching case to reflect new information, conduct additional analysis on the issue of artillery fire during the breaching operation, and reassess its conclusions as appropriate. DOD disagreed with our proposed use of the CCEP and the VA Gulf War Health Examination Registry in OSAGWI investigations. In commenting on this report, DOD stated it was concerned that these databases might be inappropriately used to establish a causal relationship between an event and the medical findings of the registries. DOD therefore maintains it would be inappropriate for case investigations, which were designed to report simply on what happened on the battlefield, to make assumptions about the significance or validity of the data in these databases without the establishment of a causal association by scientific research. DOD also stated concerns about preempting scientific research in this area and drawing premature conclusions that would be fallacious. However, DOD agreed that these databases need to be examined and analyzed for what they can contribute to understanding the illnesses of Gulf War veterans, and noted that the Department has been involved in a number of research and other analyses of these databases. We agree that information from these databases should not be used by investigators to establish a causal association and/or conclusions as described by DOD, and did not intend that it should be used for this purpose. We also agree that the establishment of Gulf War illnesses causal relationships is most appropriately a research activity. However, we also believe that the VA and DOD databases could potentially provide relevant information to the investigator about whether individuals who were at or near a site under investigation are reporting health problems, and that this information could be appropriately used, when combined with other information, to help guide the nature and scope of OSAGWI investigations. For example, case investigators could use VA Registry and CCEP data, particularly where it shows that large numbers of individuals at or near a given site are reporting health problems, as an indicator for providing investigative leads and for use in establishing the nature and scope of an investigation. This does not mean, as implied in DOD’s comments, that such use of these databases would entail routine inclusion of the reviewed data in the published case narratives, their use as a replacement for research activities, or that its use would result in interpretations of non-scientifically based cause and effect relationships. We believe that these databases can be used by investigators to help guide and scope their efforts without entailing the types of misuse described by DOD. We modified the final report text and recommendatons to clarify our position regarding this finding. DOD agreed that the Al Jubayl case narrative needed to be modified to place the events of this incident in fuller context, and that this would include that some servicemembers stationed at Al Jubayl, especially members of NMCB-24, have reported high levels of health problems. DOD also agreed to request that the Naval Health Research Center undertake an analytical comparison regarding NMCB-24 and NMCB-40, and that independent reviewers are critical to a thorough and acceptable report on OSAGWI investigations. VA also disagreed with our proposed use of the CCEP and the VA Gulf War Health Examination Registry in OSAGWI investigations in its written comments on a draft of this report. VA’s comments were similar to DOD’s regarding this matter. VA also expressed doubts regarding the usefulness to research of data comparisons involving NMCB-24 and NMCB-40. Additional discussion of DOD’s and VA’s comments and our evaluation is included in appendixes I and II.

Summary: Pursuant to a congressional request, GAO provided information on the: (1) Department of Defense's (DOD) progress in establishing an organization to address Gulf War illnesses issues; and (2) thoroughness of DOD's Office of the Special Assistant for Gulf War Illnesses' (OSAGWI) investigations into and reporting on incidents of veterans' potential exposure to chemical or biological warfare agents during the Gulf War. GAO noted that: (1) DOD has made progress in carrying out its mandate to comprehensively address Gulf-War illnesses-related issues; (2) it has assisted veterans through its outreach program by clearing large backlogs of veterans' inquiries, using a toll-free hot line, setting up a Web site, and publishing a newsletter; (3) in addition, it has assisted veterans in obtaining medical examinations and other services at DOD and Department of Veterans Affairs (VA) facilities; (4) through the course of its investigations and other work, OSAGWI has identified needed improvements in DOD's equipment, policies, and procedures and has worked with various DOD agencies to implement changes designed to provide better protection to U.S. servicemembers on a contaminated battlefield; (5) OSAGWI generally applied appropriate investigative procedures and techniques in conducting its work; (6) however, GAO found that three of the six case narratives it reviewed contained weaknesses such as failures to follow up with appropriate individuals to confirm key evidence, to identify or ensure the validity of some evidence, to include some important information, and to interview some key witnesses; (7) in the remaining three cases, OSAGWI conducted its investigations without evidence of these weaknesses; (8) in all six cases, OSAGWI missed an opportunity to perform more complete investigations because it did not take advantage of potentially valuable sources of relevant information in DOD and VA clinical databases; (9) GAO does not know whether the investigatory and reporting weaknesses it found in its review of these six cases might also exist in the cases that OSAGWI later investigated; (10) despite these weaknesses, GAO agreed with OSAGWI's conclusions about the likelihood of the presence of chemical warfare agents in five of the six cases it reviewed; (11) the one exception involved a potential exposure of U.S. Marine Corps personnel to a chemical warfare agent during a minefield breaching operation; (12) OSAGWI concluded that exposure in this case was unlikely; (13) however, GAO found that OSAGWI had overlooked some information it had in its possession and also did not include all relevant information in its case narrative; (14) after reviewing the overlooked information and considering all relevant information OSAGWI had in its files, GAO believes that OSAGWI should reassess the likelihood of exposure in this case; and (15) GAO believes that the lack of effective quality assurance policies and practices in OSAGWI's investigating and reporting processes contributed to the weaknesses noted.