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Testimony:
Before the Subcommittee on National Security, Emerging Threats, and
International Relations, Committee on Government Reform, House of
Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery Expected at 10:30 a.m. EDT:
Tuesday, July 19, 2005:
Defense Health Care:
Occupational and Environmental Health Surveillance Conducted during
Deployments Needs Improvement:
Statement of Marcia Crosse:
Director, Health Care:
GAO-05-903T:
GAO Highlights:
Highlights of GAO-05-903T, a testimony before the Subcommittee on
National Security, Emerging Threats, and International Relations,
Committee on Government Reform, House of Representatives:
Why GAO Did This Study:
Following the 1991 Persian Gulf War, research and investigations into
the causes of servicemembers’ unexplained illnesses were hampered by a
lack of servicemember health and deployment data, including inadequate
occupational and environmental exposure data. In 1997, the Department
of Defense (DOD) developed a militarywide health surveillance framework
that includes occupational and environmental health surveillance
(OEHS)—the regular collection and reporting of occupational and
environmental health hazard data by the military services.
This testimony is based on GAO’s report, entitled "Defense Health Care:
Improvements Needed in Occupational and Environmental Health
Surveillance during Deployment to Address Immediate and Long-term
Health Issues (GAO-05-632)." The testimony presents findings about how
the deployed military services have implemented DOD’s policies for
collecting and reporting OEHS data for Operation Iraqi Freedom (OIF)
and the efforts under way to use OEHS reports to address both immediate
and long-term health issues of servicemembers deployed in support of
OIF.
What GAO Found:
Although OEHS data generally have been collected and reported for OIF,
as required by DOD policy, the deployed military services have used
different data collection methods and have not submitted all of the
OEHS reports that have been completed. Data collection methods for air
and soil surveillance have varied across the services, for example,
although they have been using the same monitoring standard for water
surveillance. For some OEHS activities, a cross-service working group
has been developing standards and practices to increase uniformity of
data collection among the services. In addition, while the deployed
military services have been conducting OEHS activities, they have not
submitted all of the OEHS reports that have been completed during OIF.
Moreover, DOD officials could not identify the reports they had not
received to determine the extent of noncompliance.
DOD has made progress in using OEHS reports to address immediate health
risks during OIF, but limitations remain in employing these reports to
address both immediate and long-term health issues. OEHS reports have
been used consistently during OIF as part of operational risk
management activities intended to identify and address immediate health
risks and to make servicemembers aware of the risks of potential
exposures. While these efforts may help in reducing health risks, DOD
has not systematically evaluated their implementation during OIF. DOD’s
centralized archive of OEHS reports for OIF has several limitations for
addressing potential long-term health effects related to occupational
and environmental exposures. First, access to the centralized archive
has been limited due to the security classification of most OEHS
reports. Second, it will be difficult to link most OEHS reports to
individual servicemembers’ records because not all data on
servicemembers’ deployment locations have been submitted to DOD’s
centralized tracking database. To address problems with linking OEHS
reports to individual servicemembers, the deployed military services
have tried to include OEHS monitoring summaries in the medical records
of some servicemembers for either specific incidents of potential
exposure or for specific locations within OIF. Additionally, according
to DOD and Veterans Affairs (VA) officials, no federal research plan
has been developed to evaluate the long-term health of servicemembers
deployed in support of OIF, including the effects of potential
exposures to occupational or environmental hazards.
GAO’s report made several recommendations, including that the Secretary
of Defense improve deployment OEHS data collection and reporting and
evaluate OEHS risk management activities and that the Secretaries of
Defense and Veterans Affairs jointly develop a federal research plan to
address long-term health effects of OIF deployment. DOD plans to take
steps to meet the intent of our first recommendation and partially
concurred with the other recommendations. VA concurred with our
recommendation for a joint federal research plan.
www.gao.gov/cgi-bin/getrpt?GAO-05-903T.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Marcia Crosse at (202)
512-7119 or crossem@gao.gov.
[End of section]
Mr. Chairman and Members of the Subcommittee:
I am pleased to be here today as you consider the efforts by the
deployed military services to implement policies for collecting and
reporting occupational and environmental health surveillance data for
Operation Iraqi Freedom (OIF) and the work under way to use these data
to address both the immediate and long-term health issues of
servicemembers deployed in support of OIF. The health effects from
service in military operations have been of increasing interest since
the end of the 1991 Persian Gulf War--an interest that was renewed when
servicemembers were deployed in early 2003 to the Persian Gulf in
support of OIF. Following the 1991 Gulf War, many servicemembers
reported suffering from unexplained illnesses that they attributed to
their service in the Persian Gulf and expressed concerns about possible
exposures to chemical or biological warfare agents or environmental
contaminants. Subsequent research and investigations into the nature
and causes of these illnesses by the Department of Defense (DOD), the
Department of Veterans Affairs (VA), the Department of Health and Human
Services (HHS), the Institute of Medicine, and a Presidential Advisory
Committee were hampered by a lack of servicemember health and
deployment data, including inadequate occupational and environmental
exposure data.
To address continuing concerns about the health of servicemembers
during and after deployments and to improve health data collection on
potential exposures, DOD developed a militarywide health surveillance
framework for use during deployments beginning in 1997. A key component
of this framework is occupational and environmental health surveillance
(OEHS), an activity that includes the regular collection and reporting
of occupational and environmental health hazard data by the military
services during a deployment that can be used to monitor the health of
servicemembers and to prevent, treat, or control disease or injury. DOD
has created policies for OEHS data collection during a deployment and
for the submittal of OEHS reports to a centralized archive within
specified time frames. The military services are responsible for
implementing these policies in preparation for deployments. During a
deployment, the military services are unified under a deployment
command structure and are responsible for conducting OEHS activities in
accordance with DOD policy. Throughout this testimony, we identify the
military services operating in a deployment as "deployed military
services."
My remarks will summarize our findings on (1) how the deployed military
services have implemented DOD's policies for collecting and reporting
OEHS data for OIF and (2) the efforts under way to use OEHS reports to
address both the immediate and long-term health issues of
servicemembers deployed in support of OIF. My statement is based on our
report, entitled Defense Health Care: Improvements Needed in
Occupational and Environmental Health Surveillance during Deployments
to Address Immediate and Long-term Health Issues (GAO-05-632), which is
being released today.
To do this work, we reviewed pertinent policies, guidance, and reports
related to collecting and reporting OEHS data obtained from officials
at the Deployment Health Support Directorate (DHSD), the military
services, and the Joint Staff, which supports the Chairman of the Joint
Chiefs of Staff.[Footnote 1] We also conducted site visits to the Army,
Navy, and Air Force health surveillance centers that develop standards
and guidance for conducting OEHS.[Footnote 2] We interviewed DOD
officials and reviewed reports and documents identifying occupational
and environmental health risks and outlining recommendations for
addressing risks at deployment sites. We interviewed officials at the
U.S. Army's Center for Health Promotion and Preventive Medicine
(CHPPM), which archives OEHS reports, both classified and unclassified,
for all the military services. We also interviewed officials and
military service representatives at DOD's Deployment Manpower Data
Center on the status of a centralized deployment tracking database to
identify deployed servicemembers and record their locations within the
theater of operations. Additionally, we interviewed VA officials on
their experience in obtaining and using OEHS reports from OIF to
address the health care needs of veterans. Finally, we interviewed DOD
and VA officials to examine whether the agencies have planned or
initiated health research to evaluate the long-term health of
servicemembers deployed in support of OIF using OEHS reports. We
conducted our work from September 2004 through June 2005 in accordance
with generally accepted government auditing standards.
