oversight

Defense Infrastructure: DOD Can Improve Its Response to Environmental Exposures on Military Installations

Published by the Government Accountability Office on 2012-05-01.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

             United States Government Accountability Office

GAO          Report to Congressional Committees




May 2012
             DEFENSE
             INFRASTRUCTURE
             DOD Can Improve Its
             Response to
             Environmental
             Exposures on Military
             Installations




GAO-12-412
                                             May 2012

                                             DEFENSE INFRASTRUCTURE
                                             DOD Can Improve Its Response to Environmental
                                             Exposures on Military Installations
Highlights of GAO-12-412, a report to
congressional committees




Why GAO Did This Study                       What GAO Found
There have been various reported             DOD relies on four types of policies to identify and respond to many but not all
incidents of individuals being               aspects of environmental exposures: (1) environmental restoration policies
potentially exposed to environmental         address hazardous releases at military Installations; (2) occupational and
hazards while on military installations.     environmental health policies address workplace exposures; (3) deployment
Indeed, some incidents, such as              health policies address the collection of occupational and environmental health
contaminated air due to burn pits in         data for deployed individuals; and (4) public health emergency management
Afghanistan and Iraq and                     policies. Nonetheless, there are some limitations in the policies’ coverage. For
contaminated water at Camp Lejeune,          example, DOD’s environmental restoration policies do not specify when to
North Carolina, have received
                                             conduct public health assessments at its sites beyond the initial assessment of
considerable attention, and in the case
                                             certain priority sites required by the Superfund law. In addition, DOD has not fully
of Camp Lejeune have resulted in
claims seeking billions of dollars from
                                             documented its responses to recommendations that result from the
the government.                              assessments. DOD officials responsible for oversight reported that they did not
                                             know what actions, if any, installations had taken on about 80 percent of the
Public Law 111-383, §314(2011)               recommendations. Without a comprehensive tracking system, DOD has no
directed GAO to assess Department of         assurance that it is addressing recommendations appropriately and could be
Defense (DOD) policies regarding             missing opportunities to identify and resolve concerns about some health threats.
environmental exposures. GAO’s               Further, DOD has no policy guiding services and their installations on appropriate
objectives were to determine (1) the         actions to address health risks from past exposures, which DOD attributes to the
extent to which DOD has policies that        Superfund law not specifically requiring responsible parties to address such risks.
identify and respond to environmental
exposures, (2) what programs exist to
                                             Although several programs potentially provide either health care or compensation
provide health care or compensation to
individuals for environmental                to various types of individuals suffering from environmental exposures, the ability
exposures, and (3) which features of         of some individuals to actually obtain benefits—particularly compensation—is
other federal programs may provide           often complicated by documentary, scientific, and legal factors. First, it is often
options in designing future                  difficult to document an environmental exposure because they are often not
compensation programs. GAO briefed           always identified at the time they occurred. Second, it is often difficult to establish
the Armed Services Committees in             causation between an environmental exposure and a health condition, because
December 2011, to satisfy the                scientific research has not always established a clear link. Third, although under
mandate. To address these objectives,        certain circumstances some individuals have legal standing under the Federal
GAO reviewed relevant                        Tort Claims Act to file a lawsuit against the U.S. government for damages due to
documentation, visited installations,        an environmental exposure, damages under the Federal Tort Claims Act are not
and interviewed relevant officials.          available to other types of individuals, and for certain types of claims due to legal
                                             precedent or statutes.
What GAO Recommends
GAO is making recommendations to             In several cases, Congress has established alternative programs to provide
DOD to identify and respond to               compensation to specific populations exposed to specific environmental hazards,
limitations in its policies for responding   such as for individuals involved in the production of nuclear weapons and those
to environmental exposures. DOD              who worked in coal mines. Agency officials in charge of managing these
generally disagreed with GAO’s               alternative programs told us that certain features of these programs have proven
recommendations, commenting that             to be beneficial to both claimants and administrators and should be considered
current policies are adequate. GAO           for inclusion if any future programs are established to compensate individuals for
believes the recommendations remain          environmental exposures on military installations. For example, Department of
valid, as discussed in the report.           Labor and Department of Justice officials told GAO a compensation program that
                                             resolves claims in a nonadversarial manner and provides outreach to potential
                                             claimants is more beneficial to both claimants and administrators. In contrast, a
View GAO-12-412. For more information,
contact Brian Lepore at (202) 512-4523 or
                                             more adversarial with limited claimant assistance usually leads to delays and
LeporeB@gao.gov and David Trimble at (202)   increased cost for both claimants and the agency adjudicating claims.
512-9338 or TrimbleD@gao.gov.
                                                                                       United States Government Accountability Office
Contents


Letter                                                                                       1
               Background                                                                    5
               DOD Has Policies for Identifying and Responding to Environmental
                 Exposures but They Have Limitations                                         9
               Several Programs May Provide Health Care or Compensation for
                 Environmental Exposures but Access May Be Affected by
                 Various Factors                                                           23
               Certain Features of Alternative Programs for Compensation
                 Established for Specific Environmental Exposures May Provide
                 Potential Options for Future Programs                                     34
               Conclusions                                                                 44
               Recommendations for Executive Action                                        45
               Agency Comments and Our Evaluation                                          45

Appendix I     Objectives, Scope, and Methodology                                          51



Appendix II    Selected Contaminants That Have Been Found on Some Military
               Installations and Their Effect on Humans                                    54



Appendix III   Significant Health Studies and Notification Efforts Related to
               Contamination at Marine Corps Base Camp Lejeune                             56



Appendix IV    Comments from the Department of Defense                                     57



Appendix V     Comments from the Department of Veterans Affairs                            61



Appendix VI    Comments from Department of Health and Human Services                       62



Appendix VII   GAO Contacts and Staff Acknowledgments                                      64




               Page i                                         GAO-12-412 Defense Infrastructure
Related GAO Products                                                                                             65



Table
                       Table 1: Examples of Selected Data Collection Efforts during
                                Phases of Deployment                                                             14


Figure
                       Figure 1: Four Types of Policies That Address Environmental
                                Exposures                                                                        10




                       Abbreviation

                       DOD               Department of Defense



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                       Page ii                                                 GAO-12-412 Defense Infrastructure
United States Government Accountability Office
Washington, DC 20548




                                   May 1, 2012

                                   The Honorable Carl Levin
                                   Chairman
                                   The Honorable John McCain
                                   Ranking Member
                                   Committee on Armed Services
                                   United States Senate

                                   The Honorable Howard P. “Buck” McKeon
                                   Chairman
                                   The Honorable Adam Smith
                                   Ranking Member
                                   Committee on Armed Services
                                   House of Representatives

                                   Over the years, there have been various reported incidents of active and
                                   former members of the Armed Forces, their dependents, federal
                                   contractors, and civilian employees being exposed to environmental
                                   hazards, 1 such as contaminated air and water, while living and working
                                   on military installations 2 or while deployed on contingency operations. 3


                                   1
                                     For the purpose of this report, an environmental hazard includes, among other things,
                                   the release or occurrence of a contaminant in the environment including the air, water,
                                   and land. Exposures to contaminants occur when humans have skin contact, inhale, or
                                   ingest (such as in drinking water) such contaminants at a threshold of toxicity that can
                                   potentially cause an adverse health condition. These hazards also include environmental
                                   conditions, such as those in occupational settings that may be harmful to humans.
                                   Whether or not an exposure is harmful may depend, in part, on the dose delivered to
                                   individuals and their susceptibility to it.
                                   2
                                     Section 2687 of Title 10 of the United States Code defines military installation, for the
                                   purpose of certain base realignments and closures as a base, camp, post, station, yard,
                                   center, homeport facility for any ship, or other activity under the jurisdiction of the
                                   Department of Defense, including any leased facility. Such term does not include any
                                   facility used primarily for civil works, rivers and harbors projects, flood control, or other
                                   projects not under the primary jurisdiction or control of the Department of Defense.
                                   3
                                     Under 10 U.S.C. §101(13), the term “contingency operation” means a military operation
                                   that is designated by the Secretary of Defense as an operation in which members of the
                                   armed forces are or may become involved in military actions, operations, or hostilities
                                   against an enemy of the United States or against an opposing military force or results in
                                   the call or order to, or retention of, active duty of members of the uniformed services under
                                   certain sections of Title 10 or any other provision of law during a war or during a national
                                   emergency declared by the President or Congress.




                                   Page 1                                                     GAO-12-412 Defense Infrastructure
Several incidents in particular—contaminated air at Naval Air Facility
Atsugi, Japan; contaminated air due to open burn pits in Afghanistan and
Iraq; and contaminated water at Camp Lejeune, North Carolina—have
recently garnered considerable congressional, public, and media
attention. At Naval Air Facility Atsugi, an off-base incinerator released
toxic fumes that drifted over the installation. The Department of Veterans
Affairs estimates that, from 1985 through 2001, over 25,000 individuals
on the installation could have been exposed to air contaminants.
Similarly, since the start of military operations in Afghanistan and Iraq, the
U.S. military and its contractors have burned solid waste, including
plastics, electronics, and appliances, in open burn pits on or near military
bases. These burn pits have produced smoke and harmful emissions that
military and other health professionals believe may cause acute and
chronic health effects. Moreover, at Camp Lejeune in the early 1980s,
volatile organic compounds were discovered in some water systems
serving installation housing areas. Exposure to certain volatile organic
compounds increases the risk of adverse health effects, including cancer.
The Congressional Budget Office estimates that 650,000 individuals were
stationed at Camp Lejeune at some point during the contamination
period, which lasted about 30 years, and officials at the Agency for Toxic
Substances and Disease Registry estimate that up to one million
individuals could have been exposed. According to the Navy, some
former residents and individuals who worked on Camp Lejeune have
recently filed administrative claims against the U.S. government totaling
billions of dollars in potential damages for health conditions alleged to
have resulted from exposure to the contaminated water. However, the
Department of Defense’s (DOD) response in identifying, studying,
addressing, and communicating these three environmental hazards has
raised congressional concerns in general about how DOD responds to
possible individual exposures to environmental hazards on its
installations. Congress has also expressed interest regarding how the
U.S. government provides compensation and medical benefits for those
who may have suffered adverse health effects from their exposure to
such hazards.

Section 314 of the Ike Skelton National Defense Authorization Act for
Fiscal Year 2011 set out a number of congressional findings related to
military environmental exposures and directed GAO to conduct an
assessment of possible exposures of individuals to environmental




Page 2                                          GAO-12-412 Defense Infrastructure
hazards while living and working on military installations. 4 In response to
that mandate, our objectives were to determine (1) the extent to which
DOD has policies for identifying and responding to possible human
exposures to environmental hazards on its installations, (2) what
programs currently exist to provide health care and compensation to
individuals for health conditions resulting from environmental exposures
on military installations and any factors that may affect how these
individuals obtain access to health care or compensation, and (3) what
features of alternative federal programs that provide medical benefits or
compensation to large groups of individuals affected by a specific
environmental exposure may be considered as possible options in the
design of any future programs for individuals harmed by environmental
hazards. To satisfy the mandate, we provided a briefing to the House and
Senate Armed Services Committees in December 2011. This report
provides additional information on the topics addressed in response to
that mandate.

To determine the processes DOD has in place for identifying and
responding to possible exposures to environmental hazards we reviewed
and analyzed relevant laws as well as guidance from DOD, the
Environmental Protection Agency, and the Agency for Toxic Substance
and Disease Registry. In conducting this analysis we conducted content
searches of DOD guidance documents to determine the extent to which
they addressed environmental exposures on military installations and
conducted a literature search to determine if there were any best
practices in responding to environmental exposures. We also examined
the database used to track the Agency for Toxic Substance and Disease
Registry public health assessment recommendations and DOD’s



4
  Specifically, GAO was directed to report on (1) An identification of the policies and
processes by which the Department of Defense and the military departments respond to
environmental hazards on military installations and possible exposures and determine if
there is a standard framework. (2) An identification of the existing processes available to
current and former members of the Armed Forces, their dependents, and civilian
employees to seek compensation and health benefits for exposures to environmental
hazards on military installations. (3) A comparison of the processes identified under
paragraph (2) with other potential options or methods for providing health benefits or
compensation to individuals for injuries that may have resulted from environmental
hazards on military installations. (4) An examination of what is known about the
advantages and disadvantages of other potential options or methods as well as any
shortfalls in the current processes. (5) Recommendations for any administrative or
legislative action that the Comptroller General deems appropriate in the context of the
assessment.




Page 3                                                    GAO-12-412 Defense Infrastructure
implementation of those recommendations. In addition, we interviewed
DOD officials at the Office of the Secretary of Defense and the various
components, the Environmental Protection Agency, the National
Research Council, Agency for Toxic Substance and Disease Registry,
and some members of the Agency for Toxic Substance and Disease
Registry’s Community Assistance Panel for Camp Lejeune. We also
conducted site visits to Camp Lejeune, North Carolina and Aberdeen
Proving Ground, Maryland where the Army Public Health Command, as
DOD’s Executive Agent for interaction with the Agency of Toxic
Substances and Disease Registry, has its offices. To determine the
programs that currently exist within the federal government to provide
health benefits and compensation to individuals, we obtained, reviewed,
and analyzed relevant laws and regulations, agency guidance, and other
documentation to identify the eligibility requirements and determination
procedures and extent of compensation and medical benefits provided
through various processes currently available to different types of
individuals possibly exposed to environmental hazards while working or
living on military installations. We also interviewed officials from DOD,
Department of Veterans Affairs, Department of Labor, Department of
Justice, and officials from each of the Army, Navy, and Air Force Judge
Advocate Offices. To determine the features of alternative federal
programs that provide medical benefits and monetary compensation we
reviewed and analyzed relevant laws and regulations, agency guidance,
external studies, previous GAO reports, and other documentation to
identify other comparable federal programs that provide medical benefits
and monetary compensation to large groups of individuals that have been
exposed to a specific environmental hazard. Through discussions with
Departments of Veterans Affairs, Labor, Justice, and other federal agency
officials who administer these programs, we identified the key features
associated with each program and any challenges and lessons learned
among the different features of these programs.

We conducted this performance audit between May 2011 and May 2012,
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives. (See app. I for more
information on our scope and methodology.)




Page 4                                       GAO-12-412 Defense Infrastructure
Background
Some Federal Laws       Various environmental laws govern the identification, study, and cleanup
Requiring Cleanup of    of environmental contamination at military installations. 5 Under a key law,
DOD’s Hazardous Waste   a public health agency has responsibilities for assessing the presence
                        and nature of health hazards at certain DOD sites, among other items. In
Include Mechanisms to
                        addition, statutes also specify DOD responsibilities for cleanup of its
Consider Exposures      contaminated sites. These are described below:

                        •   Comprehensive Environmental Response, Compensation, and
                            Liability Act: Better known as “Superfund,” the 1980 act established,
                            among other things, government authorities to respond to actual and
                            threatened releases of hazardous substances, pollutants, and
                            contaminants that may endanger public health and the environment. 6
                            DOD uses its own environmental restoration appropriations to finance
                            its cleanups. 7 The Environmental Protection Agency places some of
                            the most seriously contaminated sites on the National Priorities List;
                            141 DOD installations are currently on this list. The Comprehensive
                            Environmental Response, Compensation, and Liability Act also
                            authorized the establishment of the Agency for Toxic Substances and
                            Disease Registry in the Department of Health and Human Services to
                            assess the presence and nature of health hazards to communities
                            affected by Superfund sites, to inform actions to prevent or reduce
                            harmful exposures, and to expand the knowledge base about the
                            health effects that result from exposure to hazardous substances.
                            •    The Agency for Toxic Substances and Disease Registry: The
                                 Agency for Toxic Substances and Disease Registry is to conduct
                                 a health assessment of each site listed on the National Priorities
                                 List. These health assessments may result in recommendations


                        5
                          Generally, the federal environmental laws described here apply to DOD facilities within
                        the United States and its territories.
                        6
                          Pursuant to the Comprehensive Environmental Response, Compensation, and Liability
                        Act, the National Priorities List is a list of priority hazardous waste sites for attention under
                        the federal Superfund program. Environmental Protection Agency places sites on the
                        National Priorities List using criteria and a process established in regulations. Hazardous
                        waste sites that are not placed on the National Priorities List may be referred to as non-
                        National Priorities List sites.
                        7
                         While Congress established a trust fund to pay for, among other things, remedial actions
                        at nonfederal National Priorities List sites, the fund is not available for federal sites.




