In May 1997, we reported on DOD’s actions to improve deployment health surveillance before, during, and after deployments, focusing on Operation Joint Endeavor, which was conducted in the countries of Bosnia-Herzegovina, Croatia, and Hungary. We commented on the provisions of a joint medical surveillance policy draft that called for a comprehensive DOD-wide medical surveillance capability to monitor and assess the effects of deployments on servicemembers’ health. DOD subsequently finalized its joint medical surveillance policy in August 1997. Our 1997 review disclosed problems with the Army’s implementation of the medical surveillance plan for Operation Joint Endeavor in the following areas: Medical assessments. Many Army personnel who should have received post-deployment medical assessments did not receive them and the assessments that were completed were frequently done late. Of the 618 servicemembers in the 12 Army units whose medical records we reviewed, 24 percent did not receive in-theater post-deployment medical assessments, and 21 percent did not receive home station post-deployment medical assessments. Servicemembers who received home station post-deployment medical assessments received them, on average, nearly 100 days after they left theater instead of within 30 days as required by the plan. Further, pre-deployment blood serum samples were not available for 9.3 percent of the 26,621 servicemembers who had deployed to Bosnia as of March 12, 1996. The most recent blood samples for 6.4 percent of the pre-deployment blood samples were more than 5 years old. Medical record keeping. Many of the servicemembers’ medical records that we reviewed were incomplete and missing documentation of in-theater post-deployment medical assessments, medical visits during deployment, and receipt of an investigational new vaccine. More specifically, we found that 91 of the 473 servicemembers (19 percent) with a post-deployment in-theater medical assessment and 9 of the 491 servicemembers (1.8 percent) with a post-deployment home unit medical assessment did not have the assessments documented in their medical records. Furthermore, about 29 percent of the 50 battalion aid station visits we reviewed were not documented in the members’ permanent medical records. Finally, 141 of 588 servicemembers (24 percent) who received an investigational drug vaccine did not have the immunization documented in their medical records. Centralized database. The centralized database for collecting in-theater and home unit post-deployment medical assessments was incomplete for many Army personnel. More specifically, the database omitted 12 percent of the in-theater medical assessments done and 52 percent of the home unit medical assessments done for the 618 servicemembers whose records we reviewed. Deployment information. DOD officials considered the database used for tracking the deployment of Air Force and Navy personnel inaccurate. “(a) SYSTEM REQUIRED—The Secretary of Defense shall establish a system to assess the medical condition of members of the armed forces (including members of the reserve components) who are deployed outside the United States or its territories or possessions as part of a contingency operation (including a humanitarian operation, peacekeeping operation, or similar operation) or combat operation. “(b) ELEMENTS OF SYSTEM—The system described in subsection (a) shall include the use of predeployment medical examinations and postdeployment medical examinations (including an assessment of mental health and the drawing of blood samples) to accurately record the medical condition of members before their deployment and any changes in their medical condition during the course of their deployment. The postdeployment examination shall be conducted when the member is redeployed or otherwise leaves an area in which the system is in operation (or as soon as possible thereafter). “(c) RECORDKEEPING—The results of all medical examinations conducted under the system, records of all health care services (including immunizations) received by members described in subsection (a) in anticipation of their deployment or during the course of their deployment, and records of events occurring in the deployment area that may affect the health of such members shall be retained and maintained in a centralized location to improve future access to the records. “(d) QUALITY ASSURANCE—The Secretary of Defense shall establish a quality assurance program to evaluate the success of the system in ensuring that members described in subsection (a) receive predeployment medical examinations and postdeployment medical examinations and that the recordkeeping requirements with respect to the system are met.” As set forth above, these provisions require the use of pre-deployment and post-deployment medical examinations to accurately record the medical condition of servicemembers before deployment and any changes during their deployment. In a June 30, 2003, correspondence with the General Accounting Office, the Assistant Secretary of Defense for Health Affairs stated that “it would be logistically impossible to conduct a complete physical examination on all personnel immediately prior to deployment and still deploy them in a timely