In summary, although OEHS data generally have been collected and
reported for OIF, as required by DOD policy, the deployed military
services have used different data collection methods and have not
submitted all of the OEHS reports that have been completed. Data
collection methods for air and soil surveillance have varied across the
services, for example, although they have been using the same
monitoring standard for water surveillance. Compounding these
differences among the services were varying levels of training and
expertise among the deployed military service personnel who were
responsible for conducting OEHS activities, resulting in differing
practices for implementing data collection standards. For some OEHS
activities, a cross-service working group, called the Joint
Environmental Surveillance Working Group, has been developing standards
and practices to increase uniformity of data collection among the
services. In addition, the deployed military services have not
submitted to CHPPM all OEHS reports that have been completed during
OIF, as required by DOD policy. While 239 of the 277 OIF bases had at
least one OEHS report submitted to CHPPM's centralized archive as of
December 2004, CHPPM could not measure the magnitude of noncompliance
because not all of the required consolidated lists that identify all
OEHS reports completed during each quarter in OIF had been submitted.
Therefore, CHPPM could not compare the reports that it had received
against the list of reports that had been completed. According to CHPPM
officials, obstacles to the services' reporting compliance may have
included a lack of understanding by some within the deployed military
services about the type of OEHS reports that should have been
submitted. In addition, OEHS report submission may be given a lower
priority compared to other deployment mission activities. Also, while
CHPPM is responsible for OEHS archiving, it has no authority to enforce
report submission requirements. To improve OEHS reporting compliance,
DOD officials said they were revising an existing policy to add
additional and more specific OEHS requirements.
DOD has made progress using OEHS reports to address immediate health
risks during OIF, but limitations remain in employing these reports to
address both immediate and long-term health issues. OIF is the first
major deployment in which OEHS reports have been used consistently as
part of operational risk management activities intended to identify and
address immediate health risks. These activities included health risk
assessments that described and measured the potential hazards at a
site, risk mitigation activities intended to reduce potential exposure,
and risk communication efforts undertaken to make servicemembers aware
of the possible health risks of potential exposures. While these
efforts may help reduce health risks, there is no assurance that they
have been effective because DOD has not systematically evaluated the
implementation of OEHS risk management activities in OIF. Despite
progress in the use of OEHS information to identify and address
immediate health risks, CHPPM's centralized archive of OEHS reports for
OIF has limitations for addressing potential long-term health effects
related to occupational and environmental exposures for several
reasons. First, access to CHPPM's OEHS archive has been limited because
most OEHS reports are classified--which restricts their use by VA,
medical professionals, and interested researchers. Second, it will be
difficult to link most OEHS reports to individual servicemembers
because not all data on servicemembers' deployment locations have been
submitted to DOD's centralized tracking database. For example, none of
the military services submitted location data for the first several
months of OIF. To address problems with linking OEHS reports to
individual servicemembers, the deployed military services have made
efforts to include OEHS summaries in the medical records of some
servicemembers for either specific incidents of potential exposure or
for specific locations within OIF, such as air bases. Additionally,
according to DOD and VA officials, no comprehensive federal research
plan incorporating the use of the archived OEHS reports has been
developed to address the long-term health consequences of service in
OIF.
In the report we are issuing today, we recommend that the Secretary of
Defense ensure that cross-service guidance is developed to implement
DOD's revised policy for OEHS during deployments and ensure that the
military services jointly establish and implement procedures to
evaluate the effectiveness of risk management strategies during
deployments. We also recommend that the Secretary of Defense and the
Secretary of Veterans Affairs work together to develop a federal
research plan to follow the health of OIF servicemembers over time that
would include the use of OEHS reports. In commenting on a draft of this
report, DOD stated that cross-service guidance meeting the intent of
our recommendation would be developed by the Joint Staff instead of the
military services. DOD partially concurred with our other
recommendations. VA concurred with our recommendation to work with DOD
to jointly develop a federal research plan to follow the long-term
health of OIF servicemembers.
Background:
As of the end of February 2005, an estimated 827,277 servicemembers had
been deployed in support of OIF. Deployed servicemembers, such as those
in OIF, are potentially subject to occupational and environmental
hazards that can include exposure to harmful levels of environmental
contaminants such as industrial toxic chemicals, chemical and
biological warfare agents, and radiological and nuclear contaminants.
Harmful levels include high-level exposures that result in immediate
health effects.[Footnote 3] Health hazards may also include low-level
exposures that could result in delayed or long-term health effects.
Occupational and environmental health hazards may include such things
as contamination from the past use of a site, from battle damage, from
stored stockpiles, from military use of hazardous materials, or from
other sources.
Federal OEHS Policy:
As a result of numerous investigations that found inadequate data on
deployment occupational and environmental exposure to identify the
potential causes of unexplained illnesses among veterans who served in
the 1991 Persian Gulf War, the federal government increased efforts to
identify potential occupational and environmental hazards during
deployments. In 1997, a Presidential Review Directive called for a
report by the National Science and Technology Council to establish an
interagency plan to improve the federal response to the health needs of
veterans and their families related to the adverse effects of
deployment.[Footnote 4] The Council published a report that set a goal
for the federal government to develop the capability to collect and
assess data associated with anticipated exposure during deployments.
Additionally, the report called for the maintenance of the capability
to identify and link exposure and health data by Social Security number
and unit identification code. Also in 1997, Public Law 105-85 included
a provision recommending that DOD ensure the deployment of specialized
units to theaters of operations to detect and monitor chemical,
biological, and similar hazards.[Footnote 5] The Presidential Review
Directive and the public law led to a number of DOD instructions,
directives, and memoranda that have guided the collection and reporting
of deployment OEHS data.
DOD Entities Involved with Setting and Implementing OEHS Policy:
DHSD makes recommendations for DOD-wide policies on OEHS data
collection and reporting during deployments to the Office of the
Assistant Secretary of Defense for Health Affairs. DHSD is assisted by
the Joint Environmental Surveillance Working Group, established in
1997, which serves as a coordinating body to develop and make
recommendations for DOD-wide OEHS policy.[Footnote 6] The working group
includes representatives from the Army, Navy, and Air Force OEHS health
surveillance centers, the Joint Staff, other DOD entities, and VA.
Each service has a health surveillance center--the CHPPM, the Navy
Environmental Health Center, and the Air Force Institute for
Operational Health--that provides training, technical guidance and
assistance, analytical support, and support for preventive medicine
units[Footnote 7] in the theater in order to carry out deployment OEHS
activities in accordance with DOD policy. In addition, these centers
have developed and adapted military exposure guidelines for deployment
using existing national standards for human health exposure limits and
technical monitoring procedures (e.g., standards developed by the U.S.
Environmental Protection Agency and the National Institute for
Occupational Safety and Health) and have worked with other agencies to
develop new guidelines when none existed. (See fig. 1.)