                        Page 5                                                       GAO-12-412 Defense Infrastructure
           from the Agency for Toxic Substances and Disease Registry to
           the agency responsible for the site and may include actions for
           reducing the public health risk or requests for additional data or
           analysis. The Agency for Toxic Substances and Disease Registry
           relies on records and data gathered by DOD and the
           Environmental Protection Agency for the assessments. 8 With
           respect to toxic substance exposures, the agency is to maintain
           current research and literature on the health effects of toxic
           substances and prepare toxicological profiles, and, in cooperation
           with states, establish and maintain a national registry of serious
           diseases and illnesses and a national registry of persons exposed
           to toxic substances, among other things. 9
•     Superfund Amendments and Reauthorization Act: In 1986, the
      Superfund Amendments and Reauthorization Act added provisions to
      the Comprehensive Environmental Response, Compensation, and
      Liability Act, specifically governing the cleanup of federal facilities. 10
      These provisions also require the Secretary of Defense and the
      Secretary of Health and Human Services to enter into a memorandum
      of understanding regarding the manner in which DOD will support
      certain activities to be conducted by the Agency for Toxic Substances
      and Disease Registry, including the manner for transferring funds and
      personnel and for coordination of activities. 11 Under these provisions,
      a preliminary site assessment is to be completed by the responsible
      agency for each property where the agency has reported generation,
      storage, treatment, or disposal of hazardous waste. This preliminary
      assessment is reviewed by the Environmental Protection Agency,
      together with additional information, to determine whether the site
      poses a threat to human health and the environment or requires
      further investigation or assessment for potential inclusion on the
      National Priorities List.



8
  The working relationship between DOD and the Agency for Toxic Substances and
Disease Registry is established in a memorandum of understanding between the two
agencies and they jointly develop annual work plans which require that DOD fund the
Agency for Toxic Substances and Disease Registry’s efforts on DOD’s behalf. The
Department of the Navy has also established a separate memorandum of understanding
with the Agency for Toxic Substances and Disease registry for Camp Lejeune.
9
    42 U.S.C. § 9604(i) (2012).
10
     Pub. L. No. 99-499 §120(a) (1986), codified at 42 U.S.C. § 9620 (2012).
11
     10 U.S.C. § 2704(c) (2012).




Page 6                                                    GAO-12-412 Defense Infrastructure
                             •     Defense Environmental Restoration Program: Section 211 of the
                                   Superfund Amendments and Reauthorization Act established DOD’s
                                   Defense Environmental Restoration Program, providing legal authority
                                   and responsibility to DOD for cleanup activities at DOD installations
                                   and properties, including former defense sites 12 in the United States
                                   and territories. DOD conducts cleanup activities under the Defense
                                   Environmental Restoration Program at its sites listed on the National
                                   Priorities List, as well as sites that are not. Among other things, the
                                   Defense Environmental Restoration Program provisions require the
                                   Secretary of Defense to take necessary actions to ensure that the
                                   Environmental Protection Agency and state authorities receive prompt
                                   notice of the discovery of a release or threatened release, the
                                   associated extent of the threat to public health and the environment,
                                   proposals to respond to such release, and initiation of any response. 13
                                   Specifically, when DOD identifies releases or threatened releases of
                                   hazardous substances, it is to notify the Environmental Protection
                                   Agency. These provisions also require the Secretary of Defense and
                                   the Secretary of Health and Human Services to enter into a
                                   memorandum of understanding regarding the manner in which DOD
                                   will support certain activities to be conducted by the Agency for Toxic
                                   Substances and Disease Registry, including the manner for
                                   transferring funds and personnel and for coordination of activities. 14


Contaminants on Military     Military installations are the site of various mission activities such as
Installations and Pathways   specialized operations and maintenance of equipment, as well as
to Human Exposure            resembling “small cities” featuring offices, housing, water and wastewater
                             systems, and solid and hazardous waste facilities. In some cases, these
                             installations and surrounding areas became contaminated due to past
                             storage and disposal practices for substances such as solvents,
                             machining oils, metalworking fluids, and metals. Many of these
                             contaminants, such as trichloroethylene, perchloroethylene, and vinyl
                             chloride, are known or suspected carcinogens. On some installations,
                             these contaminants have spread beyond their points of origin because


                             12
                                Formerly used defense sites are located on properties that were under the jurisdiction
                             of DOD and owned by, leased to, or otherwise possessed by the United States prior to
                             October 17, 1986, but have since been transferred to states, local governments, other
                             federal entities, or private parties. See 10 U.S.C. § 2701(c)(1)(B) (2010).
                             13
                                  10 U.S.C. § 2705(a) (2010) (“Expedited notice”).
                             14
                                  10 U.S.C. § 2704(c) (2012).




                             Page 7                                                  GAO-12-412 Defense Infrastructure
they have been transported by wind currents or have entered ground
water, resulting in potential environmental exposures.

An environmental exposure is quantified by estimating the amount (how
much), duration (how long), and frequency (how often) of an individual’s
exposure to a dose of a contaminant. The dose is a primary factor in
whether the exposure may result in harm to the individual. Doses below
health standards generally do not result in harm to the exposed
individuals. For environmental exposures the routes of exposure are:
(1) ingestion—for solids and liquids; (2) inhalation—for gases and
particulates; and (3) skin contact—for all types of agents. Some
contaminants can cause harm at the site of exposure—for example, the
lungs or skin—and some cause effects only after they have been
absorbed into the blood stream and carried throughout the body. In their
travel through the body, they have the potential to affect various organs in
the body—such as lungs, liver, kidneys, heart, and brain. Appendix II
contains a description of some of the contaminants found on military
installations and their effects on humans.




Page 8                                         GAO-12-412 Defense Infrastructure
                       DOD has four types of policies to address aspects of environmental
DOD Has Policies for   exposure: (1) environmental restoration policies that require the services
Identifying and        to identify and respond to hazardous releases at military installations,
                       (2) occupational and environmental health policies that require the
Responding to          services to identify and respond to unsafe or unhealthy activities in DOD
Environmental          workplaces, (3) deployment health policies that require the services to
Exposures but They     collect and analyze occupational and environmental health data for
                       individuals deployed in military operations in order to help identify
Have Limitations       environmental exposures, and (4) public health emergency management
                       policies that establish general guidance for responding to specific
                       situations (see fig. 1). Limitations in DOD’s environmental restoration
                       policies may hinder DOD’s ability to identify and respond to all
                       environmental exposures. 15 DOD recently updated a directive that
                       complements these policies by including servicemembers’ dependents in
                       its system for collecting, analyzing and interpreting health-related data—
                       called the health surveillance data system—when associated with a
                       public health event such as a disease outbreak or widespread exposure
                       incident. 16




                       15
                          DOD has other policies that identify responsibilities and procedures for remediation of
                       environmental contamination on overseas installations or facilities or caused by DOD
                       operations. The policies are focused on remedies for “known imminent and substantial
                       endangerments to human health and safety” and any applicable country-specific policy or
                       international agreement, and are silent as to assessments of health risk from exposures.
                       See DOD Instruction 4715.8 (1998), Deputy Secretary of Defense Memorandum,
                       "Environmental Remediation Policy for DOD Activities Overseas," October 18, 1995.
                       16
                          DOD Directive 6490.02E, Comprehensive Health Surveillance, Feb. 8, 2012. The
                       revised directive defines health surveillance as the regular or repeated collection, analysis,
                       and interpretation of health-related data to monitor the health of a population and to
                       identify potential health risks. The purpose is to enable timely intervention to prevent,
                       treat, or control disease and injury. The health surveillance system is not exclusively
                       focused on health issues related to environmental exposure. It also includes data on
                       occupational (work-related) health and medical surveillance of health-related data in the
                       military health system’s electronic medical records.




                       Page 9                                                    GAO-12-412 Defense Infrastructure
Figure 1: Four Types of Policies That Address Environmental Exposures




DOD’s Environmental                    Policies under the Defense Environmental Restoration Program,
Restoration Policies                   established by Section 211 of the 1986 Superfund amendments, require
Require the Services to                the services to identify and respond to hazardous releases at military
                                       installations and offer a structure for cleanup. Under the Defense
Identify and Respond to                Environmental Restoration Program, the services are required to identify
Hazardous Releases at                  relative risks to human health and the environment from contaminated
Domestic Military
Installations


                                       Page 10                                      GAO-12-412 Defense Infrastructure
sites––those areas with releases or threatened releases of hazardous
substances. Because there have been thousands of contaminated sites
on DOD properties, DOD prioritizes these sites for funding based on,
among other things, whether a site presently poses a risk to human
health. Within this program, DOD may conduct one or more response
actions, such as investigation and cleanup of contamination from
hazardous substances, pollutants, and contaminants, and demolition and
removal of unsafe buildings and structures. The sidebar illustrates DOD’s
approach to a hazardous release at a military installation.




Page 11                                       GAO-12-412 Defense Infrastructure
DOD’s Occupational and     DOD’s Occupational and Environmental Health policies require the
Environmental Health       services to identify and respond to unsafe or unhealthy working
Policies Require the       conditions at military installations in the United States and abroad. The
                           policies apply to DOD military and civilian personnel in any DOD
Services to Identify and   workplace and certain contractors deployed with DOD. 17, 18 Accordingly,
Respond to Unsafe or       the services are responsible for establishing and publicizing programs
Unhealthy Working          that encourage personnel to identify and promptly report to supervisors
Conditions at Military     situations of imminent danger. In addition, according to these policies, the
Installations              services must conduct surveys of workplaces to identify potential
                           exposures and other worker safety and health risks, and establish
                           workplace exposure profiles. They may also conduct periodic
                           assessments to identify worksite environmental hazards.

                           DOD’s Occupational and Environmental Health policies also require the
                           monitoring of workers exposed to hazards to identify work-related health
                           problems and the collection of workplace hazards data to identify trends
                           that may require intervention. The monitoring may include baseline
                           medical examinations, periodic physical examinations, and clinical and
                           biological screening. DOD’s manual on occupational medical
                           examinations also suggests ancillary tests or biological monitoring to
                           evaluate health issues such as blood, liver, renal, and pulmonary
                           functions, and hearing loss. 19 These tests seek to detect the biological
                           effects of potentially serious exposures before the occurrence of clinical
                           illness, at a point where intervention or treatment can decrease the
                           severity of disease or limit disability and rehabilitation. Workers must be
                           informed of the results of their occupational medical examinations as
                           soon as possible following completion and are encouraged to alert a
                           supervisor if they are concerned about a workplace hazard. When data


                           17
                              DOD Instruction 6055.05 Occupation and Environmental Health (Nov. 11, 2008). While
                           the instruction primarily covers DOD personnel in work settings, another stated purpose is
                           to provide additional guidance to DOD Directive 4715.1E, Environment, Safety and
                           Occupational Health (Mar. 19, 2005), to protect DOD personnel from accidents and
                           occupational illness and the public from risk of death, injury, illness, or property damage
                           because of DOD activities, among other objectives. With respect to protection of the
                           public, the instruction does not specifically address any risky conditions or activities
                           occurring outside of the workplace.
                           18
                              The policy generally applies to contractor personnel deployed with the force. According
                           to DOD, even in such situations, if contracts do not specify that DOD is responsible
                           contractors are responsible for their personnel.
                           19
                             DOD Manual 6055.05-M, Occupational Medical Examinations and Surveillance Manual
                           (May 2, 2007).




                           Page 12                                                  GAO-12-412 Defense Infrastructure
                            suggest that an occupational environmental hazard exists, DOD’s
                            occupational and environmental health policies call for the development
                            of appropriate targeted intervention programs to reduce the occurrence of
                            occupational injury and illness. The sidebar illustrates the use of this type
                            of policy in a workplace condition.




DOD’s Deployment Health     DOD’s deployment health policies require the services to regularly collect
Policies Require the        and report a variety of data for deployed individuals to identify and
Services to Collect and     respond to health threats they may have encountered during
                            deployments. These policies apply to servicemembers, DOD civilian
Analyze Data on             employees, and, depending on the contract, deployed DOD contractor
Individuals in Deployment   personnel. 20 These individuals may be subject to hazards that can include
Settings                    exposure to harmful levels of contaminants such as industrial toxic
                            chemicals, chemical and biological warfare agents, and radiological and
                            nuclear contaminants. Since harmful levels of exposure can result in
                            immediate health effects or delayed or long-term health effects, the
                            policies establish a system whereby DOD gathers and reports a variety of
                            data on its servicemembers and civilian employees and examines the
                            data over time to address specific exposure-related questions. DOD




                            20
                              DOD contractor personnel are only included to the extent provided in the applicable
                            contracts, DOD Instruction 3020.41 (2005), or service policy.




                            Page 13                                                GAO-12-412 Defense Infrastructure
                                         established specific guidance for the services in 2006 and again in 2007
                                         that lay out data collection requirements. 21

                                         DOD collects three types of data: (1) occupational and environmental
                                         health surveillance data, including ambient air, water, and soil samples;
                                         (2) daily individual servicemember location data, such as the duty station;
                                         and (3) health outcome data, acquired from servicemember medical
                                         records. The Defense Occupational and Environmental Health Readiness
                                         System (DOEHRS) Environmental Health module was developed to
                                         capture data about existing environmental conditions in contingency
                                         operations—military operations in which members of the armed forces
                                         are involved in actions against an enemy of the United States or against
                                         an opposing military force. Table 1 provides examples of the types of data
                                         collected before, during, and after deployment.

Table 1: Examples of Selected Data Collection Efforts during Phases of Deployment

Deployment phase              Activity
Before deployment             •   Draw pre-deployment serum specimens for individual servicemembers.
                              •   Update medical records and deployment health records for individual servicemembers.
                              •   Conduct pre-deployment occupational and environmental health site assessments, including
                                  health risk assessments, of the deployment site.
During deployment             •   Conduct and validate health risk assessments of the deployment site.
                              •   Conduct occupational and environmental health site assessments of the deployment site.
                              •   Perform health surveillance activities to detect trends in the health of deployed personnel
                                  (includes biomonitoring, when required).
                              •   Document occupational and environmental health monitoring data summaries and file in
                                  servicemembers’ deployment health records.
                              •   Record servicemember location once daily and report out on a weekly basis.
Post-deployment               •   Complete post-deployment health assessments and reassessments of individual
                                  servicemembers.
                              •   Draw post-deployment serum samples for individual servicemembers.
                              •   Ensure all occupational and environmental health surveillance monitoring data and reports and
                                  health surveillance data and reports have been submitted.
                                         Source: DOD Instruction 6490.03.

                                         Note: The steps listed in this table are required for all deployments outside the continental United
                                         States greater than 30 days with non-fixed U.S. medical treatment facilities; for other deployments,
                                         the relevant commander determines which steps are required.




                                         21
                                           DOD Instruction 6490.03, Deployment Health (Aug.11, 2006); and Joint Staff
                                         Memorandum MCM-0028-07 (Nov. 2, 2007).




                                         Page 14                                                         GAO-12-412 Defense Infrastructure
The Armed Forces Health Surveillance Center regularly monitors the
health outcomes of both deployed and nondeployed servicemembers on
a population-wide basis for abnormal trends that may indicate an adverse
health outcome. In addition, it publishes a monthly report that reviews the
incidence of a variety of deployment-related conditions, such as traumatic
brain injury and motor vehicle accidents. The Millennium Cohort Study, an
ongoing health evaluation led by the Naval Health Research Center,
examines and issues reports on deployment-related health issues, for
example the effects of deployment on servicemembers’ respiratory
systems.