manner.” Therefore, DOD required both pre- and post-deployment health assessments for servicemembers who deploy for 30 or more continuous days to a land-based location outside the United States without a permanent U.S. military treatment facility. Both assessments use a questionnaire designed to help military healthcare providers in identifying health problems and providing needed medical care. The pre-deployment health assessment is generally administered at the home station before deployment, and the post-deployment health assessment is completed either in theater before redeployment to the servicemember’s home unit or shortly upon redeployment. As a component of medical examinations, the statute quoted above also requires that blood samples be drawn before and after a servicemember’s deployment. DOD Instruction 6490.3, August 7, 1997, requires that a pre-deployment blood sample be obtained within 12 months of the servicemember’s deployment. However, it requires the blood samples be drawn upon return from deployment only when directed by the Assistant Secretary of Defense for Health Affairs. According to DOD, the implementation of this requirement was based on its judgment that the Human Immunodeficiency Virus serum sampling taken independent of deployment actions is sufficient to meet both pre- and post-deployment health needs, except that more timely post-deployment sampling may be directed when based on a recognized health threat or exposure. Prior to April 2003, DOD did not require a post-deployment blood sample for servicemembers supporting the OEF and OJG deployments. In April 2003, DOD revised its health surveillance policy for blood samples and post-deployment health assessments. Effective May 22, 2003, the services are required to draw a blood sample from each redeploying servicemember no later than 30 days after arrival at a demobilization site or home station. According to DOD, this requirement for post-deployment blood samples was established in response to an assessment of health threats and national interests associated with current deployments. The department also revised its policy guidance for enhanced post-deployment health assessments to gather more information from deployed servicemembers about events that occurred during a deployment. More specifically, the revised policy requires that a trained health care provider conduct a face-to-face health assessment with each returning servicemember to ascertain (1) the individual’s responses to the health assessment questions on the post-deployment health assessment form; (2) the presence of any mental health or psychosocial issues commonly associated with deployments; (3) any special medications taken during the deployment; and (4) concerns about possible environmental or occupational exposures. The Army and Air Force did not comply with DOD’s force health protection and surveillance requirements for many of the servicemembers in our samples at the selected installations we visited. Specifically, these Army and Air Force servicemembers were missing: pre-deployment and/or post-deployment health assessments; evidence of receiving one or more of the pre-deployment immunizations required for their deployment location; and other pre-deployment requirements related to tuberculosis screening and blood serum sample storage. Also, servicemembers’ permanent medical records were missing required health-related information, and DOD’s centralized database did not include documentation of servicemember health-related information. Neither the installations nor DOD had monitoring and oversight mechanisms in place to help ensure that the force health protection and surveillance requirements were met for all servicemembers. We found that servicemembers missing one or both of their pre- and post-deployment assessments ranged from 38 to 98 percent in our samples. For example, at Fort Campbell for the OEF deployment we found that 68 percent of the 222 active duty servicemembers in our sample were missing either one or both of the required pre-deployment and post- deployment health assessments. The results of our statistical samples for the deployments at the installations visited are depicted in figure 1. For those servicemembers in our samples who had completed pre- or post-deployment health assessments, we found that as many as 45 percent of the assessments in our samples were not completed on time in accordance with requirements (see fig. 2). DOD policy requires that servicemembers complete a pre-deployment health assessment form within 30 days of their deployment and a post-deployment health assessment form within 5 days upon redeployment back to their home station. These time frames were established to allow time to identify and resolve any health concerns or problems that may affect the ability of the servicemember to deploy, and to promptly identify and address any health concerns or problems that may have arisen during the servicemember’s deployment. Not all health assessments were reviewed by a health care provider as required, as shown in figure 3. DOD policy requires that pre-deployment and post-deployment health assessments are to be reviewed immediately by a health care provider to identify any medical care needed by the servicemember.