Figure 1: Entities Involved in Setting or Implementing Occupational and
Environmental Health Surveillance (OEHS) Policy:
[See PDF for image]
[End of figure]
Deployment OEHS Reports:
DOD policies and military service guidelines require that the
preventive medicine units of each military service be responsible for
collecting and reporting deployment OEHS data.[Footnote 8] Deployment
OEHS data are generally categorized into three types of reports:
baseline, routine, or incident-driven.
* Baseline reports generally include site surveys and assessments of
occupational and environmental hazards prior to deployment of
servicemembers and initial environmental health site assessments once
servicemembers are deployed.[Footnote 9]
* Routine reports record the results of regular monitoring of air,
water, and soil, and of monitoring for known or possible hazards
identified in the baseline assessment.
* Incident-driven reports document exposure or outbreak
investigations.[Footnote 10]
There are no DOD-wide requirements on the specific number or type of
OEHS reports that must be created for each deployment location because
reports generated for each location reflect the specific occupational
and environmental circumstances unique to that location. CHPPM
officials said that reports generally reflect deployment OEHS
activities that are limited to established sites such as base camps or
forward operating bases;[Footnote 11] an exception is an investigation
during an incident outside these locations. Constraints to conducting
OEHS outside of bases include risks to servicemembers encountered in
combat and limits on the portability of OEHS equipment. In addition,
DHSD officials said that preventive medicine units might not be aware
of every potential health hazard and therefore might be unable to
conduct appropriate OEHS activities.
OEHS Reporting and Archiving Activities during Deployment:
According to DOD policy, various entities must submit their completed
OEHS reports to CHPPM during a deployment. The deployed military
services have preventive medicine units that submit OEHS reports to
their command surgeons,[Footnote 12] who review all reports and ensure
that they are sent to a centralized archive that is maintained by
CHPPM.[Footnote 13] Alternatively, preventive medicine units can be
authorized to submit OEHS reports directly to CHPPM for archiving. (See
fig. 2.)
Figure 2: Submittal of Deployment Occupational and Environmental Health
Surveillance (OEHS) Reports to the Centralized Archive:
[See PDF for image]
[A] The command surgeons of deployed preventive medicine units are
either Joint Task Force command surgeons or military service component
command surgeons. In OIF, there are two Joint Task Forces, each with a
command surgeon. In addition, the Army, Navy, Air Force, and Marine
Corps have their own subordinate component commands in a deployment,
each with a command surgeon.
[End of figure]
According to DOD policy, baseline and routine reports should be
submitted within 30 days of report completion.[Footnote 14] Initial
incident-driven reports should be submitted within 7 days of an
incident or outbreak. Interim and final reports for an incident should
be submitted within 7 days of report completion. In addition, the
preventive medicine units are required to provide quarterly lists of
all completed deployment OEHS reports to the command surgeons. The
command surgeons review these lists, merge them, and send CHPPM a
quarterly consolidated list of all the deployment OEHS reports it
should have received.
To assess the completeness of its centralized OEHS archive, CHPPM
develops a quarterly summary report that identifies the number of
baseline, routine, and incident-driven reports that have been submitted
for all bases in a command. This report also summarizes the status of
OEHS report[Footnote 15] submissions by comparing the reports CHPPM
receives with the quarterly consolidated lists from the command
surgeons that list each of the OEHS reports that have been completed.
For OIF, CHPPM is required to provide a quarterly summary report to the
commander of U.S. Central Command[Footnote 16] on the deployed military
services' compliance with deployment OEHS reporting requirements.
Uses of Deployment OEHS Reports:
During deployments, military commanders can use deployment OEHS reports
completed and maintained by preventive medicine units to identify
occupational and environmental health hazards[Footnote 17] and to help
guide their risk management decision making. Commanders use an
operational risk management process to estimate health risks based on
both the severity of the risks to servicemembers and the likelihood of
encountering the specific hazard. Commanders balance the risk to
servicemembers of encountering occupational and environmental health
hazards while deployed, even following mitigation efforts, against the
need to accomplish specific mission requirements. The operational risk
management process, which varies slightly across the services,
includes:
* risk assessment, including hazard identification, to describe and
measure the potential hazards at a location;
* risk control and mitigation activities intended to reduce potential
exposures; and:
* risk communication efforts to make servicemembers aware of possible
exposures, any risks to health that they may pose, the countermeasures
to be employed to mitigate exposure or disease outcome, and any
necessary medical measures or follow-up required during or after the
deployment.
Along with health encounter[Footnote 18] and servicemember location
data, archived deployment OEHS reports are needed by researchers to
conduct epidemiologic studies on the long-term health issues of
deployed servicemembers. These data are needed, for example, by VA,
which in 2002 expanded the scope of its health research to include
research on the potential long-term health effects on servicemembers in
hazardous military deployments. In a letter to the Secretary of Defense
in 2003, VA said it was important for DOD to collect adequate health
and exposure data from deployed servicemembers to ensure VA's ability
to provide veterans' health care and disability compensation. VA noted
in the letter that much of the controversy over the health problems of
veterans who fought in the 1991 Persian Gulf War could have been
avoided had more extensive surveillance data been collected. VA asked
in the letter that it be allowed access to any unclassified data
collected during deployments on the possible exposure of servicemembers
to environmental hazards of all kinds.
Deployed Military Services Use Varying Approaches to Collect OEHS Data
and Have Not Submitted All OEHS Reports for OIF:
The deployed military services generally have collected and reported
OEHS data for OIF, as required by DOD policy. However, the deployed
military services have used different OEHS data collection standards
and practices, because each service has its own authority to implement
broad DOD policies. To increase data collection uniformity, the Joint
Environmental Surveillance Working Group has made some progress in
devising cross-service standards and practices for some OEHS
activities. In addition, the deployed military services have not
submitted all of the OEHS reports they have completed for OIF to
CHPPM's centralized archive, as required by DOD policy. However, CHPPM
officials said that they could not measure the magnitude of
noncompliance because they have not received all of the required
quarterly consolidated lists of OEHS reports that have been completed.
To improve OEHS reporting compliance, DOD officials said they were
revising an existing policy to add additional and more specific OEHS
requirements.
Data Collection Standards and Practices Vary by Service, Although
Preliminary Efforts Are Under Way to Increase Uniformity:
OEHS data collection standards[Footnote 19] and practices have varied
among the military services because each service has its own authority
to implement broad DOD policies, and the services have taken somewhat
different approaches. For example, although one water monitoring
standard has been adopted by all military services, the services have
different standards for both air and soil monitoring. As a result, for
similar OEHS events, preventive medicine units may collect and report
different types of data. Each military service's OEHS practices for
implementing data collection standards also have differed because of
varying levels of training and expertise among the service's preventive
medicine units. For example, CHPPM officials said that Air Force and
Navy preventive medicine units had more specialized personnel with a
narrower focus on specific OEHS activities than Army preventive
medicine units, which included more generalist personnel who conducted
a broader range of OEHS activities. Air Force preventive medicine units
generally have included a flight surgeon, a public health officer, and
bioenvironmental engineers. Navy preventive medicine units generally
have included a preventive medicine physician, an industrial hygienist,
a microbiologist, and an entomologist. In contrast, Army preventive
medicine unit personnel generally have consisted of environmental
science officers and technicians.