While DOD has made progress in identifying potential occupational and
environmental health hazards during deployments since the 1991 Gulf
War, technological challenges remain. Currently, DOD estimates
exposures using occupational and environmental health surveillance data
coupled with individuals’ once-daily location tracking information, but
cannot precisely determine exposure concentrations and durations that
provide individuals’ unique exposure profiles. According to DOD officials,
problems with collecting individual exposure data for all types of
environmental exposures could be addressed in some cases by the use
of certain dosimeters or exposure biomarkers, 22 but such technologies
have not been developed for all types of exposure hazards. DOD officials
reported that DOD has partnered with the National Institute for
Environmental Health Sciences and the National Research Council to
learn more about the potential use of these technologies. They also told
us that DOD is in the process of developing a personal dosimeter for
naphthalene––a fuel component that may be carcinogenic––which they
consider to be an important first step toward developing dosimeters for
other chemicals and health threats. In addition to the technological
limitations, DOD officials said there are logistical difficulties associated
with the implementation of individual sampling devices on deployed
personnel. The sidebar illustrates DOD’s data collection efforts and
challenges in Afghanistan and Iraq.




22
  Dosimeters are sensor devices that individuals wear to monitor real-time exposure to
hazardous materials. Biomarkers of exposure consist of antibodies, metabolites, or the
parent compound itself (or its metabolic products), present in biological fluids or tissues.
Biomarkers of exposure indicate that the hazardous agents in the environment actually
entered into the body (pathway completion) resulting in an exposure to that individual.




Page 15                                                    GAO-12-412 Defense Infrastructure
DOD’s Policy on Public   DOD’s Public Health Emergency Management policy establishes
Health Emergency         guidance for the services in responding to public health emergencies,
Management Establishes   such as natural disasters or nuclear attacks, to protect installations,
                         facilities, and personnel—including military and civilian personnel,
General Guidance and     dependents of military and civilian personnel, contractors, and other
References Additional    individuals visiting installations that are located either in or outside of the
Documents for More       United States. 23 While DOD officials told us the policy does not specify
Specific Guidance        what steps should be taken immediately following an emergency, it does
                         reference a number of other policies—including DOD’s Installation
                         Emergency Management Program policy and Installation Chemical,
                         Biological, Radiological, Nuclear, and High-Yield Explosive Emergency
                         Response Guidelines—and gives the Under Secretary of Defense for
                         Personnel and Readiness the authority to issue additional implementing
                         guidance. 24 DOD’s Installation Emergency Management Program policy
                         aligns DOD emergency management activities with national
                         preparedness and response guidelines and covers a range of potential
                         hazards, including natural hazards, such as earthquakes and tsunamis,
                         and human-caused hazards, including air or water contamination and
                         terrorist attacks. According to a DOD official, each public health
                         emergency is different, and the types of data that should be collected will
                         depend on the significance of the hazard. This official told us that
                         standard risk assessment models are applied in such emergencies and
                         public health and occupational and environmental health professionals
                         make decisions on how to respond on a case-by-case basis, based on
                         what they perceive the health threat to be. The sidebar illustrates DOD’s
                         response to the 2011 Fukushima Daiichi disaster in Japan.




                         23
                            In areas outside of the United States, DOD Instruction 6200.03 applies to the extent
                         that it is consistent with local conditions, and the requirements of applicable treaties,
                         agreements, and other arrangements with foreign governments and allied forces.
                         24
                            DOD Instruction 6055.17, DOD Installation Emergency Management (IEM) Program
                         (Jan. 13, 2009 with changes incorporated Sept. 16, 2008); and DOD Instruction 2000.18,
                         Department of Defense Installation Chemical, Biological, Radiological, Nuclear, and High-
                         Yield Explosive Emergency Response Guidelines (Dec. 4, 2002).




                         Page 16                                                   GAO-12-412 Defense Infrastructure
Limitations in DOD’s        Because DOD’s environmental restoration policies do not fully address
Environmental Restoration   the use of public health assessments or what actions should be taken to
Policies May Hinder Its     respond to health risks that may have resulted from past exposures,
                            DOD’s ability to identify and respond to environmental exposures on DOD
Ability to Identify and     installations may be limited. A goal of DOD’s strategic plan for
Respond to Exposures        installations is to provide effective, safe, and environmentally sound living
                            and working places in support of DOD missions. 25 Nonetheless, DOD
                            policies under the Defense Environmental Restoration Program are silent
                            regarding how to (1) document responses to public health
                            recommendations and findings of significant risk, (2) specify when to
                            conduct public health assessments beyond the initial assessment at
                            National Priorities List sites, 26 and (3) respond to health risks associated
                            with past environmental exposures.

DOD Has Not Fully           For DOD sites proposed for or listed on the National Priorities List, the
Documented Responses to     Agency for Toxic Substances and Disease Registry conducts a public
Public Health               health assessment of the site that may result in recommendations to
Recommendations             DOD. 27 Some assessments may also identify serious public health
                            concerns known as “findings of significant risk.” The Defense
                            Environmental Restoration Program’s management guidance states that
                            DOD is to track the Agency for Toxic Substances and Disease Registry’s
                            progress in completing public health assessments. 28 This guidance is,
                            however, silent regarding what actions DOD should take in response to



                            25
                               Deputy Under Secretary of Defense, Installations and Environment, Defense
                            Installations Strategic Plan, 2007.
                            26
                               While public health assessments are not required beyond the initial assessment, DOD
                            officials stated that they can be useful. For example, restoration efforts that may take
                            several years can include site characterization efforts that lead to additional information
                            that could change the results of the initial health assessment. In addition, the initial
                            assessments are required only at National Priorities List sites.
                            27
                               In 2010 we found that because the Agency for Toxic Substances and Disease Registry
                            did not have policies and procedures that describe how the agency is to comprehensively
                            assess and categorize the risk of work it initiates to prepare public health products,
                            management could not ensure that it consistently managed the risk related to all new
                            work, or established product preparation procedures commensurate with the risk. GAO,
                            Agency for Toxic Substances and Disease Registry: Policies and Procedures for Public
                            Health Product Preparation Should Be Strengthened, GAO-10-449 (Washington, D.C.:
                            Apr. 30, 2010).
                            28
                              Office of the Deputy Undersecretary of Defense, Installations and Environment,
                            Management Guidance for the Defense Environmental Restoration Program (September
                            2001).




                            Page 17                                                  GAO-12-412 Defense Infrastructure
these recommendations and findings of significant risk or the timeliness of
its response. According to a 1995 Guidelines document signed by the
Deputy Under Secretary of Defense (Environmental Security) and the
Assistant Surgeon General, DOD installations and the Agency for Toxic
Substances and Disease Registry are supposed to report annually on
actions taken in response to the recommendations resulting from health
assessments, among other items. 29 A 2011 memorandum of
understanding between DOD and the Department of Health and Human
Services explicitly cites the Guidelines but gives no direction regarding its
further implementation. The memorandum of understanding documents
the working relationship between the two agencies but currently the
process they follow does not ensure that status information on the
recommendations is provided to or documented by the office of the DOD
lead agent for the Agency for Toxic Substances and Disease Registry
program. Status information may indicate that a recommendation has
been fully implemented; a recommendation will be implemented in the
future, as part of a planned study; DOD does not agree with a
recommendation; or other relevant information. Under the Superfund law,
department heads are to take steps to reduce the exposure and eliminate
or substantially mitigate the risk if the Agency for Toxic Substances and
Disease Registry finds that an exposure presents a significant risk to
human health. 30 Furthermore, federal internal control standards
encourage the prompt resolution of audits and reviews, which would
include public health assessments. 31

DOD developed a tracking system that identifies characteristics such as
the date and nature of recommendations to particular installations;
however, it does not always identify whether each installation responded
to the recommendations or findings of significant risk. As a result,
according to the DOD lead agent, the tracking system does not reflect


29
   Guidelines for the Coordination of the Comprehensive Response, Compensation and
Liability Act (CERCLA) Activities Between the Agency for Toxic Substances and Disease
Registry and the Department of Defense, February 1995.
30
  42 U.S.C. § 9604(i)(11) (2012), 10 U.S.C. § 2704(e) (2012), Exec. Order 12580 § 2(k),
52 Fed. Reg. 2923 (Jan. 23, 1987).
31
   GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1
(Washington, D.C.: November 1999). According to these standards, government agencies
are to promptly record the results of transactions and events that impact operations and
ensure that the findings of audits and reviews are promptly resolved and communicated to
management.




Page 18                                                GAO-12-412 Defense Infrastructure
what actions, if any, DOD took on about 80 percent of the approximately
1,200 recommendations made since the inception of the environmental
restoration program. 32

According to DOD officials, the installations are expected to elevate
matters of concern with the public health agency’s recommendations to
the Office of the Secretary of Defense as needed, but otherwise, the lead
agent’s office does not systematically monitor recommendations or
findings of significant risk. The Defense Environmental Restoration
Program management guidance states that the Office of the Secretary of
Defense provides oversight to the lead agent and components on Agency
for Toxic Substances and Disease Registry involvement at installations.
While DOD officials said they rely on individual installations to respond to
recommendations from the Agency for Toxic Substances Disease
Registry, without accurate data or a systematic means to track the status
of responses to recommendations and findings of significant risk, the
Office of the Secretary of Defense has no assurance that installations
have responded to known public health risks. The sidebar illustrates
DOD’s approach to a draft public health assessment with DOD-wide
implications.




32
   The DOD lead agent for the Agency for Toxic Substances and Disease Registry
Program indicated that DOD has received almost 1,200 recommendations from the
Agency for Toxic Substances and Disease Registry since the inception of the Defense
Environmental Restoration Program. During the course of this engagement, DOD officials
told us they are trying to obtain the status of Agency for Toxic Substances and Disease
Registry recommendations from the installations.




Page 19                                               GAO-12-412 Defense Infrastructure
DOD’s Environmental                 DOD’s Defense Environmental Restoration Program management
Restoration Program Does Not        guidance does not address if or when DOD components should
Specify When to Conduct             voluntarily seek a public health assessment at National Priorities List sites
Public Health Assessments           beyond the initial assessment completed when a site is proposed for the
beyond the Initial Assessment       list. 33 After the initial public health assessment, it may take many years for
at National Priorities List Sites   site characterization and restoration. During that period additional
                                    contaminants or exposure pathways may be discovered that could make
                                    the original public health assessment obsolete. In addition, the guidance
                                    does not require public health assessments for non-National Priorities List
                                    sites, which could have environmental hazards equivalent to sites on the
                                    National Priorities List, and despite the fact that officials from the Agency
                                    for Toxic Substances and Disease Registry said that the majority of their
                                    DOD-related work in recent years involves non-National Priorities List
                                    sites. 34 According to federal internal control guidelines, management
                                    should assess the risks faced from external (and internal) sources and
                                    decide what actions to take to mitigate them. 35 While DOD officials said
                                    that DOD relies on the judgment of environmental professionals at the
                                    installations, without a standard set of guidelines on when to request a
                                    public health assessment other than an initial assessment for a site on
                                    the National Priorities List, DOD lacks assurance that it is consistently
                                    identifying and addressing possible health risks from exposures at some
                                    National Priorities List sites and non-National Priorities List sites.

DOD Environmental                   DOD’s Defense Environmental Restoration Program is focused on
Restoration Policies Do Not         cleanup to avoid present and future exposures but does not provide
Address Health Risks from Past      guidance on whether or when DOD should assess public health risks
Exposures                           from past exposures or identify potentially affected individuals. For
                                    example, at Camp Lejeune, while environmental compliance and Defense
                                    Environmental Restoration Program policies were relevant to the actions



                                    33
                                       See DOD, Defense Environmental Restoration Program Management Guidance (2008),
                                    p. 30. While the memorandum of understanding between DOD and the Agency for Toxic
                                    Substances and Disease Registry indicates that requests from installations to the Agency
                                    for Toxic Substances and Disease Registry are to be coordinated through the service
                                    component and must be approved by DOD if deemed appropriate, program policies do not
                                    provide installations with information on whether and when they may request such
                                    assistance.
                                    34
                                      DOD had almost 34,000 non-National Priorities List sites in fiscal year 2010. As we
                                    have previously reported, 141 DOD sites were listed on the National Priorities List as of
                                    February 2012; only 2 DOD sites have been newly listed since 2005.
                                    35
                                         GAO/AIMD-00-21.3.1.




                                    Page 20                                                  GAO-12-412 Defense Infrastructure
taken to provide safe drinking water and to begin investigating the
groundwater contamination, there was no policy guiding installations on
what actions it should consider to address past exposures. Instead, most
actions to address past exposures have come about based on Agency for
Toxic Substances and Disease Registry studies and congressional
direction. 36

In determining priorities and requirements in the cleanup process, DOD
officials told us DOD assesses relative risk to human health and the
environment posed by contamination but does so in terms of present or
future exposures; it generally does not identify or assess risks posed by
past exposures. 37 DOD officials told us that none of the cleanup laws
require retroactive public health assessments or identification of
individuals potentially affected by past exposures. However, officials from
the Agency for Toxic Substances and Disease Registry also told us that,
from a public health point of view, they consider it important to contact


36
   See John Warner National Defense Authorization Act of 2007, Pub. L. No. 109–364 §
318 (Oct. 17, 2006) (requiring, among other things, the Navy to enter into an agreement
with the National Academy of Sciences to conduct a comprehensive review and
evaluation of the available scientific and medical evidence regarding associations between
exposure to contaminated drinking water at Camp Lejeune and adverse health effects).
Also, the National Defense Authorization Act for Fiscal Year 2008, Pub. L. No 110-181 §
315 (Jan. 28, 2008) required, among other things, that the Secretary of the Navy make
reasonable efforts to identify and notify directly certain individuals—those served by the
contaminated water systems or civilian employees in particular time frames—who may
have been exposed to the contaminated drinking water at Camp Lejeune. In addition, the
act required that the Agency for Toxic Substances and Disease Registry develop a health
survey that would voluntarily request personal health information from these individuals.
The act stated that the survey may lead to scientifically useful health information
associated with certain contaminants, such as trichloroethylene, tetrachloroethylene and
vinyl chloride, identified in the Agency for Toxic Substances and Disease Registry studies
that may provide a basis for further reliable scientific studies of potentially adverse health
impacts of exposure to contaminated water at Camp Lejeune.
37
   DOD officials told us that the Agency for Toxic Substances and Disease Registry,
however, may consider risks posed by past exposures. DOD officials told us that there
were only two examples of DOD attempting to identify individuals who might have been
affected by past environmental exposures: (1) the ongoing efforts at determining the
health effects of contaminated drinking water at Camp Lejeune; and (2) notifying, via the
Internal Revenue Service, former residents about radon levels at higher than regulatory
standards in 2007 and 2008 in some housing at the Marine Corps Logistics Base, Albany,
Georgia. The Agency for Toxic Substances and Disease Registry officials told us that,
from a public health point of view, they would consider notification of prior site occupants
when notification could result in actions that directly benefit people’s health, such as
where past exposures are considered likely to have caused an increased incidence of a
disease for which early screening has proven beneficial.




Page 21                                                   GAO-12-412 Defense Infrastructure
                         prior site occupants when notification could result in actions that directly
                         benefit people’s health. Moreover, where there has been a release of
                         hazardous substances and where DOD is the lead agency, section 111(g)
                         of the Superfund law, in conjunction with an executive order, requires
                         DOD to notify potentially injured parties of such releases. 38, 39 However, it
                         is not required to notify individuals directly; rather, it can issue a broad,
                         public announcement, such as a newspaper notice. 40 As a result,
                         potentially affected individuals may not be aware of their exposure and
                         subsequent health risks.


Revised DOD Policy May   During the course of our review, we found that servicemembers’
Reduce Previous Gap in   dependents living on permanent overseas installations in nonemergency
DOD’s Response to        situations were not covered by any of the policies, but a revised policy
                         may reduce this gap. For example, servicemembers’ dependents, who
Exposures                were potentially exposed to contaminated air while at the Naval base in
                         Atsugi, Japan, were not covered by any of the four types of policies.
                         Specifically, according to DOD officials, the base was exempt from
                         (1) environmental restoration policies because these policies apply only in
                         the United States, 41 (2) occupational and environmental health policies
                         because the exposures occurred outside of the workplace,
                         (3) deployment policies because permanent installations are not
                         considered deployments, and (4) the public health emergency
                         management policy because it did not fit the definition of a public health
                         emergency. As such, no DOD policy existed to guide the Navy on their



                         38
                            Releases generally include any spilling, leaking, pumping, pouring, emitting, emptying,
                         discharging, injecting, escaping, leaching, dumping, or disposing into the environment,
                         including abandonment or discarding of barrels or containers. 40 C.F.R. § 300.5 (2012).
                         Hazardous substances include substances such as toxic chemicals and hazardous
                         wastes designated under Superfund and other laws.
                         39
                            Section 111(g) directs the President to provide such notification. Executive Order 12580
                         section 8, Employee Protection and Notice to Injured, delegates this responsibility to DOD
                         for its facilities.
                         40
                           Comprehensive Environmental Response, Compensation, and Liability Act § 111(g), 42
                         U.S.C. § 9611(g) (2012).
                         41
                           Outside the United States, the Defense Environmental Restoration Program does not
                         apply; instead, environmental agreements may be negotiated with the host nation. The
                         overseas environmental restoration policy does not specifically address exposures. See
                         DOD Instruction 4715.8 (1998), Deputy Secretary of Defense Memorandum,
                         "Environmental Remediation Policy for DOD Activities Overseas," October 18, 1995.




                         Page 22                                                  GAO-12-412 Defense Infrastructure
                            approach to conducting environmental surveillance, medical testing, or
                            notification of the potentially exposed dependents. In February 2012,
                            DOD revised its comprehensive health surveillance directive to include
                            servicemembers’ dependents when collecting health surveillance data in
                            the case of a possible environmental exposure or public health event at a
                            domestic or overseas installation. 42 DOD officials told us the revised
                            directive has the potential to improve DOD’s response to environmental
                            exposures, but not necessarily past exposures, since those would be
                            addressed on a case-by-case basis. However, it is too soon to determine
                            how this directive will be implemented and whether it will improve DOD’s
                            ability to address dependents potentially affected by exposures.


                            Although several programs potentially provide either health care or
Several Programs May        compensation to active servicemembers, military retirees, veterans,
Provide Health Care         dependents, federal workers, or contractors suffering from adverse health
                            conditions potentially caused by environmental exposures, the ability of
or Compensation for         some individuals to establish eligibility and actually obtain these
Environmental               benefits—particularly compensation—is often affected by documentary,
Exposures but Access        scientific, and legal factors.

May Be Affected by
Various Factors
Several Programs May        Servicemembers, veterans, military retirees, and their dependents,
Provide Health Care or      federal workers, and some contractors may have access to health care or
Health Benefits for         health benefits either through the Departments of Defense, Labor, and
                            Veterans Affairs, state workers’ compensation, or a private health care
Individuals Harmed by       program regardless of the cause of the condition. Individuals, depending
Environmental Exposures     on their eligibility, may obtain health care or health benefits from one or
While Working or Residing   more of the following programs:
on Military Installations
                            •     TRICARE: DOD’s TRICARE program may provide health care to
                                  servicemembers and their dependents, eligible National Guard and
                                  Reserve personnel and their dependents, and military retirees and
                                  their dependents and survivors. Servicemembers include members of
                                  the National Guard and Reserves on active duty for at least 30 days. 43


                            42
                                 DOD Directive 6490.02E, Comprehensive Health Surveillance (Feb. 8, 2012).
                            43
                              TRICARE is established under the authority of Chapter 55 of Title 10 of the United
                            States Code.




                            Page 23                                                GAO-12-412 Defense Infrastructure
•     Veterans Health Administration: The Veterans Health
      Administration, within the Department of Veterans Affairs may provide
      health care to veterans, military retirees, and certain other individuals
      through numerous outpatient clinics, medical centers, and long-term
      health care facilities. The Veterans Health Administration may also
      provide health coverage to spouses, survivors, and children of
      veterans who are permanently and totally disabled from a service-
      connected disability or who died in the line of duty or from a service-
      connected disability. 44
•     Federal Employees’ Health Benefits: The Federal Employees’
      Health Benefits program, which is administered by the Office of
      Personnel Management, may provide health care benefits to federal
      workers who choose to enroll. 45
•     Federal Employee Compensation Act: For appropriated fund
      employees, the Department of Labor’s Federal Employees
      Compensation Act program may provide benefits, including medical
      care, to covered employees who experience work-related injuries.
      When necessary, the Federal Employees Compensation Act program
      also provides vocational rehabilitation assistance to help injured
      workers return to work. 46
•     Nonappropriated Fund Instrumentalities Act: Under the
      Nonappropriated Fund Instrumentalities Act, an extension of the
      Longshore and Harbor Workers’ Compensation Act, 47 civilian
      employees employed by nonappropriated fund operations at domestic
      and overseas military bases (e.g., base exchanges, child care, food
      service, housekeeping, etc) may receive medical treatment for work-




44
     See 38 U.S.C. §§1710 and 1781.
45
     See generally Chapter 89 of Title 5 of the United States Code.
46
     See generally, Chapter 81 of Title 5 of the United States Code.
47
   The Longshore and Harbor Workers’ Compensation Act, administered by the U.S.
Department of Labor, provides medical benefits, compensation for lost wages, and
rehabilitation services to longshoremen, harbor workers, and other maritime workers who
are injured during the course of employment or suffer from diseases caused or worsened
by conditions of employment. Several other statutes extend the provisions of the act to
cover other classes of private-industry workers. These include workers engaged in the
extraction of natural resources of the outer continental shelf, employees on American
defense bases, and those working under contracts with the U.S. government for defense
or public-works projects, outside of the continental United States.




Page 24                                                    GAO-12-412 Defense Infrastructure
                                  related injuries, including those resulting from environmental
                                  exposures. 48
                            •     Defense Base Act: The Defense Base Act, an extension of the
                                  Department of Labor’s Longshore and Harbor Workers’
                                  Compensation Program Act, requires U.S. government contractors
                                  and subcontractors to purchase workers’ compensation insurance
                                  coverage for their employees working overseas. 49 This insurance
                                  would cover medical treatment required as a result of work-related
                                  injuries. 50
                            •     State Workers Compensation: Some state workers’ compensation
                                  programs may also provide health care benefits for work-related
                                  health conditions to contractors working in the United States, although
                                  eligibility requirements and benefits may vary from state to state. In
                                  some instances, the federal Longshore and Harbor Workers
                                  Compensation Act may provide such benefits.

Several Programs May        The Departments of Defense, Veterans Affairs, and Labor, as well as
Provide Compensation for    some state workers’ compensation programs may also provide
Individuals Harmed by       compensation to servicemembers, military retirees, veterans, federal
                            workers, and contractors for service or work-related health conditions
Environmental Exposures     associated with issues such as exposure to environmental hazards.
While Working or Residing   These programs include:
on Military Installations
                            •     DOD’s Disability Evaluation System: The Department of Defense
                                  Disability Evaluation System may provide compensation to
                                  servicemembers for service-connected health conditions.
                                  Servicemembers may receive either a lump sum for their health
                                  condition or monthly compensation, depending on the severity of the
                                  condition.
                            •     Veterans Benefits Administration: The Veterans Benefits
                                  Administration programs within the Department of Veterans Affairs
                                  may provide monthly compensation to military retirees and veterans


                            48
                              See 5 U.S.C. §8171. Nonappropriated fund employees are civilian employees who are
                            paid from funds that are not appropriated by Congress. Nonappropriated fund employees
                            on military installations work, for example, in military exchanges and morale, welfare, and
                            recreation programs.
                            49
                               Some exceptions may apply for employers who provide proof to the Secretary of Labor,
                            showing the ability to pay compensation directly, and receive authorization to provide
                            direct compensation.
                            50
                                 See 42 U.S.C. §1651.




                            Page 25                                                  GAO-12-412 Defense Infrastructure
      with service-connected health conditions and sometimes their
      dependents and survivors.
•     Federal Employees’ Compensation Act: The Federal Employees’
      Compensation Act program may provide wage-replacement
      compensation to covered employees with work-related health
      conditions.
•     Nonappropriated Fund Instrumentalities Act: The Nonappropriated
      Fund Instrumentalities Act, an extension of the Longshore and Harbor
      Workers’ Compensation Act, provides disability compensation for
      work-related injuries and survivor benefits for civilian employees
      employed by nonappropriated fund operations at domestic and
      overseas military bases (e.g., base exchanges, child care, food
      service, housekeeping, etc). Vocational rehabilitation services are
      available to assist permanently disabled workers to return to work.
•     Defense Base Act: The Defense Base Act, an extension of the
      Longshore and Harbor Workers’ Compensation Act, may provide
      financial compensation to eligible civilian employees of U.S.
      government contractors with work-related health conditions who
      perform work overseas.
•     State Workers Compensation: Some state workers compensation
      programs may provide wage-replacement compensation for work-
      related health conditions to contractors at military installations within
      the United States, although eligibility requirements and benefits may
      vary from state to state. In some instances, the federal Longshore and
      Harbor Workers Compensation Act may provide such benefits.

Although spouses and dependents who are injured while residing on
military installations may access health care through TRICARE or other
health care programs, they are not eligible to receive financial
compensation from the Departments of Defense, Veterans Affairs, or
Labor, under the above programs, for adverse health conditions resulting
from environmental exposures on military installations. They may,
however, file a tort claim against the federal government seeking financial
compensation under the Federal Tort Claims Act. 51 The act provides a
means for some individuals injured by wrongful or negligent acts or
omissions of federal employees to receive compensation from the U.S.
government through an administrative claim process or, if not resolved at
the administrative level, through the federal courts, subject to certain
exceptions. For example, claimants will be unable to recover in cases in


51
     28 U.S.C. §§1346(b), 2671-2680.




Page 26                                           GAO-12-412 Defense Infrastructure
                               which federal employees took actions that are susceptible to policy
                               analysis. 52


Access to Compensation Is      Although the above programs potentially provide either health care or
Often Affected by              compensation to active servicemembers, veterans, military retirees, and
Documentary, Scientific,       their dependents; federal workers; or contractors suffering from adverse
                               health conditions potentially caused by environmental exposures, the
and Legal Factors              ability of some individuals to establish eligibility and actually obtain these
                               benefits—particularly compensation—is often affected by documentary,
                               scientific, and legal factors.

Difficulty in Documenting an   Obtaining compensation for an environmental exposure may depend on
Environmental Exposure         an individual’s ability to document an actual exposure to a contaminant,
                               since establishing a causal link between the exposure and the adverse
                               health condition may be necessary for obtaining certain benefits or
                               compensation under many existing adjudication processes. This usually
                               requires not only documentation of a release of a contaminant but also
                               that the individual was potentially exposed to the contaminant (i.e., in the
                               area of the release at the time and place it occurred) at a level plausibly
                               related to an adverse health outcome. However, it is often difficult to
                               document the specific time, place, or level of an environmental exposure
                               because such exposures are not always identified, defined, and
                               measured at the time of the occurrence since adverse effects of the
                               exposure may not be immediately apparent. This is true for environmental
                               exposures both on and off military installations. When environmental
                               exposures are not identified at the time of the release, the opportunity to
                               collect data on both the level of exposure and individuals present at the
                               time of the release may be lost. For example, in 2010 we reported that
                               U.S. forces in Afghanistan and Iraq did not sample or monitor burn pit
                               emissions as provided by a key U.S. Central Command regulation, and,
                               as a result, the health impacts of burn pit exposure on individuals are not
                               well understood. Although DOD and the Department of Veterans Affairs
                               have commissioned studies to enhance their understanding of burn pit
                               emissions, the current lack of data on emissions specific to burn pits and



                               52
                                 According to U.S. v. Gaubert, 499 U.S. 315, 323 (1991), “…the purpose of this
                               exception is to prevent judicial ‘second-guessing’ of legislative and administrative
                               decisions grounded in social, economic and political policy through the medium of an
                               action in tort.”




                               Page 27                                                GAO-12-412 Defense Infrastructure
related exposures limit efforts to characterize potential health impacts on
servicemembers and contractors. 53

Additionally, it is often difficult to document those individuals who were
potentially exposed to a harmful release because such exposures have
not always been recorded in personnel medical files at the time they
occurred. For example, after the Vietnam War one of the primary
difficulties in determining who was exposed to Agent Orange in Vietnam
was the lack of records. 54 Although many returning veterans suspected a
scientific link between dioxin—a key contaminant in Agent Orange—and
certain adverse health conditions, veterans filing claims and Department
of Veterans Affairs officials adjudicating claims were hampered by a lack
of information about who was in Vietnam when certain areas were
sprayed with Agent Orange. In many cases, veterans and Department of
Veterans Affairs adjudicators had to rely on rudimentary measures such
as self-reports of exposure, service in Vietnam, military occupation, and
service in combat zones. Similarly, in 2005 we reported that most of the
federal agencies identified as likely to have had employees in Vietnam—
DOD, the Central Intelligence Agency, and the Departments of State,
Agriculture, and Treasury—were unable to provide us with the exact
number of civilian employees they had working in Vietnam during the war.
Officials from these agencies told us that it was difficult to identify these
workers, because personnel records were kept solely on paper, as
computers were not in common use at that time. Agency officials told us
that these paper records might have been destroyed or, if such records
still existed, had not been indexed or organized in searchable formats. In
addition, the location of some records was unknown because of the loss




53
     See GAO-11-63.
54
   Agent Orange is a mixture of herbicides initially developed to control broad-leafed
weeds in agricultural settings. In large quantities, it causes large-scale defoliation. It
primarily was used during the Vietnam War to defoliate large areas in order to deprive the
opposition forces of cover and food crops. Between 1962 and 1971, more than 21 million
gallons of Agent Orange were sprayed across Southeast Asia. Though the military was
unaware of it at the time of its initial use, it was later discovered that Agent Orange also
contained a dioxin, which is a by-product of the manufacturing process. This dioxin is
classified as a human carcinogen. According to the Department of Veterans Affairs,
cancers currently associated with exposure to Agent Orange and other herbicides are
chronic lymphocytic leukemia, Hodgkin’s lymphoma, multiple myeloma, non-Hodgkin’s
lymphoma, prostate cancer, various respiratory cancers (lung, bronchus, larynx, trachea),
and some soft tissue sarcomas.




Page 28                                                   GAO-12-412 Defense Infrastructure
                               of institutional knowledge resulting from staff turnover over the years. 55
                               This lack of records may continue to be an issue, particularly for
                               exposures occurring in the past that may at some point in the future result
                               in adverse health conditions. For example, some veterans returning from
                               Afghanistan and Iraq blame emissions from open air burn pits for several
                               health conditions, including respiratory illnesses. However, the Institute of
                               Medicine recently issued a report that was inconclusive regarding the
                               connection between burn pit emissions and adverse health conditions.
                               One of the major reasons cited by the Institute of Medicine for the
                               inconclusive results was insufficient data on troops’ exposures to open air
                               burn pits. According to the study, some of the incomplete information that
                               hampered the Institute’s analysis included information on how many
                               people worked in or near the pits, for how long, and how frequently. 56

Difficulty in Scientifically   In many cases, obtaining compensation for an environmental exposure
Linking an Environmental       further depends on an individual’s ability to establish causation between
Exposure to Health Condition   an exposure and the adverse health condition, but this is often difficult
                               because scientific research has not always established a clear link
                               between the contaminant and an adverse health effect. This is true for
                               environmental exposures both on and off military installations. Further
                               complicating the matter is the fact that for many environmental exposures
                               there is a latency period—the time period from initial exposure to a
                               contaminant and the date an adverse health condition is diagnosed.
                               When there is a long latency period between an environmental exposure
                               and an adverse health condition, choosing between multiple causes of
                               exposure may be difficult. Where multiple alternative causes are present,
                               science is often unable to demonstrate that a particular individual’s
                               environmental exposure was the cause of the condition. For example, it is
                               difficult to definitively rule out other environmental or lifestyle risk factors
                               that could have caused the condition during the years between the
                               exposure and the appearance of the condition. Indeed, another major
                               reason cited by the Institute of Medicine for the inconclusive results of
                               their burn pit study was high background levels of ambient pollution from
                               other sources, such as diesel fumes and dust that might also be



                               55
                                  GAO, Agent Orange: Limited Information is Available on the Number of Civilians
                               Exposed in Vietnam and Their Workers’ Compensation Claims, GAO-05-371
                               (Washington, D.C.: Apr. 22, 2005).
                               56
                                 Institute of Medicine, Long-Term Health Consequences of Exposure to Burn Pits in Iraq
                               and Afghanistan (Washington, D.C.: Oct. 31, 2011).