DOD officials also said other issues could contribute to differences in
data collected during OIF. DHSD officials said that variation in OEHS
data collection practices could occur as a result of resource
limitations during a deployment. For example, some preventive medicine
units may not be fully staffed at some bases. A Navy official also said
that OEHS data collection can vary as different commanders set
guidelines for implementing OEHS activities in the deployment theater.
To increase the uniformity of OEHS standards and practices for
deployments, the military services have made some progress--
particularly in the last 2 years--through their collaboration as
members of the Joint Environmental Surveillance Working Group. For
example, the working group has developed a uniform standard, which has
been adopted by all the military services, for conducting environmental
health site assessments, which are a type of baseline OEHS
report.[Footnote 20] These assessments have been used in OIF to
evaluate potential environmental exposures that could have an impact on
the health of deployed servicemembers and determine the types of
routine OEHS monitoring that should be conducted. Also, within the
working group, three subgroups--laboratory, field water, and equipment-
-have been formed to foster the exchange of information among the
military services in developing uniform joint OEHS standards and
practices for deployments. For example, DHSD officials said the
equipment subgroup has been working collaboratively to determine the
best OEHS instruments to use for a particular type of location in a
deployment.
Deployed Military Services Have Not Submitted All Required OEHS Reports
for OIF, and the Magnitude of Noncompliance Is Unknown:
The deployed military services have not submitted all the OEHS reports
that the preventive medicine units completed during OIF to CHPPM for
archiving, according to CHPPM officials. Since January 2004, CHPPM has
compiled four summary reports that included data on the number of OEHS
reports submitted to CHPPM's archive for OIF. However, these summary
reports have not provided information on the magnitude of noncompliance
with report submission requirements because CHPPM has not received all
consolidated lists of completed OEHS reports that should be submitted
quarterly. These consolidated lists were intended to provide a key
inventory of all OEHS reports that had been completed during OIF.
Because there are no requirements on the specific number or type of
OEHS reports that must be created for each base, the quarterly
consolidated lists are CHPPM's only means of assessing compliance with
OEHS report submission requirements. Our analysis of data supporting
the four summary reports[Footnote 21] found that, overall, 239 of the
277 bases[Footnote 22] had at least one OEHS baseline (139) or routine
(211) report submitted to CHPPM's centralized archive through December
2004.[Footnote 23]
DOD officials suggested several obstacles that may have hindered OEHS
reporting compliance during OIF. For example, CHPPM officials said
there are other, higher priority operational demands that commanders
must address during a deployment. In addition, CHPPM officials said
that some of the deployed military services' preventive medicine units
might not understand the types of OEHS reports to be submitted or might
view them as an additional paperwork burden. CHPPM and other DOD
officials added that some preventive medicine units might have limited
access to communication equipment to send reports to CHPPM for
archiving.[Footnote 24] CHPPM officials also said that while they had
the sole archiving responsibility, CHPPM did not have the authority to
enforce OEHS reporting compliance for OIF--this authority rests with
the Joint Staff and the commander in charge of the deployment.
DOD has several efforts under way to improve OEHS reporting compliance.
CHPPM officials said they have increased communication with deployed
preventive medicine units and have facilitated coordination among each
service's preventive medicine units prior to deployment. CHPPM has also
conducted additional OEHS training for some preventive medicine units
prior to deployment, including both refresher courses and information
about potential hazards specific to the locations where the units were
being deployed. In addition, DHSD officials said they were revising an
existing policy to add additional and more specific OEHS requirements.
However, at the time of our review, a draft of the revision had not
been released, and therefore specific details about the revision were
not available.
Progress Made in Using OEHS Reports to Address Immediate Health Risks,
Though Limitations Remain for Addressing Both Immediate and Long-term
Health Issues:
DOD has made progress in using OEHS reports to address immediate health
risks during OIF, but limitations remain in employing these reports to
address both immediate and long-term health issues. During OIF, OEHS
reports have been used as part of operational risk management
activities intended to assess, mitigate, and communicate to
servicemembers any potential hazards at a location. There have been no
systematic efforts by DOD or the military services to establish a
system to monitor the implementation of OEHS risk management
activities, although DHSD officials said they considered the relatively
low rates of disease and nonbattle injury in OIF an indication of OEHS
effectiveness. In addition, DOD's centralized archive of OEHS reports
for OIF is limited in its ability to provide information on the
potential long-term health effects related to occupational and
environmental exposures for several reasons, including limited access
to most OEHS reports because of their security classification,
incomplete data on servicemembers' deployment locations, and the lack
of a comprehensive federal research plan incorporating the use of
archived OEHS reports.
DOD Has Made Progress in Using Deployment OEHS Data and Reports in Risk
Management but Does Not Monitor Implementation of These Efforts:
To identify and reduce the risk of immediate health hazards in OIF, all
of the military services have used preventive medicine units' OEHS data
and reports in an operational risk management process. A DOD official
said that while DOD had begun to implement risk management to address
occupational and environmental hazards in other recent deployments, OIF
was the first major deployment to apply this process throughout the
deployed military services' day-to-day activities, beginning at the
start of the operation.[Footnote 25] The operational risk management
process includes risk assessments of deployment locations, risk
mitigation activities to limit potential exposures, and risk
communication to servicemembers and commanders about potential hazards.
* Risk Assessments. Preventive medicine units from each of the services
have generally used OEHS information and reports to develop risk
assessments that characterized known or potential hazards when new
bases were opened in OIF. CHPPM's formal risk assessments have also
been summarized or updated to include the findings of baseline and
routine OEHS monitoring conducted while bases are occupied by
servicemembers, CHPPM officials said. During deployments, commanders
have used risk assessments to balance the identified risk of
occupational and environmental health hazards, and other operational
risks, with mission requirements. Generally, OEHS risk assessments for
OIF have involved analysis of the results of air, water, or soil
monitoring.[Footnote 26] CHPPM officials said that most risk
assessments that they have received characterized locations in OIF as
having a low risk of posing health hazards to servicemembers.[Footnote
27]
* Risk Control and Mitigation. Using risk assessment findings,
preventive medicine units have recommended risk control and mitigation
activities to commanders that were intended to reduce potential
exposures at specific locations. For OIF, risk control and mitigation
recommendations at bases have included such actions as modifying work
schedules, requiring individuals to wear protective equipment, and
increasing sampling to assess any changes and improve confidence in the
accuracy of the risk estimate.
* Risk Communication. Risk assessment findings have also been used in
risk communication efforts, such as providing access to information on
a Web site or conducting health briefings to make servicemembers aware
of occupational and environmental health risks during a deployment and
the recommended efforts to control or mitigate those risks, including
the need for medical follow-up. Many of the risk assessments for OIF we
reviewed recommended that health risks be communicated to
servicemembers.
While risk management activities have become more widespread in OIF
compared with previous deployments, DOD officials have not conducted
systematic monitoring of deployed military services' efforts to conduct
OEHS risk management activities. As of March 2005, neither DOD nor the
military services had established a system to examine whether required
risk assessments had been conducted, or to record and track resulting
recommendations for risk mitigation or risk communication activities.