                               Page 29                                                GAO-12-412 Defense Infrastructure
                                 responsible for the respiratory conditions. According to the Institute of
                                 Medicine, because of the existence of these pollutants, it could not
                                 establish a conclusive link between burn pit emissions and the adverse
                                 health conditions being experienced by some individuals.

                                 The water contamination at Camp Lejeune further underscores the
                                 difficulties associated with these documentary and scientific factors.
                                 Specifically, little data exist regarding Camp Lejeune’s past water quality
                                 tests and the extent to which contaminants were found in the water. As a
                                 result, the Agency for Toxic Substances and Diseases Registry is
                                 conducting a water modeling assessment to fill in the gaps in the data.
                                 The Agency for Toxic Substances and Diseases Registry hopes the water
                                 modeling will help identify the time and place certain areas at Camp
                                 Lejeune received contaminated drinking water and ultimately help to
                                 determine who was exposed, at what levels, and for how long. For
                                 example, the data collection efforts for the Agency for Toxic Substances
                                 and Diseases Registry’s studies revealed that the area serviced by
                                 Holcomb Boulevard water system on Camp Lejeune received water that
                                 may have contained volatile organic compounds for a longer period than
                                 was previously thought. Furthermore, once it has been established that a
                                 veteran was exposed to contaminated water at Camp Lejeune, the
                                 Department of Veterans Affairs needs to determine whether the alleged
                                 health condition can generally be caused by the exposures received
                                 during service and whether the health condition in a specific claim was
                                 caused by the exposure in deciding whether to provide compensation.
                                 These difficulties may affect veterans’ ability to obtain benefits and
                                 compensation. Data provided by the Department of Veterans Affairs show
                                 that in calendar year 2011, the department completed decisions on 849
                                 claims from veterans alleging an adverse health condition resulting from
                                 the contaminated water at Camp Lejeune. Of these 849 claims, 212
                                 (25 percent) claims were granted and 637 (75 percent) were denied.
                                 According to the Department of Veterans Affairs, those claims that were
                                 denied failed to demonstrate one or more of the following: (1) service at
                                 Camp Lejeune during the period of water contamination, (2) a current
                                 disease or disability, or (3) a medical nexus or link between a current
                                 disability and service at Camp Lejeune. According to the Department of
                                 Veterans Affairs, a total of 1,151 claims are still being adjudicated.

Difficulty in Seeking a Remedy   Active duty servicemembers, military retirees, veterans, and other federal
for an Environmental Exposure    workers are able to seek compensation through Departments of Defense,
under the Federal Tort Claims    Veterans Affairs, and Labor programs, but other individuals may need to
Act                              seek a remedy under the Federal Tort Claims Act. Certain individuals
                                 have legal standing under the Federal Tort Claims Act to file a lawsuit



                                 Page 30                                        GAO-12-412 Defense Infrastructure
against the U.S. government for damages due to an environmental
exposure under some circumstances. But damages under the Federal
Tort Claims Act are not available to other types of individuals, and for
certain types of claims, due to legal precedent or statutes. For example,
most active duty servicemembers, military retirees, and veterans may not
bring suit under the Federal Tort Claims Act due to the doctrine outlined
in the Supreme Court case Feres v. United States, 57 and its successor
cases, for personal injuries that arise incident to their military service, and
such claims or lawsuits they attempt to file under the Federal Tort Claims
Act are subject to dismissal. However, active duty servicemembers,
military retirees, and veterans may be eligible for compensation through
Department of Defense or Veterans Affairs programs. Similarly, the
Federal Employees’ Compensation Act provides the exclusive remedy for
federal workers and their dependents if the worker is injured or killed in
the performance of duties. Thus, the disability compensation, medical,
and other benefits provided for under the Federal Employees’
Compensation Act are the exclusive means by which federal workers can
seek compensation from the U.S. government. While compensation
programs are established for some individuals who work on military
installations, others, including dependents and contractors, may choose
to pursue legal damages from the U.S. government, under the Federal
Tort Claims Act, for injuries they sustained as a result of an environmental
exposure.

Although the Federal Employees’ Compensation Act effectively bars
federal workers and their dependents from pursuing compensation
through tort claims in civil lawsuits, 58 employees of government
contractors may pursue damages from the U.S. government for an
environmental exposure received on the job and dependents of active
duty servicemembers may seek compensation for their own personal
injuries. However, success under the Federal Tort Claims Act may be
unlikely. The discretionary function exception within the Federal Tort
Claims Act prevents recovery for health conditions caused by
discretionary actions or omissions of federal employees in cases in which
the employees’ actions are susceptible to policy analysis. 59 According to



57
     Feres v. United States, 340 U.S. 135 (1950).
58
     5 U.S.C. §8116 (c).
59
     28 U.S.C. §2680 (a).




Page 31                                             GAO-12-412 Defense Infrastructure
Department of Justice officials, this includes many decisions made by
federal personnel, although not in cases where the government ignores a
specific and mandatory agency rule or policy. Department of Justice
officials told us that, as a result, many claims against the U.S.
government alleging harm due to governmental negligence are eventually
dismissed.

According to Navy officials, as of January 2012, about 2,900 former
residents and former employees of Camp Lejeune had filed administrative
claims against the U.S. government for adverse health effects, alleged to
have resulted from contaminated water, seeking billions of dollars in
potential damages. In accordance with limitations on adjudication of
claims, set out in the National Defense Authorization Acts for Fiscal Years
2011 and 2012, 60 the Navy stated it is currently not adjudicating these
claims, and is awaiting the outcome of several ongoing and planned
studies by the Agency for Toxic Substances and Diseases Registry. In
addition to filing administrative claims with the Navy, some claimants
have also exercised their rights under the Federal Tort Claims Act and
filed lawsuits against the U.S. government in federal district courts.
According to the Department of Justice, as of March 2012, 12 of the
approximately 2,900 administrative claims had resulted in the filing of
lawsuits in federal district court. Among other things, we were told that
some of these lawsuits seek damages for various physical ailments and
emotional distress alleged to have resulted from the government’s alleged
negligence in protecting the water supply at Camp Lejeune. Furthermore,
Department of Defense officials told us that lawsuits have been filed in
federal court in at least 43 states in which current and former
servicemembers have alleged, among other things, that a contractor’s
negligent management of burn pit operations, contrary to applicable
contract provisions, exposed them to air pollutants that subsequently
caused adverse health conditions. According to officials, the contractor
has moved to dismiss the suits, arguing, among other things, that it
cannot be held liable for any health conditions that may have occurred to
service personnel because its burn pit activities occurred at the direction
of the military.




60
  Limitations on adjudication are found in The Ike Skelton National Defense Authorization
Act for Fiscal Year 2011, Pub. L. No. 111-383, §313 (2011).and the National Defense
Authorization Act for Fiscal Year 2012, Pub. L. No. 112-81, §319 (2011).




Page 32                                                GAO-12-412 Defense Infrastructure
Actions Taken to Limit    In an effort to limit some of the difficulties associated with these factors,
Difficulties Associated   Congress has, in some cases, created presumptions that bridge gaps in
with These Factors        the evidence related to causation and documentation, making it easier for
                          a group of veterans to be compensated. For example, to qualify for a
                          Department of Veterans Affairs disability compensation claim, a veteran is
                          normally required to demonstrate the following: (1) that a health condition
                          currently exists, (2) that an event of disease or injury occurred or was
                          aggravated in the line of duty, and (3) that a medical connection or
                          “nexus” can be shown between the service event and the existing health
                          condition. However, when the exposures of military personnel in Vietnam
                          to Agent Orange could not be clearly documented, Congress enacted
                          legislation establishing the presumption that veterans who served in
                          Vietnam during a specified time frame, and subsequently developed
                          certain health conditions, provided in the statute or prescribed in
                          regulations, had been exposed. 61, 62 This presumption relieves the veteran
                          of proving one or more of the eligibility requirements for direct service
                          connection and shifts the burden of proof from the veteran to the
                          government in order to rebut the presumption.

                          In addition, DOD and Department of Veterans Affairs officials told us they
                          are taking steps to overcome some of the difficulties in confirming
                          scientific links between certain contaminants and adverse health
                          conditions and in maintaining documentation regarding environmental
                          exposures. DOD officials told us they are potentially implementing an
                          electronic individual longitudinal exposure record for every
                          servicemember that would be designed to provide linkages between
                          differing types of data—environmental monitoring, biomarkers, and troop
                          locations and activity—and an individual’s medical records. DOD and the
                          Department of Veterans Affairs are also conducting scientific studies
                          designed to follow a large group of individuals over a long period of time
                          to determine any increased incidence of diseases, including those due to
                          a potential environmental exposure. For example, the Millennium Cohort
                          Study, an ongoing health evaluation led by the Naval Health Research
                          Center, is targeted at examining deployment-related health conditions by
                          comparing a cohort of servicemembers that were deployed and a cohort



                          61
                               Agent Orange Act of 1991, Pub. L. No. 102-4 (1991), as amended.
                          62
                            38 U.S.C. §1116. Similar statutory presumptions exist for prisoners of war, veterans
                          exposed to ionizing radiation, and those who served in Southwest Asia during the Gulf
                          War.




                          Page 33                                                 GAO-12-412 Defense Infrastructure
                       that was not deployed. According to Department of Veterans Affairs
                       officials, conducting these types of scientific studies will provide
                       documentation and scientific information on adverse health conditions,
                       that if found to be significantly different between deployed and
                       nondeployed servicemembers, may provide officials with information to
                       further examine the link between potential environmental exposures and
                       adverse health conditions. These efforts may provide exposure-related
                       documentation that is currently not readily available, and may remove
                       some of the burden of documenting an environmental exposure.


                       Beyond the previously discussed traditional avenues generally available
Certain Features of    for seeking compensation for work-related injuries or injuries resulting
Alternative Programs   from an environmental exposure, Congress has, in some cases,
                       established alternative programs to provide compensation and some
for Compensation       medical benefits to specific populations harmed by specific environmental
Established for        exposures. The structures of these alternative programs for
Specific               compensation vary and the programs are not generally designed to
                       address all past or future environmental exposures occurring on military
Environmental          installations, such as those discussed in this report. However, in the past
Exposures May          few years, Congress has considered several legislative options to provide
                       benefits and compensation for certain individuals exposed to specific
Provide Potential      environmental hazards on military installations. 63 Some features of the
Options for Future     alternative programs for compensation may help to inform any future
                       compensation programs that Congress may choose to create.
Programs




                       63                                                         th
                          Caring for Camp Lejeune Veterans Act of 2011, S. 277, 112 Cong. (2011), the Janey
                                                       th
                       Ensminger Act, H.R. 1742, 112 Cong. (2011) and the Examination of Exposures to
                       Environmental Hazards During Military Service and Health Care for Camp Lejeune and
                                                                                                      th
                       Atsugi Naval Air Facility Veterans and their Families Act of 2010, S. 3378, 111 Cong.
                       (2010).




                       Page 34                                               GAO-12-412 Defense Infrastructure
Congress Has Established    In a few instances, Congress has established alternative programs for
Alternative Programs for    compensating specific populations harmed by specific environmental
Compensation for Specific   exposures that take the place of traditional avenues for seeking
                            compensation and may help overcome some of the challenges in
Populations Harmed by       compensating individuals for health conditions that result from
Specific Environmental      environmental exposures. We identified three such programs 64 designed
Exposures                   to provide compensation and medical benefits to U.S. citizens harmed by
                            exposure to contaminants and examined the programs’ structure and
                            features for providing benefits. 65 These programs are:

                            •    The Radiation Exposure Compensation Program 66 provides partial
                                 restitution to eligible onsite participants, uranium miners, millers, and
                                 ore transporters, and nearby populations who were exposed to
                                 radiation from atmospheric nuclear weapons testing, or as a result of
                                 their employment in the uranium mining industry during the Cold War,
                                 and developed certain adverse health conditions.
                            •    The Energy Employees Occupational Illness Compensation
                                 Program 67 provides compensation and medical benefits to eligible
                                 nuclear weapons workers and their survivors harmed from exposure
                                 to radiation or toxic contaminants.
                            •    The Black Lung Program 68 provides medical and income assistance
                                 to eligible individuals who were exposed to coal mine dust through
                                 work in the mines and were diagnosed with totally disabling
                                 pneumoconiosis (black lung disease). In such cases, the former


                            64
                              We identified one other environmental exposure-related compensation program, the
                            Marshall Islands Nuclear Claims Tribunal, but did not include it our analysis because it
                            does not provide compensation to U.S. citizens.
                            65
                               Congress has also established compensation programs for injuries or death for injuries
                            caused by factors other than environmental exposures, such as the Smallpox Vaccine
                            Injury Compensation Program and the National Vaccine Injury Compensation Program.
                            However, our analysis only included programs that provide compensation for injuries
                            caused by an exposure to a harmful contaminant in the environment, not, for example, as
                            a result of a vaccine. See app. I for a complete description of our compensation program
                            selection criteria.
                            66
                              See the Radiation Exposure Compensation Act, Pub. L. No. 101-426 (1990), codified at
                            42 U.S.C. §2210 note, as amended.
                            67
                              See the Energy Employees Occupational Illness Compensation Act of 2000, Title
                            XXXVI of the Floyd D. Spence National Defense Authorization Act for Fiscal Year 2001,
                            Pub. L. No. 106-398 (2000), codified at 42 U.S.C. §§7384- 7385s-15, as amended.
                            68
                              See Title IV of the Federal Coal Mine Health and Safety Act of 1969, Pub. L. No. 91-
                            173 (1969), codified at 30 U.S.C. Chapter 22, Subchapter IV, as amended.




                            Page 35                                                  GAO-12-412 Defense Infrastructure
    miner’s income assistance may be augmented on behalf of certain
    dependent family members. The program also provides income
    assistance to the survivors of miners who died due to black lung
    disease and to certain survivors of miners who were awarded benefits
    as a result of lifetime claims. 69 The sidebar illustrates how costs in
    these three programs exceeded initial estimates as the federal role in
    the programs expanded.
While these alternative programs for compensation were each designed
to compensate individuals injured by exposure to harmful contaminants,
the way in which the programs are structured varies, including who
administers the program, how it is funded, and the benefits it provides.
For example:

•   Administration: The administration of the programs differs. For
    example, the Department of Justice administers the Radiation
    Exposure Compensation Program. In contrast, the Department of
    Labor administers the Black Lung Program, and shares responsibility
    for administering the Energy Employees Occupational Illness
    Compensation Program with the Departments of Health and Human
    Services, Energy and Justice. Responsibility for administering the
    Black Lung Program has changed since its inception. Specifically,
    claims for the Black Lung Program were initially processed and paid
    by the Social Security Administration but, as designed by the original
    legislation, the Department of Labor began processing claims in 1973
    and took over all Black Lung Program claims processing in 1997. In
    2002, Congress officially transferred all legal responsibility and
    funding for the program to the Department of Labor.

•   Funding: Funding for the three programs varies. Although initially
    funded solely through annual appropriations, the Black Lung Program
    is now funded largely by the coal mining industry. Individual claims
    are paid either by a responsible coal mine operator (or its insurance
    carrier) or by the Black Lung Disability Trust Fund, which is financed
    by an excise tax on coal and supplemented by additional funds. In
    contrast, the Energy Employees Occupational Illness Compensation
    Program and the Radiation Exposure Compensation Program are
    completely federally funded.


69
   Black lung is a term that includes coal workers’ pneumoconiosis and any other chronic
respiratory or pulmonary impairment arising out of coal mine employment. 30 U.S.C.§ 902
(b).




Page 36                                                GAO-12-412 Defense Infrastructure
                            •    Benefits: Benefits also vary among the three programs. Some of the
                                 benefits they provide include lump sum compensation payments and
                                 payments for lost wages, medical and rehabilitation costs, and
                                 attorney’s fees. For example, the Black Lung Program provides
                                 diagnostic testing for miners; monthly payments based on the federal
                                 salary scale for eligible miners or their survivors; medical treatment for
                                 eligible miners; and, in some cases, payment of claimants’ attorney
                                 fees. The Radiation Exposure Compensation Program, in contrast,
                                 provides only a lump sum payment for restitution to those that
                                 developed adverse health conditions or their survivors.

Certain Features of These   In the past few years, Congress has considered several legislative
Programs May Provide        options to specifically provide compensation and benefits for individuals
Potential Options for       exposed to specific environmental hazards on military installations. 70 The
                            alternative programs for compensation that we examined contain certain
Future Programs             features that may provide potential options if future programs for
                            environmental exposure compensation are considered. These features
                            address such issues as whether to use an adversarial or nonadversarial
                            approach to adjudicating claims, the kinds of outreach and claims
                            assistance offered, how eligibility for benefits is determined, and the
                            frequencies and types of payments when such compensation is awarded.

Nonadversarial versus       The Radiation Exposure Compensation Program and the Energy
Adversarial Proceedings     Employees Occupational Illness Compensation Program resolve claims in
                            a nonadversarial manner; thus, claims are adjudicated through a process
                            in which the adjudicator investigates the facts of the case to determine
                            the eligibility of the claimant. 71 In contrast, the Black Lung Program is
                            adversarial; thus, claims are adjudicated through a process in which two
                            opposing parties, such as the coal miner and his former employer,
                            present their arguments for and against awarding compensation, and



                            70                                                          th
                               Caring for Camp Lejeune Veterans Act of 2011, S. 277, 112 Cong. (2011), the Janey
                                                            th
                            Ensminger Act, H.R. 1742, 112 Cong. (2011) and the Examination of Exposures to
                            Environmental Hazards During Military Service and Health Care for Camp Lejeune and
                                                                                                           th
                            Atsugi Naval Air Facility Veterans and their Families Act of 2010, S. 3378, 111 Cong.
                            (2010).
                            71
                              See generally, 28 C.F.R. Part 79 for regulations pertaining to claims filed under the
                            Radiation Exposure Compensation Program Act and 20 C.F.R. Part 30 for regulations
                            pertaining to claims filed under the Energy Employees Occupational Illness Compensation
                            Act.




                            Page 37                                               GAO-12-412 Defense Infrastructure
responsibility for the payment of benefits is assigned to the liable party if
the claim is approved. 72 In this process, the coal mine operators typically
serve as the opposing party to the claimant, and if a claimant is awarded
benefits, the mine operator determined to be the responsible employer of
the miner must generally pay the benefits, either directly or through
insurance. If no mine operator can be held liable for payments, the Black
Lung Disability Trust Fund pays the cost of black lung claims from funds
collected through an excise tax on coal.

Department of Labor officials told us that they prefer the nonadversarial
features of the Radiation Exposure Compensation Program and the
Energy Employees Occupational Illness Compensation Program because
these features can improve the timeliness of processing claims.
Conversely, the adversarial features in the Black Lung Program have
contributed to delays in reaching a final disposition of claims by allowing
opposing parties to provide evidence to refute initial claims and to appeal
claim decisions. For example, a party displeased with the initial decision
of the Division of Coal Mine Workers’ Compensation in the Department of
Labor’s Office of Workers’ Compensation Programs can request a
hearing with a Department of Labor Administrative Law Judge within 30
days after the Office of Workers’ Compensation Program decision is filed.
Dissatisfied parties can appeal Administrative Law Judge decisions to the
Department of Labor Benefits Review Board and Benefits Review Board
decisions can be appealed to the appropriate United States Circuit Court
of Appeals. Finally, Circuit Court of Appeals decisions may be appealed
to the Supreme Court of the United States. In 2009, GAO found that this
structure led to a high rate of appeals that prolong the resolution of
claims. 73 Both miners and coal mine operators frequently seek appeals,
and for those claimants awarded compensation during the initial
adjudication in fiscal year 2008, the coal mine operators found liable
appealed the decision approximately 80 percent of the time. 74 Since
decisions are routinely appealed, GAO previously found that each level of
appeal review can take up to a year to adjudicate; ultimately, a claim may
remain in the adjudication process for years with the administering federal


72
  See generally 20 C.F.R. Part 725 for regulations pertaining to the claims process of the
Black Lung Program.
73
   GAO, Black Lung Benefits Program: Administrative and Structural Changes Could
Improve Miners’ Ability to Pursue Claims,GAO-10-7 (Washington, D.C.: Oct. 30, 2009).
74
     GAO-10-7.




Page 38                                                 GAO-12-412 Defense Infrastructure
                        agency incurring the cost for the years of processing the claim. For
                        example, for claims between 2001 and 2008, 28 percent of the claims of
                        miners awarded compensation from coal mine operators spent 3 to 8
                        years within the adjudication process. 75 During this period, the claimant’s
                        ultimate entitlement to compensation will remain in doubt. 76

Outreach and Claimant   All three programs provide outreach and assistance services to potential
Assistance              claimants. The Energy Employees Occupational Illness Compensation
                        Program sponsors outreach activities, including town hall meetings and
                        traveling resource centers, to disseminate information about benefits and
                        provide assistance to claimants in applying for benefits. For the Black
                        Lung Program, 15 black lung grantees, which provide specialized
                        diagnosis and treatment services, outreach, and educational programs to
                        help patients and their families deal with the disease have been
                        established through grants from the Department of Health and Human
                        Services. The Radiation Exposure Compensation Program has
                        established grant-based Radiation Exposure Screening and Education
                        Programs that support programs for health screening, education, medical
                        referral, and appropriate follow-up services for eligible individuals.

                        Departments of Labor and Justice officials told us that when programs
                        provide outreach and assistance to potential claimants both claimants
                        and administrators benefit because the filed claims are more complete
                        and contain fewer errors. For the Radiation Exposure Compensation
                        Program, these features allow program administrators to meet with
                        citizens, respond to questions about the program, conduct town hall
                        meetings, and assist in filling out claim forms. For the Energy Employees
                        Occupational Illness Compensation Program, town hall meetings have
                        provided information to more remote locations where individuals may not
                        have known they might have been exposed to radiation and, according to
                        the Department of Labor’s 2009 annual report, this outreach resulted in
                        86 new claims in fiscal year 2009. In addition, resource centers located
                        near major Department of Energy facilities helped claimants complete
                        necessary claim forms and gather documentation such as employment


                        75
                             GAO-10-7.
                        76
                           The adversarial system in the Black Lung Program does not delay commencement of
                        an awarded claimant’s benefits, however; the program provides that benefits shall be paid
                        to awarded claimants prior to the final adjudication of the claim. If the responsible operator
                        does not voluntarily pay interim benefits, the Black Lung Disability Trust Fund will pay on
                        the operator’s behalf. See 20 C.F.R. 725.522.




                        Page 39                                                   GAO-12-412 Defense Infrastructure
                               verification to support their claims. In fiscal year 2009, this outreach
                               helped claimants file 9,935 claims. Further, the Energy Employees
                               Occupational Illness Compensation Program continues to assist
                               claimants by enhancing its database on the types of chemical and toxic
                               contaminants that existed at the major Department of Energy facilities,
                               easing claimants’ evidentiary burdens and speeding the claims process.

Eligibility Requirements and   According to officials from the agencies that administer the alternative
Associated Presumptions        programs for compensation we reviewed and our prior work, the eligibility
                               requirements of a given program may have an impact on the difficulty of
                               claimants trying to establish eligibility, the time needed to process claims,
                               and the cost of administering the program. The evidence needed by
                               claimants varies based on the criteria for each program, which are set out
                               in statutes and regulations. For example, under many compensation
                               programs, claimants must typically show a link between an environmental
                               exposure and subsequent adverse health conditions to be eligible.
                               However, the three programs we examined have certain presumptions
                               that alleviate the need for claimants to fully establish a causal link
                               between an environmental exposure and subsequent adverse health
                               condition. These presumptions address, among other things, locations at
                               which environmental exposures are presumed to have occurred, time
                               frames during which claimants present in certain locations are presumed
                               to have been exposed, and health conditions that are presumed to have
                               been caused by an exposure. According to officials from the agencies
                               that administer the alternative programs for compensation, although
                               presumptions may reduce the burden on the claimant they may
                               potentially increase costs. In addition, very specific presumptions can
                               reduce eligibility for individuals who do not meet established criteria but
                               who, in fact, developed adverse health conditions due to exposure, while
                               very broad presumptions may overstate the connection between an
                               exposure and adverse health conditions, allowing claimants who were not
                               harmed by the exposure to obtain benefits and potentially increasing the
                               cost of the program unnecessarily. The three alternative programs for
                               compensation that we reviewed further illustrate how eligibility
                               requirements may have an impact on the difficulty of claimants trying to
                               establish eligibility, the time needed to process claims, and the cost of
                               administering the program.

                               •   The Energy Employees Occupational Illness Compensation Program
                                   provides compensation for several different types of claimants. Part B
                                   provides compensation for, among others, employees of the
                                   Department of Energy, its contractors or subcontractors, and atomic
                                   weapons employers with radiation-induced cancer who developed the


                               Page 40                                         GAO-12-412 Defense Infrastructure
      cancer after working at a covered facility and whose cancer is
      determined to be at least as likely as not related to the employment.
      The Energy Employees Occupational Illness Compensation Program
      relies on extensive medical and scientific processes that reconstruct
      the radiation dose exposure by estimating the type and level of
      radiation exposure to each affected organ to collect accurate evidence
      for those claimants with a potential radiation-exposure related cancer,
      which, based on previous GAO work, may increase the time and
      administrative cost to adjudicate a claim. 77 In 2010, GAO found that it
      took 3 or more years to process claims that required a radiation dose
      reconstruction, while those that did not require this reconstruction took
      about a year to adjudicate. 78 In addition, the direct administrative
      costs for cases that require a dose reconstruction for potential
      radiation-exposure related cancer, based on our 2010 report, are
      estimated at about $20,000 per case, while the administrative costs of
      other cases under the program ranged from $6,000-$8,000 per
      case. 79 However, in some cases in which it is not feasible to estimate
      with sufficient accuracy the radiation dose received by employees at
      Department of Energy facilities who were likely exposed to radiation—
      and there is a reasonable likelihood that such radiation dose may
      have endangered employees’ health—the Energy Employees
      Occupational Illness Compensation Program Act provides for the
      addition of a class of those employees to the special exposure cohort.
      Unlike claimants who are not members of the special exposure
      cohort, members of the cohort who are diagnosed with any of the
      cancers specified by Congress are not required to establish that the
      cancer was “at least as likely as not” related to their employment. For
      members of the cohort, this presumption reduces the evidence
      necessary to meet eligibility requirements by removing the need to
      establish causation between the exposure and the illness. According
      to Department of Labor officials, for members of any of the more than
      70 additional classes of employees added to the special exposure
      cohort, the claim approval rate is 60 percent, compared to 34 percent
      for claimants who are not in the special exposure cohort. 80 Agency


77
   GAO, Energy Employees Compensation: Additional Oversight and Transparency Would
Improve Program’s Credibility, GAO-10-302 (Washington, D.C.: Mar. 22, 2010).
78
     GAO-10-302.
79
     GAO-10-302.
80
     GAO-10-302.




Page 41                                            GAO-12-412 Defense Infrastructure
      officials told us that the special exposure cohort alleviates the need for
      administrators to determine whether evidence supports the existence
      of a link between the employment and the illness for each individual,
      thus reducing administrative costs and the time needed for
      adjudicating claims. However, these presumptions may overstate the
      connection between an exposure and adverse health conditions and
      potentially increase the cost of benefits provided in the program by
      allowing claimants who were not harmed by the exposure to obtain
      benefits.

•     In order to receive benefits under the Black Lung Program, claimants
      must generally show that the miner has or had pneumoconiosis, the
      pneumoconiosis resulted in total disability or death, and that the
      pneumoconiosis arose, at least in part, out of coal mine employment.
      The requirement to establish causation between the coal mine
      employment and the adverse health condition may increase the
      difficulty for claimants trying to establish eligibility. For example, prior
      GAO work has shown that few claimants have been able to meet the
      program’s evidentiary requirements set by law. 81 In 2008, 87 percent
      of claims within the Black Lung Program were denied, with over 60
      percent of the claims denied during the initial adjudication because
      claimants could not prove that they had pneumoconiosis or that
      pneumoconiosis had caused disability or death. 82 The Black Lung
      Program has some presumptions, set out in statute, that ease this
      requirement for claimants who worked at a coal mine. 83 However,
      some of these presumptions are rebuttable, and according to agency
      officials, can still be refuted by the mine operator.

•     Claimants seeking compensation under the Radiation Exposure
      Compensation Program must show that they were exposed to
      radiation from atmospheric nuclear testing or as a result of their
      employment in the uranium mining industry, and that they developed
      a related adverse health condition, specified in law or regulation.
      These claimants are not required to establish causation between the


81
     GAO-10-7.
82
     GAO-10-7.
83
   For example, 30 U.S.C. §921 (c)(1) states that “if a miner who is suffering or suffered
from pneumoconiosis was employed for ten years or more in one or more coal mines
there shall be a rebuttable presumption that his pneumoconiosis arose out of such
employment.”




Page 42                                                   GAO-12-412 Defense Infrastructure
                                exposure and the adverse health condition. According to a
                                Department of Justice report, the Radiation Exposure Compensation
                                Program was designed to utilize existing records so that claims could
                                be resolved in a reliable, objective, and nonadversarial manner, with
                                little administrative cost to the program or person filing the claim. For
                                example, residents who lived downwind of atmospheric nuclear
                                weapons tests may use a record for ownership of a home to show that
                                they were present in a location during a specific time frame to meet
                                the qualifications of the program. While this approach may be
                                beneficial for administrators and claimants, the officials from the
                                agencies that administer the compensation programs told us that not
                                requiring the establishment of causation using scientific evidence
                                potentially diminishes the accuracy of decisions for claims, and may
                                increase the number of claimants who were not harmed by the
                                exposure but are approved for benefits. A study by the National
                                Academy of Sciences emphasizes this by concluding that eligibility for
                                the Radiation Exposure Compensation Program should be based on a
                                more scientific approach that emphasizes a “probability of causation”
                                model that uses a mathematical formula to determine whether
                                radiation exposure is likely the cause of an individual’s cancer. 84

Frequencies and Types of   The frequencies and types of payment provided vary among alternative
Payment                    programs for compensation, and may impact the administrative costs of
                           compensation programs. For example, the Energy Employees
                           Occupational Illness Compensation Program Act and the Radiation
                           Exposure Compensation Act provide lump sum payments in varying
                           amounts, while the Black Lung Program provides monthly payments. The
                           Energy Employees Occupational Illness Compensation Program and the
                           Black Lung Program also provide compensation for some medical
                           expenses, and the Black Lung Program provides, in some cases,
                           payment of claimants’ attorney fees. According to Departments of Labor
                           and Justice officials who administer these programs, the frequency and
                           type of payments a program provides impacts administrative costs of the
                           program. For example, although a lump sum benefit payment has low
                           administrative costs since it is a one-time payment, some officials noted
                           that there may be moral implications with lump sum payments especially
                           in cases where the claimant may misallocate their lump sum award and
                           need to pursue benefits from other federal programs such as Social



                           84
                             The National Academies Press, Assessment of the Scientific Information for the
                           Radiation Exposure Screening and Education Program (Washington, D.C.: 2005).