In the absence of a systematic monitoring process, CHPPM officials said
they conducted ad hoc reviews of implementation of risk management
recommendations for sites where continued, widespread OEHS monitoring
has occurred, such as at Port Shuaiba, Kuwait, a deepwater port where a
large number of servicemembers have been stationed, or other locations
with elevated risks. DHSD officials said they have initiated planning
for a comprehensive quality assurance program for deployment health
that would address OEHS risk management, but the program was still
under development.
DHSD and military service officials said that developing a monitoring
system for risk management activities would face several challenges. In
response to recommendations for risk mitigation and risk communication
activities, commanders may have issued written orders and guidance that
were not always stored in a centralized, permanent database that could
be used to track risk management activities. Additionally, DHSD
officials told us that risk management decisions have sometimes been
recorded in commanders' personal journals or diaries, rather than
issued as orders that could be stored in a centralized, permanent
database.
In lieu of a monitoring system, DHSD officials said that DOD considers
the rates of disease and nonbattle injury in OIF as a general measure
or indicator of OEHS effectiveness. As of January 2005, OIF had a 4
percent total disease and nonbattle injury rate--in other words, an
average of 4 percent of servicemembers deployed in support of OIF had
been seen by medical units for an injury or illness in any given week.
This rate is the lowest DOD has ever documented for a major deployment,
according to DHSD officials. For example, the total disease and
nonbattle injury rate for the 1991 Gulf War was about 6.5 percent, and
the total rate for Operation Enduring Freedom in Central Asia has been
about 5 percent. However, while this indicator provides general
information on servicemembers' health status, it is not directly linked
to specific OEHS activities and therefore is not a clear measure of
their effectiveness.
Access to Most Archived OEHS Reports Is Limited by Security
Classification:
Access to archived OEHS reports by VA, medical professionals, and
interested researchers has been limited by the security classification
of most OEHS reports.[Footnote 28] Typically, OEHS reports are
classified if the specific location where monitoring activities occur
is identified. VA officials said they would like to have access to OEHS
reports in order to ensure appropriate postwar health care and
disability compensation for veterans, and to assist in future research
studies. However, VA officials said that, because of these security
concerns, they did not expect access to OEHS reports to improve until
OIF has ended.
Although access to OEHS reports has been restricted, VA officials said
they have tried to anticipate likely occupational and environmental
health concerns for OIF based on experience from the 1991 Persian Gulf
War and on CHPPM's research on the medical or environmental health
conditions that exist or might develop in the region. Using this
information, VA has developed study guides for physicians on such
topics as health effects from radiation and traumatic brain injury and
also has written letters for OIF veterans about these issues.
DOD has begun reviewing classification policies for OEHS reports, as
required by the Ronald W. Reagan National Defense Authorization Act for
Fiscal Year 2005.[Footnote 29] A DHSD official said that DOD's newly
created Joint Medical Readiness Oversight Committee is expected to
review ways to reduce or limit the classification of data, including
data that are potentially useful for monitoring and assessing the
health of servicemembers who have been exposed to occupational or
environmental hazards during deployments.
Difficulties Exist in Linking Archived OEHS Reports to Individual
Servicemembers, but Some Efforts Are Under Way to Include Information
in Medical Records:
Linking OEHS reports from the archive to individual servicemembers will
be difficult because DOD's centralized tracking database for recording
servicemembers' deployment locations currently does not contain
complete or comparable data. In May 1997, we reported that the ability
to track the movement of individual servicemembers within the theater
is important for accurately identifying exposures of servicemembers to
health hazards.[Footnote 30] However, the Defense Manpower Data
Center's centralized database has continued to experience problems in
obtaining complete, comparable data from the services on the location
of servicemembers during deployments, as required by DOD
policies.[Footnote 31] Data center officials said the military services
had not reported location data for all servicemembers for OIF. As of
October 2004, the Army, Air Force, and Marine Corps each had submitted
location data for approximately 80 percent of their deployed
servicemembers, and the Navy had submitted location data for about 60
percent of its deployed servicemembers.[Footnote 32] Additionally, the
specificity of location data has varied by service. For example, the
Marine Corps has provided location of servicemembers only by country,
whereas each of the other military services has provided more detailed
location information for some of their servicemembers, such as base
camp name or grid coordinate locations. Furthermore, the military
services did not begin providing detailed location data until OIF had
been ongoing for several months.
DHSD officials said they have been revising an existing policy[Footnote
33] to provide additional requirements for location data that are
collected by the military services, such as a daily location record
with grid coordinates or latitude and longitude coordinates for all
servicemembers. Though the revised policy has not been published, as of
May 2005 the Army and the Marine Corps had implemented a new joint
location database in support of OIF that addresses these revisions.
During OIF, some efforts have been made to include information about
specific incidents of potential and actual exposure to occupational or
environmental health hazards in the medical records of servicemembers
who may have been affected. According to DOD officials, preventive
medicine units have been investigating incidents involving potential
exposure during the deployment. For a given incident, a narrative
summary of events and the results of any medical procedures generally
were included in affected servicemembers' medical records.
Additionally, rosters were generally developed of servicemembers
directly affected and of servicemembers who did not have any acute
symptoms but were in the vicinity of the incident. For example, in
investigating an incident involving a chemical agent used in an
improvised explosive device, CHPPM officials said that two soldiers who
were directly involved were treated at a medical clinic, and their
treatment and the exposure were recorded in their medical records.
Although 31 servicemembers who were providing security in the area were
asymptomatic, doctors were documenting this potential exposure in their
medical records.
In addition, the military services have taken some steps to include
summaries of potential exposures to occupational and environmental
health hazards in the medical records of servicemembers deployed to
specific locations. The Air Force has created summaries of these
hazards at deployed air bases and has required that these be placed in
the medical records of all Air Force servicemembers stationed at these
bases. (See app. I for an example.) However, Air Force officials said
no follow-up activities have been conducted specifically to determine
whether all Air Force servicemembers have had the summaries placed in
their medical records. Similarly, the Army and Navy jointly created a
summary of potential exposure for the medical records of servicemembers
stationed at Port Shuaiba, the deepwater port used for bringing in
heavy equipment in support of OIF where a large number of
servicemembers have been permanently or temporarily stationed. Since
December 2004, port officials have made efforts to make the summary
available to servicemembers stationed at Port Shuaiba so that these
servicemembers can include the summary in their medical records.
However, there has been no effort to retroactively include the summary
in the medical records of servicemembers stationed at the port prior to
that time.
No Federal Research Plan Exists for Using OEHS Reports to Follow the
Health of OIF Servicemembers over Time:
According to DOD and VA officials, no federal research plan that
includes the use of archived OEHS reports has been developed to
evaluate the long-term health of servicemembers deployed in support of
OIF, including the effects of potential exposure to occupational or
environmental hazards. In February 1998 we noted that the federal
government lacked a proactive strategy to conduct research into Gulf
War veterans' health problems and suggested that delays in planning
complicated researchers' tasks by limiting opportunities to collect
critical data.[Footnote 34] However, the Deployment Health Working
Group, a federal interagency body responsible for coordinating research
on all hazardous deployments, recently began discussions on the first
steps needed to develop a research plan for OIF.[Footnote 35] At its
January 2005 meeting, the working group tasked its research
subcommittee to develop a complete list of research projects currently
under way that may be related to OIF.[Footnote 36] VA officials noted
that because OIF is ongoing, the working group would have to determine
how to address a study population that changes as the number of
servicemembers deployed in support of OIF changes.[Footnote 37]
Although no coordinated federal research plan has been developed, other
separate federal research studies are underway that may follow the
health of OIF servicemembers. For example, in 2000 VA and DOD
collaborated to develop the Millennium Cohort study, a 21-year
longitudinal study evaluating the health of both deployed and
nondeployed military personnel throughout their military careers and
after leaving military service. According to the principal
investigator, the Millennium Cohort study was designed to examine the
health effects of specific deployments if enough servicemembers in that
deployment enrolled in the study. However, the principal investigator
said that as of February 2005 researchers had not identified how many
servicemembers deployed in support of OIF had enrolled in the study. In
another effort, a VA researcher has received funding to study mortality
rates among OIF servicemembers. According to the researcher, if
occupational and environmental data are available, the study will
include the evaluation of mortality outcomes in relation to potential
exposure for OIF servicemembers.
Concluding Observations:
As we stated in our report, DOD's efforts to collect and report OEHS
data could be strengthened. Currently, OEHS data that the deployed
military services have collected during OIF may not always be
comparable because of variations among the services' data collection
standards and practices. Additionally, the deployed military services'
uncertain compliance with OEHS report submission requirements casts
doubt on the completeness of CHPPM's OEHS archive. These data
shortcomings, combined with incomplete data in DOD's centralized
tracking database of servicemembers' deployment locations, limit
CHPPM's ability to respond to requests for OEHS information about
possible exposure to occupational and environmental health hazards of
those who are serving or have served in OIF. DOD officials have said
they are revising an existing policy on OEHS data collection and
reporting to add additional and more specific OEHS requirements.
However, unless the military services take measures to direct those
responsible for OEHS activities to proactively implement the new
requirements, the services' efforts to collect and report OEHS data may
not improve. Consequently, we recommended that the Secretary of Defense
ensure that cross-service guidance is created to implement DOD's
policy, once that policy has been revised, to improve the collection
and reporting of OEHS data during deployments and the linking of OEHS
reports to servicemembers. DOD responded that cross-service
implementation guidance for the revised policy on deployment OEHS would
be developed by the Joint Staff.
While DOD's risk management efforts during OIF represent a positive
step in helping to mitigate potential environmental and occupational
risks of deployment, the lack of systematic monitoring of the deployed
military services' implementation activities prevents full knowledge of
their effectiveness. Therefore, we recommended that the military
services jointly establish and implement procedures to evaluate the
effectiveness of risk management efforts. DOD partially concurred with
our recommendation and stated that it has procedures in place to
evaluate OEHS risk management through a jointly established and
implemented lessons learned process. However, in further discussions,
DOD officials told us that they were not aware of any lessons learned
reports related to OEHS risk management for OIF.
Furthermore, although OEHS reports alone are not sufficient to identify
the causes of potential long-term health effects in deployed
servicemembers, they are an integral component of research to evaluate
the long-term health of deployed servicemembers. However, efforts by a
joint DOD and VA working group to develop a federal research plan for
OIF that would include examining the effects of potential exposure to
occupational and environmental health hazards have just begun, despite
similarities in deployment location to the 1991 Persian Gulf War. As a
result, we recommended that DOD and VA work together to develop a
federal research plan to follow the health of servicemembers deployed
in support of OIF that would include the use of archived OEHS reports.
DOD partially concurred with our recommendation, and VA concurred. The
difference in VA and DOD's responses to this recommendation illustrates
a disconnect between each agency's understanding of whether and how
such a federal research plan should be established. Therefore,
continued collaboration between the agencies to formulate a mutually
agreeable process for proactively creating a federal research plan
would be beneficial in facilitating both agencies' ability to
anticipate and understand the potential long-term health effects
related to OIF deployment versus taking a more reactive stance in
waiting to see what types of health problems may surface.
Mr. Chairman, this completes my prepared statement. I would be happy to
respond to any question you or other Members of the Subcommittee may
have at this time.
GAO Contact and Staff Acknowledgments:
For further information about this testimony, please contact Marcia
Crosse at (202) 512-7119 or crossem@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this testimony. In addition to the contacts named
above, Bonnie Anderson, Assistant Director, Karen Doran, Beth Morrison,
John Oh, Danielle Organek, and Roseanne Price also made key
contributions to this testimony.
[End of section]
Appendix I: Example of an Occupational and Environmental Health
Surveillance Summary Created by the Air Force:
PREVIOUS EDITION IS USABLE:
AUTHORIZED FOR LOCAL REPRODUCTION:
CHRONOLOGICAL RECORD OF MEDICAL CARE:
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each
entry):
ENVIRONMENTAL/OCCUPATIONAL HEALTHWORKPLACE EXPOSURE DATA:
This assessment covers individuals deployed to BAGHDAD AIR BASE (BDAB),
IRAQ for the time period 15 DEC 03 to 30 APR 2004.
Purpose: To comply with the deployment health surveillance requirements
of Presidential Review Directive 5 and JCSM 0006-02, Updated Procedures
for Deployment Health Surveillance and Readiness. CENTAF/SG officially
sanctions use of this form and recommends it be maintained in the
individual s permanent medical record with the DD Form 2796, Post
Deployment Health Assessment, covering the same time period.
Camps Sather and Griffin, the primary AF locations on Baghdad
International Airport (BIAP), were part of the Iraqi Military Training
portion of BIAP. However, this specific area was not heavily used. The
small Iraqi terminal on site was for military guests and distinguished
visitors. Base housing and training was on the other side of the main
road outside Camp Sather. While there is farming around BIAP, we are
not aware of any specific farming activities within Camp Sather;
however, there is evidence of flooded fields in/around Camp Griffin. We
are also not aware of any major spills within the BIAP AF cantonment.
BDAB refers to both Camps Sather and Griffin.
Environmental Exposure Data and Risk Assessment:
1. Airborne Dust: The level of airborne particulate matter is high
throughout the Middle East due to wind blown dust and sand. Expected
health effects associated with exposures to airborne particulates
include eye, nose, and throat irritation, sneezing, coughing, sinus
congestion, sinus drainage, and aggravation of asthma conditions. Based
on air sampling performed in and around BIAP, the overall health risk
to personnel from exposure to airborne dust is assessed as low. PM sub
10 and manganese air samples taken in late May 2003 indicated
concentrations nearly double their respective military exposure
guidelines. However, no long-term health affects are anticipated for
personnel as for a period less than two years.
2. Airborne Emissions From Petroleum Production/Other Nearby
Industrial/Disposal Activities: There are multiple industrial
activities near BIAP. Chemical storage and processing plants are
located within 5-10 miles of BIAP, primarily to the east and south.