                           Page 43                                               GAO-12-412 Defense Infrastructure
              Security Disability Insurance. Conversely, although monthly payments
              may cost more in the longer term compared to lump sum payments,
              especially if an adverse health condition must be periodically monitored
              through the program in order to establish continued eligibility, a monthly
              or periodic payment, on the other hand, would provide a steady stream of
              income to the claimant but may also cost more to administer since the
              funding agency must process payments on a monthly basis.


              In the most recent Defense Installations Strategic Plan, DOD states its
Conclusions   goals of providing effective, safe, and environmentally sound living and
              working places in support of DOD missions. However, limitations in some
              of the existing policies targeting such areas as environmental restoration
              complicate DOD’s efforts to consistently address environmental
              exposures for individuals living or working on its installations. DOD only
              recently revised its policy on health surveillance to include dependents
              when collecting data that could improve its ability to address health risks
              that may have resulted from environmental exposures. However, this
              policy does not apply retroactively to past events such as those at Camp
              Lejeune.

              DOD does not fully track the status of its responses to recommendations
              and findings of significant risk from the Agency for Toxic Substances and
              Disease Registry’s public health assessments. In addition, the current
              process does not ensure that status information on recommendations is
              provided to or documented by the lead agent’s office, as prescribed in the
              guidelines referenced in the memorandum of understanding between the
              two agencies. As such, DOD cannot ensure that it has taken timely and
              appropriate responses to all public health risks. Furthermore, because
              DOD does not have a policy establishing when it is appropriate for
              installations to request public health assessments or follow-up work
              beyond the initial assessment of proposed National Priorities List sites by
              the Agency for Toxic Substances and Disease Registry, DOD could be
              missing opportunities to identify and resolve concerns about some health
              threats. While DOD officials told us that cleanup laws do not require
              identification of individuals potentially affected by past exposures, events
              like the contamination at Camp Lejeune indicate a need for some
              guidance on whether, when, and how to respond to health concerns
              raised about such individuals.




              Page 44                                        GAO-12-412 Defense Infrastructure
                      To ensure that DOD meets its goal of providing effective, safe, and
Recommendations for   environmentally sound living and working places, and to assess potential
Executive Action      gaps in policy coverage for individuals living or working on its installations
                      who are exposed to environmental hazards, the Secretary of Defense
                      should direct the Under Secretary of Defense for Acquisition, Technology,
                      and Logistics to take the following three actions:

                      (1) Establish procedures to comprehensively track and document the
                      status and nature of DOD responses to Agency for Toxic Substances and
                      Disease Registry recommendations and findings of significant risk to
                      ensure that DOD and its components monitor the status of these
                      recommendations and findings of significant risk and respond in a timely
                      manner. These procedures should be reflected in an updated
                      memorandum of understanding prepared in collaboration with the Agency
                      for Toxic Substances and Disease Registry, and could include revisions
                      to the agencies’ joint guidelines or other mechanisms.

                      (2) Establish a policy that identifies when installations should consider
                      requesting public health assessments in addition to the initial
                      assessments at National Priorities List sites.

                      (3) Provide guidance on what actions, if any, DOD should take to identify
                      and address possible health risks faced by individuals from past
                      exposures at military installations.


                      We provided copies of this report for review and comment to the
Agency Comments       Departments of Defense, Veterans Affairs, Health and Human Services,
and Our Evaluation    Labor, and Justice. The Departments of Defense, Veterans Affairs, and
                      Health and Human Services provided written comment letters; all of the
                      departments provided technical comments which we have incorporated
                      as appropriate. The Departments of Defense’s, Veterans Affairs’, and
                      Health and Human Services’ written comment letters are reprinted in
                      appendices IV, V, and VI, respectively. The Department of Veterans
                      Affairs supported the recommendations, stating that “the Department of
                      Defense’s adoption of the report recommendations would likely lead to
                      prompt provision of additional information on exposures, and ultimately
                      help veterans and others potentially exposed.” The Department of Health
                      and Human Services expressed its support for the first recommendation
                      indicating that it would be available to collaborate with DOD to update the
                      current memorandum of understanding. In its comments, DOD partially
                      concurred with our first recommendation and did not concur with our



                      Page 45                                         GAO-12-412 Defense Infrastructure
second and third recommendations. We continue to believe our
recommendations remain valid, as discussed in the report.

DOD partially concurred with our first recommendation––to establish
procedures to comprehensively track and document the status and nature
of DOD responses to public health recommendations and reflect these
procedures in an updated memorandum of understanding. Specifically:

    •     DOD stated that it will review its procedures for tracking DOD’s
          responses to Agency for Toxic Substances and Disease Registry
          recommendations and, if needed, make the appropriate changes
          to its tracking system. As noted in our report, the tracking system
          data provided to GAO indicated that DOD did not have information
          on the status of DOD’s response to 80 percent of the
          recommendations. Therefore, we believe DOD needs to make
          improvements to its tracking system. Without these improvements,
          DOD is missing opportunities to ensure that vital public health
          issues are adequately addressed.

    •     In regards to the memorandum of understanding, DOD stated that
          changes are not necessary. We disagree. The current
          memorandum of understanding does not expressly call for
          tracking recommendations, which we believe is an important
          coordination activity. As we note in our report, the memorandum
          of understanding does refer to DOD guidelines for tracking
          recommendations, but these have not been updated in 17 years.
          Moreover, these guidelines are not being followed, as our report
          shows and DOD officials acknowledged. These guidelines called
          for regular updates and an annual report on the status of
          recommendations and public health actions at each site. On the
          other hand, the Agency for Toxic Substances and Disease
          Registry officials told us that updating the memorandum of
          understanding with DOD, to address tracking recommendations
          would be useful. Given that DOD is not following the tracking
          procedures in its existing guidelines and overlooking the status of
          80 percent of the recommendations, we believe that the
          memorandum of understanding should be revised to expressly
          address tracking responsibilities to help ensure that identified
          public health risks are addressed.

DOD did not concur with our second recommendation––to establish a
policy that identifies when installations should consider requesting public
health assessments in addition to the initial assessments at National


Page 46                                          GAO-12-412 Defense Infrastructure
Priorities List sites. DOD stated that its agrees that there should be
policies in place to guide decisions on soliciting public health
assessments, but believes the appropriate policies and responsibilities
are already in place. We disagree with DOD for several reasons:

    •     First, DOD states that additional public health assessments
          conducted by the Agency for Toxic Substances and Disease
          Registry would duplicate the risk assessments conducted by DOD
          and others, which it believes are more comprehensive. We believe
          DOD’s comments overlook the important distinctions between the
          two assessments. Risk assessments are intended to enable the
          selection of cleanup remedies to reduce or eliminate current and
          future exposures, but these risk assessments generally do not
          include epidemiology or assessments of health risk to populations
          from current, future, and past exposures, as the public health
          assessments do––a fact which DOD officials acknowledged.
          Thus, these assessments have distinct purposes and scopes.

    •     Second, DOD states that supplementary policy for additional
          public health assessments for DOD cleanup sites is not needed,
          but did not elaborate on the reasons why. In the course of
          conducting a DOD cleanup program, installations may become
          aware of past exposures––such as at Tyndall Air Force Base or
          Camp Lejeune––years after an initial health assessment was
          developed. In fact, site characterization and restoration activities
          may take many years, and new health risks may be discovered
          during this process. However, without this guidance, it is unclear
          when it is appropriate to request a new health assessment.

    •     Third, DOD states that its current policies require the assessment
          of health risks to servicemembers and their dependents living on
          its installations; however, until DOD’s February 2012 revised
          directive, it was unclear when and if health surveillance data were
          collected for servicemembers’ dependents. As we said in the
          report, it is too soon to determine whether the implementation of
          this directive will include all individuals living or working on DOD
          installations––particularly servicemembers’ dependents living on
          overseas installations. As such, policies beyond the general
          directive are needed to ensure appropriate data are collected that
          might support a public health assessment when necessary.

    •     Finally, DOD states that assessments at Naval Air Station Atsugi,
          Japan, and Naval Air Station Fallon, Nevada, were initiated based


Page 47                                           GAO-12-412 Defense Infrastructure
          on health concerns raised by military families living on these
          installations. However, in our view, these examples highlight
          DOD’s reactive––rather than proactive––approach to responding
          to health concerns. In the case of air pollution at Atsugi, no DOD
          policy existed to guide the Navy on their approach to conducting
          environmental surveillance, medical testing, or notification of the
          potentially exposed dependents. As a result, it took several years
          for DOD to complete a risk assessment and notify
          servicemembers and their dependents about the long-term health
          effects. It took at least 13 years after the initial complaints for DOD
          and the U.S. government to get the Japanese government to
          close the incinerator that contributed to the air pollution. Policies to
          guide decisions on soliciting public health assessments could
          accelerate DOD’s response to future public health concerns.

DOD did not concur with our third recommendation––to provide guidance
on actions to identify and address possible health risks faced by
individuals from past exposures at military installations. DOD stated that it
follows federal law, and its current guidance and policy are adequate for
reasonably anticipated actions. We disagree for two reasons:

    •     The experiences at Atsugi Naval Air Station and Camp Lejeune
          demonstrate that DOD’s current guidance and policy are not
          adequate to encompass situations that have potentially severe
          health implications, which DOD has already encountered in the
          past. At Atsugi, an off-base incinerator in Japan released toxic
          fumes that drifted onto the naval base and may have exposed
          over 25,000 individuals on the installation to toxic air contaminants
          from 1985 through 2001, according to the Department of Veterans
          Affairs, despite individual complaints starting around 1988. At
          Camp Lejeune, potential exposure to volatile organic compounds
          in drinking water has resulted in administrative claims by
          servicemembers against the U.S. government totaling billions of
          dollars in potential damages for health conditions alleged to have
          resulted from exposure to contaminated water. In these examples,
          no current DOD policy or guidance was available to provide focus
          and direction in how officials should address past exposures. We
          continue to believe that these experiences could inform new
          policies by DOD to provide guidance to the services and their
          installations on how to manage situations that encounter similar
          challenges in the future, while maintaining appropriate flexibility.




Page 48                                            GAO-12-412 Defense Infrastructure
      •    DOD stated that its cleanup policy is adequate because the
           Comprehensive Environmental Response, Compensation, and
           Liability Act does not require responsible parties to identify
           individuals who may have been exposed to contamination in the
           past. We agree that the act does not generally require responsible
           parties to identify exposed individuals, but that was not the basis
           for our recommendation; moreover, DOD is not limited to meeting
           the minimum requirements of federal law. GAO was mandated by
           Congress to review the extent to which DOD has a standard
           framework for responding to environmental hazards and possible
           exposures, among other things, and to make recommendations
           for any administrative action “that the Comptroller General deems
           appropriate in the context of the assessment.” 85 In determining
           whether there is a standard framework, we found these gaps in
           policy. In light of these gaps and our mandate, we believe it is
           appropriate and have recommended that DOD develop guidance
           to assist the services and their installations in these situations.
           Further, we emphasize that our recommendation calls for
           guidance, but leaves its substance—such as what actions, if any,
           are appropriate—to DOD.

In its written comments on a draft of this report, the Department of
Veterans Affairs stated that environmental exposure data should be
available in service treatment records and that this information is vitally
important for the Department to adequately adjudicate claims based on
environmental exposures. Accordingly, the Department stated that DOD’s
adoption of our report recommendations would likely lead to the prompt
provision of additional information on exposures, and ultimately help
veterans and others potentially exposed. The Department of Veterans
Affairs’ written comments are reprinted in appendix V.

In its written comments on a draft of this report, the Department of Health
and Human Services stated that in regards to our first recommendation,
the Agency for Toxic Substances and Disease Registry would be
available for collaboration with DOD to update the current memorandum
of understanding that is in place regarding the Agency for Toxic
Substances and Disease Registry’s recommendations and findings for




85
     Ike Skelton National Defense Authorization Act of 2011, Pub. L. No. 111-383 § 314.




Page 49                                                  GAO-12-412 Defense Infrastructure
significant risk. The Department of Health and Human Services’ written
comments are reprinted in appendix VI.


We are sending copies of this report to interested congressional
committees and the Secretaries of Defense, Labor, Veterans Affairs; the
Under Secretary of Defense for Acquisition, Technology, and Logistics;
the Attorney General; and the Director of the Centers for Disease Control
and Prevention. The report also is available at no charge on GAO’s
website at http://www.gao.gov.

If you or your staff have any questions concerning this report, you may
contact us at: Brian J. Lepore, (202) 512-4523 or leporeb@gao.gov or
David C. Trimble, (202) 512-9338 or trimbled@gao.gov. Contact points
for our Offices of Congressional Relations and Public Affairs may be
found on the last page of this report. Key contributors to this report are
listed in appendix VII.




Brian J. Lepore, Director
Defense Capabilities and Management




David C. Trimble, Director
Natural Resources and Environment




Page 50                                         GAO-12-412 Defense Infrastructure
Appendix I: Objectives, Scope, and
              Appendix I: Objectives, Scope, and
              Methodology



Methodology

              The objectives of our report were to determine (1) the extent to which the
              Department of Defense (DOD) has policies for identifying and responding
              to possible human exposures to environmental hazards on its
              installations; (2) what programs currently exist to provide health care and
              compensation to individuals for adverse health conditions resulting from
              environmental exposures on military installations and any factors that
              may affect these individuals’ access to health care or compensation; and
              (3) the features of alternative federal programs that provide medical
              benefits or compensation to large groups of individuals affected by a
              specific environmental exposure, which may be considered as possible
              options in the design of any future programs for individuals harmed by
              environmental hazards.

              To determine the extent to which DOD has policies for identifying and
              responding to possible human exposures to environmental hazards on its
              installations, we reviewed and analyzed relevant laws as well as DOD,
              Environmental Protection Agency, and Agency for Toxic Substance and
              Disease Registry guidance and other documentation to identify the extent
              to which DOD identifies and responds to environmental exposures that
              may pose a risk to human health. In conducting this analysis, we
              catalogued DOD guidance and conducted content analysis to determine
              the extent to which the guidance addressed environmental exposures on
              military installations. Additionally, we conducted a literature search in
              professional journals to identify DOD policies in responding to
              environmental exposures. We also examined the database used to track
              the Agency for Toxic Substances and Disease Registry’s public health
              assessment recommendations and DOD’s implementation of those
              recommendations. In addition, we interviewed DOD officials at the Office
              of the Secretary of Defense and the various components, as well as
              officials at the Environmental Protection Agency, the Agency for Toxic
              Substances and Disease Registry, and some members of the Agency for
              Toxic Substances and Disease Registry’s Community Assistance Panel
              for Camp Lejeune. The Agency for Toxic Substances and Disease
              Registry created the community assistance panel as the forum for the
              Camp Lejeune community to voice concerns and provide input into future
              health studies regarding the water contamination at Camp Lejeune. We
              attended the July 2011 meeting of the Community Assistance Panel held
              in Wilmington, North Carolina and also conducted site visits to Camp
              Lejeune, North Carolina and Aberdeen Proving Ground, Maryland where
              the Army, as DOD’s Executive Agent for interaction with the Agency for
              Toxic Substances and Disease Registry, has its offices.