However, operations at these facilities are severely limited in the
aftermath of combat activities in/around BIAP. Multiple industrial
activities, to include manufacturing, construction, and petroleum
refining are located in the greater Baghdad metropolitan area. With the
prevailing winds from the northwest, BIAP is located downwind from only
a few industrial activities, primarily light to medium manufacturing
facilities. Routine exposure of BIAP personnel to airborne emissions
from off-base industrial sources is assessed as minimal to nonexistent,
with no increased risk to health resulting from routine exposure. Army
units in/around BIAP no longer burn out human and other waste products,
and no units BIAP burn trash/garbage. There is no health risk expected
from these intermittent exposures.
3. Endemic Diseases: Leishmaniasis (both cutaneous and visceral) occurs
in Iraq at a sporadic level. On-base vector surveillance, during
transmission season, yielded many sand flies from unbated traps, some
of which tested positive for leishmaniasis. Risk to BDAB personnel is
assessed as low, so long as the sand fly burden is kept under control.
Cases may not present with symptoms until 4-6 months post-redeployment.
Malaria is present in Iraq, but to date has not been a significant
issue in the Baghdad area. Anopheles mosquitoes are present on BIAP and
95% of endemic malaria is Plasmodium vivax. CENTCOM reporting
instructions require personnel to treat uniforms with permethrin and
apply DEET to exposed skin as necessary to prevent bites. Sanitation
varies within the country, but typically is well below U.S. standards.
Consuming local food or water poses a significant risk to personnel for
bacterial diarrhea. Personnel were advised to consume only food, water,
and ice from approved sources. Tuberculosis (TB) disease risk
assessment for Iraq is low. Unless individuals had exposure to anyone
known or suspected of having active TB, worked closely with refugees or
prisoners, or had prolonged contact with the local populace, a post-
deployment tuberculin skin test is not required. Plague is restricted
to focal areas; enzootic foci historically have existed along the
Tigris-Euphrates River--extending to Kuwait. Plague risk assessment is
low.
4. Drinking Water: Bottled water is the source of 100% of the drinking
water used on BDAB. All bottled water comes from approved sources and
is tested by 447 EMEDS to ensure water quality meets all applicable
standards. BDAB has a water distribution system that is supplied via
truck by US Army reverse osmosis purification units located at North
Palace, using water from a lake fed by the Tigris River. Tap water is
considered non-potable and only recommended for cleaning and hygiene
purposes.
5. Hazardous Animals and Insects: Several species of venomous snakes,
scorpions and spiders have been identified on base. Generally, they are
limited in number and BDAB personnel experience minimal sightings or
contact. Unless otherwise specified in the medical record, individual
reported no adverse contact (i.e. bites). Feral cats and dogs have also
been noted in the area. Rats and mice have been a nuisance; one rat
bite was reported in the summer of 2003.
6. Waste Sites/Waste Disposal: Hazardous waste storage on BDAB is
limited to used and off-spec POL products, and small spill cleanup
residue. Currently, proper handling, storage, and disposal of
industrial waste generated on base (mainly oil, fuel and hydraulic
fluid) are strictly enforced. Airborne exposure to base personnel from
stored waste is assessed as minimal to nonexistent. No obvious signs of
significant past spills or tank leakage were noted when coalition
forces occupied BIAP, although POL personnel did drain and remove
several extant tanks. Trash and garbage are containerized and routinely
collected by contractors. Latrines are pumped out by trucks and waste
is disposed off-BIAP.
7. Nuclear, Biological or Chemical (NBC) Weapon Exposure: There has
been no evidence of any use, storage, release, or exposure of NBC
agents to personnel at this site.
8. Agricultural Emissions: Surrounding land is moderately agricultural.
Many farms are within 1-2 miles of the perimeter fence, with numerous
potentially flooded fields for rice cultivation. Aerial photos previous
to May 2003 revealed that much of BIAP, including parts of the AF
cantonment, were rice cultivation areas. While we haven'''t witnessed
any significant application, herbicide/pesticide use probably routinely
occurs just outside the base. However, airborne exposure to base
personnel is assessed as minimal to nonexistent.
9. Depleted Uranium (DU): DU is a component of some aircraft present
and/or transient on/through BDAB. There is no evidence of DU munitions
having been expended at BIAP. Therefore, there is no potential airborne
exposure to DU. Exposure is classified as far below permissible
exposure levels.
10. Hazardous Materials: There are only a few permanent structures on
BDAB. Both lead-based paint and potential asbestos-containing material
have been tentatively identified in various locations on BIAP; however,
personnel are not performing activities that involve routine exposure,
thereby minimizing health risk. There were multiple sites where Iraqi
hazardous materials caches were located; however, personnel exposures
were minimized/eliminated by removing or limiting access to the
materials.
Occupational Exposure Data and Risk Assessment:
1. Noise: Aircraft, aircraft ground equipment, generators and other
equipment produce hazardous noise. Workers routinely exposed to
hazardous noise are those working on or near the flight line and/or in
selected industrial shops. These workers have comparable noise exposure
at home station and are on the hearing conservation program. For all
individuals, appropriate hearing protection is provided for protection
against hazardous noise. Additionally, the whole of Camp Sather is
within 300 yards of an extremely active flightline.
2. Heat Stress: Daily temperature range: Mar - Oct from 75 F to 125 F;
Nov - Feb from 55 F to 95 F. Personnel are continually educated on heat
stress dangers, water intake and work/rest cycles. Unless separately
documented, individual had no heat related injury.
3. Airborne Exposure to Chemical Hazards: Unless specified in a duty-
specific supplement, individual exposure to chemical inhalation is
considered similar to duties performed at home station. On base
industrial activities include routine aircraft, equipment and
installation maintenance. Generally, majority of the chemicals used on
BDAB are oils, greases, lubricants, hydraulic fluids and fuel. Little
to no corrosion control activities are performed and no solvent tanks
exist on site. No industrial activity is performed that generates, or
has been expected to generate, airborne exposures above permissible
exposure levels or medical action levels.
4. Chemical Contact and Eye Protection: Unless specified in a job-
specific supplement, individual exposure to chemical contact is
considered similar to duties performed at home station. Workers are
provided appropriate protective equipment (i.e. nitrile/rubber gloves,
goggles, safety glasses and face shields) when and where needed.
5. Radiation: Ionizing radiation is emitted from medical/dental x-ray
and OSI operations, and low-level radioactive materials present in
equipment such as chemical agent monitors and alarms. No worker has
been identified as exceeding 10% of the 5 REM/year OS HA permissible
exposure level. Radio frequency (RF) radiation is emitted from multiple
radar systems and communication equipment. Systems are marked with
warning signs and communication workers receive appropriate training.
Unless otherwise documented, no worker has been identified as exceeding
RF-radiation permissible exposure limits. Significant UV radiation from
the sun is expected on exposed unprotected skin. BDAB personnel have
been advised to minimize sun exposure through the use of sunscreen and
wear of sleeves down. Additionally, BDAB is a high light level
environment. Many cases of photosensitivity dermatitis were observed.
Some were no doubt exacerbated by the use of doxycycline for malaria
prophylaxis. Unless otherwise stated in medical record, individual
reported no radiation/light related injuries.
6. Ergonomics: Individual exposure to ergonomic stress from job related
duty is substantially similar to duties performed at home station, with
potential moderate increase in lifting involved with unique deployment
requirements such as erection of tents and shelters. Unless otherwise
stated in medical record, individual reported no ergonomic stress
related injuries.