              Page 51                                        GAO-12-412 Defense Infrastructure
Appendix I: Objectives, Scope, and
Methodology




To determine what programs currently exist to provide health care and
compensation to individuals for adverse health conditions resulting from
environmental exposures on military installations and any factors that
may affect these individuals’ access to health care or compensation, we
reviewed and analyzed relevant laws and regulations, agency guidance,
scientific journals, and other documentation to identify the eligibility
requirements and determination procedures and extent of compensation
and medical benefits provided through various processes currently
available to different types of individuals (veterans and servicemembers
and current and former military dependents, federal civilian workers, and
contractors) possibly exposed to environmental hazards while working or
living on military installations. We reviewed the following programs: the
Federal Employee Compensation Act Program, Department of Defense’s
TRICARE, Department of Defense’s Disability Evaluation System,
Department of Veterans Affairs’ disability benefits and health care
benefits programs, State Workers’ Compensation Programs, the Defense
Base Act, and Federal Employee Health Benefits Program. We then
developed matrices comparing the eligibility requirements and
determination procedures of the various programs to identify what types
of individuals were eligible for the various programs and if there were any
gaps in coverage. We met agency officials from the Departments of
Defense, Veterans Affairs, Labor, and Justice, to obtain further insight
into the administration and eligibility requirements of the various
programs; find out the reasons for any gaps in coverage and what
challenges exist in obtaining benefits or compensation; and determine the
potential adverse effects any such gaps and challenges may have on
individuals exposed to environmental hazards. In addition, we interviewed
officials from each of the Army, Navy, and Air Force Judge Advocate
Offices to obtain information regarding environmental exposure tort
claims and the process for filing claims. To assess the reliability of claims
data obtained from the Department of the Navy and the Department of
Veterans Affairs, we interviewed agency officials regarding the processes
and procedures used to verify accurate data are maintained within the
databases. Although we did not independently validate the claims data,
we found these data to be sufficiently reliable for our purposes.

To determine the features of alternative federal programs that provide
medical benefits or compensation to large groups of individuals affected
by a specific environmental exposure, which may be considered as
possible options in the design of any future programs for individuals
harmed by environmental hazards, we reviewed and analyzed relevant
laws and regulations, academic journals, external studies, and previous
GAO reports to identify alternative compensation programs that (1)


Page 52                                         GAO-12-412 Defense Infrastructure
Appendix I: Objectives, Scope, and
Methodology




provided monetary compensation for specific adverse health conditions or
death and/or medical benefits, (2) provided compensation based on
exposure to a harmful contaminant in the environment, and (3) were
federal programs that covered U.S. citizens. Using these criteria, we
identified three programs: The Black Lung Program administered by the
Department of Labor, the Energy Employee Occupational Illness
Compensation Program administered by the Department of Labor, and
the Radiation Exposure Compensation Program administered by the
Department of Justice as the most comparable of environmental
exposure compensation programs. We identified one other environmental
exposure-related compensation program, the Marshall Islands Nuclear
Claims Tribunal, but did not include it our analysis because it does not
provide compensation to U.S. citizens. Although we collected and
reviewed information regarding other compensation programs such as the
Smallpox Vaccine Injury Compensation Program, the National Vaccine
Injury Compensation Program, and the September 11th Victim
Compensation Fund, we did not include these programs in our analysis
as they do not provide compensation for injuries caused by environmental
hazards. Both the Smallpox Vaccine Injury Compensation Program and
the National Vaccine Injury Compensation Program provide
compensation for injuries caused by vaccines and the September 11th
Victim Compensation Fund only provides compensation based on death
or injury caused by terrorist attacks. To identify and assess the features of
these alternative compensation programs, including the benefit and
challenges to the design of features, we reviewed prior GAO reports, met
with GAO experts who have reported on these programs, interviewed
agency officials with the Departments of Labor and Justice, and obtained
and reviewed documentation and claims data on the programs from
agency officials. To assess the reliability of claims data obtained by the
Departments of Labor and Justice, we interviewed agency officials and
received written documentation on internal control used by the agencies
and the processes and procedures used to verify accurate data are
maintained within the databases. Although we did not independently
validate the claims data, we found these data to be sufficiently reliable for
our purposes.

We conducted this performance audit between May 2011 and May 2012
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.


Page 53                                         GAO-12-412 Defense Infrastructure
Appendix II: Selected Contaminants That
              Appendix II: Selected Contaminants That Have
              Been Found on Some Military Installations and
              Their Effect on Humans


Have Been Found on Some Military
Installations and Their Effect on Humans
              The Department of Defense has 141 installations on the national priorities
              list. In some cases, these installations and surrounding areas became
              heavily contaminated due to storage and disposal of substances such as
              solvents, machining oils, metalworking fluids, and metals. Many of these
              contaminants, such as trichloroethylene, perchloroethylene, and vinyl
              chloride, are known or suspected carcinogens. On some installations,
              these contaminants have spread far beyond their points of origin because
              they have been transported by wind currents or have leached into
              groundwater supplies, resulting in potential environmental exposures.
              Some of these contaminants include:

              •   Perchlorate is a rocket fuel component and by-product of rocket and
                  missile testing and is also found in some fertilizers and fireworks.
                  Now ubiquitous in the environment, it has spread from numerous
                  manufacturing sites into drinking water systems and can also
                  accumulate in leafy food crops and fruit irrigated by perchlorate-
                  contaminated water. According to the Agency for Toxic Substances
                  and Disease Registry, perchlorate’s main target for toxicity in humans
                  is the thyroid gland. In humans, perchlorate accumulates in the thyroid
                  gland and can block iodide transfer into the thyroid, resulting in iodine
                  deficiency and lower thyroid activity. The populations most sensitive to
                  perchlorate exposure are children and fetuses, as adequate iodide is
                  crucial for neurological development.

              •   Trichloroethylene and Perchloroethylene are solvents that have
                  historically been used as metal degreasers and as ingredients in dry-
                  cleaning spot removers, adhesives, paint removers, and typewriter
                  correction fluids. According to the Environmental Protection Agency,
                  exposure to trichloroethylene and perchloroethylene can result in
                  cardiac arrhythmia, liver damage, and possible kidney effects, as well
                  as an increased risk for a variety of cancers (esophagus, kidney,
                  bladder, lung, pancreas, and cervix). Trichloroethylene and
                  perchloroethylene degrade in groundwater over time to vinyl chloride.

              •   Vinyl chloride is a colorless gas with a sweet odor. Vinyl chloride is
                  used to manufacture numerous products in building construction, the
                  automotive industry, electrical wire insulation and cables, piping,
                  industrial and household equipment, and medical supplies, and is
                  depended upon heavily by the rubber, paper, and glass industries.
                  Vinyl chloride is a known human carcinogenic and, according to the
                  Environmental Protection Agency, long-term exposure to vinyl
                  chloride may lead to liver cancer.




              Page 54                                         GAO-12-412 Defense Infrastructure
Appendix II: Selected Contaminants That Have
Been Found on Some Military Installations and
Their Effect on Humans




•   Benzene is a colorless liquid with a sweet odor that is highly
    flammable, evaporates in the air very quickly, and dissolves slightly in
    water. Benzene is formed from both natural processes and human
    activities. Natural sources of benzene include volcanoes and forest
    fires. Benzene is a natural part of crude oil, gasoline, and cigarette
    smoke. It is widely used in the United States. Some industries use
    benzene to make other chemicals that are used to make plastics,
    resins, and nylon and synthetic fibers. Benzene is also used to make
    some types of lubricants, rubbers, dyes, detergents, drugs, and
    pesticides. In humans, benzene causes cells not to work correctly.
    For example, it can cause bone marrow not to produce enough red
    blood cells, which can lead to anemia. Also, it can damage the
    immune system by changing blood levels of antibodies and causing
    the loss of white blood cells. The Department of Health and Human
    Services has determined that benzene causes cancer in humans.

•   Lead is extensively used in ammunition and firearms and, as a result,
    is prevalent in the soil of current and former firing ranges on many
    military installations. Lead can affect almost every organ and system
    in the body. The main target for lead toxicity is the nervous system,
    both in adults and children. Exposure to high lead levels can severely
    damage the brain and kidneys in adults or children.




Page 55                                         GAO-12-412 Defense Infrastructure
Appendix III: Significant Health Studies and
                                                Appendix III: Significant Health Studies and
                                                Notification Efforts Related to Contamination
                                                at Marine Corps Base Camp Lejeune


Notification Efforts Related to Contamination
at Marine Corps Base Camp Lejeune
1997 – An Agency for Toxic Substances and Disease Registry health assessment stated that exposure to volatile organic compounds in three
drinking water systems on base was a public health hazard. The Agency also stated that the exposures were not likely to cause health problems in
adults but recommended that studies be conducted to evaluate the risks of childhood cancer related to volatile organic compound exposure at Camp
Lejeune and noted that adverse pregnancy outcomes were also of concern.


1998 – An Agency for Toxic Substances and Disease Registry study found a statistically significant association between exposure and some adverse
pregnancy outcomes.


1999 – 2012 – An Agency for Toxic Substances and Disease Registry case-control study of specific birth defects and childhood cancers at Camp
Lejeune was initiated to evaluate whether in utero exposure and/or exposure during the first year of life to contaminated drinking water at the base
was associated with specific birth defects and childhood cancers. Agency for Toxic Substances and Disease Registry expects completion of the study
some time in 2012.


2005 – An expert panel reported on the Agency for Toxic Substances and Disease Registry’s computer models of past Camp Lejeune drinking water
systems. The Agency for Toxic Substances and Disease Registry said it accepted the panel’s recommendations for more rigorous record searches in
order to reconstruct events for the water modeling studies.


2007 – A Marine Corps online notification registration database and a new telephone line was activated to place former Camp Lejeune residents,
workers, and other interested parties on a contact list to receive results from research initiatives.


2008 – The National Defense Authorization Act for Fiscal Year 2008, Pub. L. No 110-181 § 315 required, among other things, that the Secretary of
the Navy make reasonable efforts to identify and notify directly certain individuals – those served by the contaminated water systems or civilian
employees in particular timeframes—who may have been exposed to the contaminated drinking water at Camp Lejeune.


2008 – A Marine Corps and Internal Revenue Service mailing was sent to about 150,000 individuals who resided or worked at Camp Lejeune during
the applicable timeframe encouraging individuals to join the contact list to be notified about research initiatives.


2009 – The Agency for Toxic Substances and Disease Registry said it withdrew its 1997 public health assessment after additional information
emerged related to exposures to volatile organic compounds in drinking water at Camp Lejeune. The public health agency said inaccuracies
regarding the exclusion of benzene in the 1997 assessment caused the withdrawal. The Agency for Toxic Substances and Disease Registry plans to
revise the public health assessment once a water modeling study is complete. In the meantime, the Agency for Toxic Substances and Disease
Registry said it stands behind the information related to the other nine exposure pathways.


2009 – The National Research Council completed a report in response to a request from the Navy, mandated by Congress (Pub. L. No. 109-364,
§318), to review evidence on whether adverse health outcomes are associated with past contamination of the water supply at Camp Lejeune. Among
other things, the National Research Council concluded that most questions about whether exposures at Camp Lejeune resulted in adverse health
effects cannot be answered definitively even with further scientific study.


2010 – The Agency for Toxic Substances and Disease Registry began conducting a mortality study looking at all causes of death, including cancers
and other fatal diseases to determine if there is a link between the death and exposure to contaminated drinking water at Camp Lejeune. The study
focuses on Marines who started active duty and DOD civilian employees who began work at Camp Lejeune between June 1975 and December 1985.


2011 – The Agency for Toxic Substances and Disease Registry launched a health survey of 300,000 Marine Corps personnel and civilians regarding
diseases that may be associated with chemical exposures in the drinking water, in response to a mandate in the 2008 National Defense Authorization
Act. This is the largest health survey ever conducted by the Agency for Toxic Substances and Disease Registry, which expects to release its findings
in 2014.


                                                Source: DOD and Agency for Toxic Substances and Disease Registry.




                                                Page 56                                                             GAO-12-412 Defense Infrastructure
Appendix IV: Comments from the
             Appendix IV: Comments from the Department
             of Defense



Department of Defense




             Page 57                                     GAO-12-412 Defense Infrastructure
Appendix IV: Comments from the Department
of Defense




Page 58                                     GAO-12-412 Defense Infrastructure
Appendix IV: Comments from the Department
of Defense




Page 59                                     GAO-12-412 Defense Infrastructure
Appendix IV: Comments from the Department
of Defense




Page 60                                     GAO-12-412 Defense Infrastructure
Appendix V: Comments from the Department
             Appendix V: Comments from the Department
             of Veterans Affairs



of Veterans Affairs




             Page 61                                    GAO-12-412 Defense Infrastructure
Appendix VI: Comments from Department of
             Appendix VI: Comments from Department of
             Health and Human Services



Health and Human Services




             Page 62                                    GAO-12-412 Defense Infrastructure
Appendix VI: Comments from Department of
Health and Human Services




Page 63                                    GAO-12-412 Defense Infrastructure
Appendix VII: GAO Contacts and Staff
                  Appendix VII: GAO Contacts and Staff
                  Acknowledgments



Acknowledgments

                  Brian J. Lepore, (202) 512-4523 or leporeb@gao.gov
GAO Contacts
                  David C. Trimble, (202) 512-9338 or trimbled@gao.gov


                  In addition to the individuals named above, Diane Raynes (Assistant
Acknowledgments   Director), Mark J. Wielgoszynski (Assistant Director), Shawn Arbogast,
                  Elizabeth Beardsley, Marissa Dondoe, Laurie Ellington, Dani Greene,
                  Joanne Landesman, Nicholas McKay, Jennifer Neer, Alison O’Neill,
                  Daniel Semick, Amie Steele, and Nicole Willems made key contributions
                  to this report.




                  Page 64                                     GAO-12-412 Defense Infrastructure
Related GAO Products
             Related GAO Products




             Hearing Loss Prevention: Improvements to DOD Hearing Conservation
             Programs Could Lead to Better Outcomes. GAO-11-114. Washington,
             D.C.: January 31, 2011.

             Afghanistan and Iraq: DOD Should Improve Adherence to Its Guidance
             on Open Pit Burning and Solid Waste Management. GAO-11-63.
             Washington, D.C.: October 15, 2010.

             Superfund: Interagency Agreements and Improved Project Management
             Needed to Achieve Cleanup Progress at Key Defense Installations.
             GAO-10-348. Washington, D.C.: July 15, 2010.

             Agency for Toxic Substances and Disease Registry: Policies and
             Procedures for Public Health Product Preparation Should Be
             Strengthened. GAO-10-449. Washington, D.C.: April 30, 2010.

             Energy Employees Compensation: Additional Oversight and
             Transparency Would Improve Program’s Credibility. GAO-10-302.
             Washington, D.C.: March 22, 2010.

             Black Lung Benefits Program: Administrative and Structural Changes
             Could Improve Miners’ Ability to Pursue Claims. GAO-10-7. Washington,
             D.C.: October 30, 2009.

             Superfund: Greater EPA Enforcement and Reporting are Needed to
             Enhance Cleanup at DOD Sites. GAO-09-278. Washington, D.C.: March
             13, 2009.

             Radiation Exposure Compensation: Radiation Exposure Compensation
             Act: Program Status. GAO-07-1037R. Washington, D.C.: September 7,
             2007.

             Environmental Contamination: Department of Defense Activities Related
             to Trichloroethylene, Perchlorate, and Other Emerging Contaminants.
             GAO-07-1042T. Washington, D.C.: July 12, 2007.

             Defense Health Care: Issues Related to Past Drinking Water
             Contamination at Marine Corps Base Camp Lejeune. GAO-07-933T.
             Washington, D.C.: June 12, 2007.

             Defense Health Care: Activities Related to Past Drinking Water
             Contamination at Marine Corps Base Camp Lejeune. GAO-07-276.
             Washington, D.C.: May 11, 2007.


             Page 65                                     GAO-12-412 Defense Infrastructure
           Related GAO Products




           Federal Compensation Programs: Perspectives on Four Programs.
           GAO-06-230. Washington, D.C.: November 18 2005.

           Defense Health Care: Improvements Needed in Occupational and
           Environmental Health Surveillance during Deployment to Address
           Immediate and Long-term Health Issues. GAO-05-632. Washington, D.C.:
           July 14, 2005.

           Perchlorate: A System to Track Sampling and Cleanup Results is
           Needed. GAO-05-462. Washington, D.C.: May 20, 2005.

           Agent Orange: Limited Information Is Available on the Number of Civilians
           Exposed in Vietnam and Their Workers’ Compensation Claims.
           GAO-05-371. Washington, D.C.: April 22, 2005.

           Environmental Compliance: Better DOD Guidance Needed to Ensure
           That the Most Important Activities Are Funded. GAO-03-639. Washington,
           D.C.: June 17, 2003.




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           Page 66                                      GAO-12-412 Defense Infrastructure
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