7. Bloodborne Pathogens: Individual exposure to bloodborne pathogens
from job related duty is considered similar to duties performed at home
station. Applicable workers are provided appropriate protective
equipment and have been placed on the bloodborne pathogen program.
Unless otherwise stated elsewhere in the medical record, individual
reported no significant unprotected exposures.
//SIGNED//:
HOSPITAL OR MEDIAL FACILITY: 447 EMEDS, Baghdad Air Base Iraq:
RELATIONSHIP TO SPONSOR: Self:
PATIENT S IDENTIFICATION: (For typed or written entries, give: Name
last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDICAL CARE:
Medical Record:
STANDARD FORM 600 (REV. 6-97) Prescribed by GSAHCMR:
FIRMR (41 CFR) 201-9.202-1:
STANDARD FORM 600 (REV. 6-97) BACK:
[End of section]
FOOTNOTES
[1] The Chairman of the Joint Chiefs of Staff is the principal military
adviser to the President, the National Security Council, and the
Secretary of Defense.
[2] The Navy supports OEHS activities for the Marine Corps.
[3] Harmful levels of environmental contaminants are determined by the
concentration of the substance and the duration of exposure.
[4] Presidential Review Directive/National Science and Technology
Council - 5 (April 21, 1997). The National Science and Technology
Council is a cabinet-level council that helps coordinate federal
science, space, and technology research and development for the
president.
[5] National Defense Authorization Act for Fiscal Year 1998. Pub. L.
No. 105-85, §768, 111 Stat. 1629, 1828 (1997) ("Sense of Congress").
[6] The working group makes recommendations for deployment OEHS policy
to the Deputy Assistant Secretary of Defense for Force Health
Protection and Readiness, who serves as the director of DHSD.
[7] Each military service has preventive medicine units, though they
may be named differently. Throughout this report, we use the term
preventive medicine unit to apply to the units fielded by all military
services.
[8] While in the deployment location, preventive medicine units create
and store reports both electronically and on paper.
[9] Some bases can have more than one baseline report.
[10] DOD officials said the analysis of servicemembers' responses to a
post-deployment health assessment questionnaire is another means to
identify potential exposures that should be investigated. These
assessments, designed to identify health issues or concerns that may
require medical attention, use a questionnaire that is to be completed
in theater and asks servicemembers if they believe they have been
exposed to a hazardous agent.
[11] Throughout the testimony we refer to both base camps and forward
operating bases collectively as bases. A forward operating base is
usually smaller than a base camp in troop strength and infrastructure
and is normally constructed for short-duration occupation.
[12] The command surgeons of deployed preventive medicine units are
either Joint Task Force command surgeons or military service component
command surgeons. In OIF, there are two Joint Task Forces, each with a
command surgeon. In addition, the Army, Navy, Air Force, and Marine
Corps have their own subordinate component commands in a deployment,
each with a command surgeon.
[13] DOD has designated CHPPM as the entity responsible for archiving
all OEHS reports from deployments.
[14] DOD policy does not prescribe a time frame for how long preventive
medicine units have to complete a report.
[15] CHPPM also receives some deployment OEHS data that have not been
incorporated into a report, such as tables of water sampling
measurements.
[16] The U.S. Central Command is the combatant command responsible for
all OIF operations.
[17] Along with deployment OEHS reports, commanders also examine
medical intelligence, operational data, and medical surveillance (such
as reports of servicemembers seen by medical units for injury or
illness) to identify occupational and environmental health hazards.
[18] Examples of health encounter data are medical records of in-
patient and out-patient care, health assessments completed by
servicemembers before and after a deployment, and blood serum samples.
[19] OEHS standards generally set out technical requirements for
monitoring, including the type of equipment needed and the appropriate
frequency of monitoring.
[20] This standard was approved in October 2003.
[21] Incident-driven reports reflect OEHS investigation of unexpected
incidents and would not be submitted to CHPPM's archive according to
any identified pattern. Therefore, we did not comment on the services'
submission of incident-driven reports.
[22] The U.S. Central Command has established and closed bases
throughout the OIF deployment; therefore, the number of bases for each
summary report varied.
[23] A base may have had both baseline and routine reports submitted to
the OEHS archive.
[24] DOD officials said that during a deployment, preventive medicine
units share the military's classified communication system with all
other deployed units and transmission of OEHS reports might be a lower
priority than other mission communications traffic. Also, preventive
medicine units might not deploy with communications equipment.
[25] OEHS risk management activities began to be employed during
previous deployments, such as Operation Joint Guardian in Kosovo and
Operation Enduring Freedom in Central Asia, but it was not formally
adopted as a tool to assess deployment health hazards until 2002. See
Office of the Chairman, The Joint Chiefs of Staff, Memorandum MCM-0006-
02, "Updated Procedures for Deployment Health Surveillance and
Readiness," Feb. 1, 2002.
[26] An Army operational risk management field manual describes the
steps in determining risk level, including identifying the hazard,
assessing the severity of the hazard, and determining the probability
that the hazard will occur. DOD has also developed technical guides
that detail toxicity thresholds and associated potential health effects
from exposure to hazards.
[27] Risk assessments can designate identified occupational or
environmental health risks as posing a low, moderate, high, or
extremely high risk to servicemembers.
[28] Individuals desiring to review classified documents must have the
appropriate level of security clearance and a need to access the
information. VA officials have been able to access some OEHS data on a
case-by-case basis.
[29] Pub. L. No. 108-375, §735, 118 Stat. 1811, 1999 (2004).
[30] GAO, Defense Health Care: Medical Surveillance Improved Since Gulf
War, but Mixed Results in Bosnia, GAO/NSIAD-97-136 (Washington D.C.:
May 13, 1997).
[31] DOD policy requires the Defense Manpower Data Center to maintain a
system that collects information on deployed forces, including daily-
deployed strength, in total and by unit; grid coordinate locations for
each unit (company size and larger); and inclusive dates of individual
servicemembers' deployment. See DOD Instruction 6490.3, "Implementation
and Application of Joint Medical Surveillance for Deployment," Aug. 7,
1997. In addition, a 2002 DOD policy requires combatant commands to
provide the Defense Manpower Data Center with rosters of all deployed
personnel, their unit assignments, and the unit's geographic locations
while deployed. See Office of the Chairman, The Joint Chiefs of Staff,
Memorandum MCM-0006-02, "Updated Procedures for Deployment Health
Surveillance and Readiness," February 1, 2002.
[32] The military services submitted location data for both OIF and
Operation Enduring Freedom in Central Asia; Defense Manpower Data
Center officials said they were unable to separate the data from the
two operations.
[33] DOD Instruction 6490.3, "Implementation and Application of Joint
Medical Surveillance for Deployment," Aug. 7, 1997.
[34] GAO, Gulf War Illnesses: Federal Research Strategy Needs
Reexamination, GAO/T-NSIAD-98-104 (Washington D.C.: Feb. 24, 1998).
[35] The Deployment Health Working Group includes representatives from
DOD, VA, and HHS.
[36] This effort also includes identifying research for Operation
Enduring Freedom.
[37] Epidemiologic studies generally have a fixed study population that
does not vary over time, according to VA officials.