oversight

Defense Health Care: Medical Surveillance Improved Since Gulf War, but Mixed Results in Bosnia

Published by the Government Accountability Office on 1997-05-13.

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

                   United States General Accounting Office

GAO                Report to Congressional Requesters




May 1997
                   DEFENSE HEALTH
                   CARE
                   Medical Surveillance
                   Improved Since Gulf
                   War, but Mixed Results
                   in Bosnia




GAO/NSIAD-97-136
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      National Security and
      International Affairs Division

      B-275801

      May 13, 1997

      The Honorable Strom Thurmond
      Chairman
      The Honorable Carl Levin
      Ranking Minority Member
      Committee on Armed Services
      United States Senate

      The Honorable Floyd Spence
      Chairman
      The Honorable Ronald Dellums
      Ranking Minority Member
      Committee on National Security
      House of Representatives

      Approximately 697,000 military personnel served in the Persian Gulf from
      August 1990 to June 1991. Soon after redeploying from the Persian Gulf,
      many experienced health problems such as fatigue, muscle and joint pain,
      memory loss, and severe headaches. After over 30 studies, 18 public
      hearings conducted by the Presidential Advisory Committee on Gulf War
      Veterans’ Illnesses, and significant Department of Defense (DOD) efforts,
      the nature and causes of these illnesses remain unclear. The Presidential
      Advisory Committee’s final report concluded that many of the health
      concerns of Gulf War veterans may never be fully resolved because of a
      lack of data.

      Concerned about the health data problem, Congress directed us to
      determine the extent to which the medical records for personnel who
      deployed to the Persian Gulf War are complete.1 We found that, according
      to the DOD officials we interviewed, the Persian Gulf War medical records
      are widely recognized as incomplete and inaccurate in documenting all
      medical events for servicemembers while deployed to the Persian Gulf.
      Accordingly, as agreed with your Committees, we sought to determine
      what action, if any, DOD has taken to improve medical surveillance before,
      during, and after deployments, focusing especially on Operation Joint
      Endeavor, which was conducted in the countries of Bosnia-Herzegovina,
      Croatia, and Hungary.

      To accomplish this objective, we interviewed officials and obtained
      pertinent documentary evidence from officials at the Office of the

      1
       National Defense Authorization Act for Fiscal Year 1997 (sec. 744).



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                                        Assistant Secretary of Defense for Health Affairs; the Joint Staff; the
                                        Offices of the Surgeons General at Army, Navy, and Air Force
                                        Headquarters in Washington, D.C.; and other responsible offices. We also
                                        (1) obtained information from the DOD Deployment Surveillance Team’s
                                        database in Falls Church, Virginia, and (2) reviewed the medical records
                                        for active duty servicemembers in selected Army units in Germany who
                                        deployed to Operation Joint Endeavor. Appendix II describes, in more
                                        detail, the scope and methodology for this report.


                                        A military medical surveillance system that collects, analyzes, and
Background                              disseminates health information facilitates DOD’s ability to intervene in a
                                        timely manner to address health care problems experienced by military
                                        personnel. DOD believes such a system is one of the principal means to
                                        ensure a fit and healthy force and to prevent disease and injuries from
                                        degrading warfighting capabilities. Based on our review of the Presidential
                                        Advisory Committee and the Institute of Medicine reports2 and discussions
                                        with DOD officials, for the purposes of this report we identified four major
                                        elements of a military medical surveillance system, as shown in table 1.

Table 1: Major Elements of a Military
Medical Surveillance System                                        Environmental
                                                                   health threat
                                        Deployment                 assessment and     Medical
                                        information                disease monitoring assessments                   Recordkeeping
                                        Who deployed               Predeployment            Predeployment           All servicemember
                                                                   health threat            medical                 health events
                                        Location in theater        assessment               assessments             in-theater and at
                                                                                                                    home unit
                                        When they were there       Continuous               Postdeployment
                                                                   in-theater               medical                 Predeployment and
                                                                   monitoring of health     assessments             postdeployment
                                                                   threats                                          medical
                                                                                            Centralized             assessments
                                                                   Monitoring of            collection of
                                                                   disease and              medical assessment Use of
                                                                   nonbattle injuries       data               investigational drugs


                                        The Presidential Advisory Committee and the Institute of Medicine
                                        investigations into the causes of illnesses experienced by Gulf War

                                        2
                                         Health Consequences of Service During the Persian Gulf War: Recommendations for Research and
                                        Information Systems, Institute of Medicine, Medical Follow-up Agency (Washington, D.C.: National
                                        Academy Press, 1996); Presidential Advisory Committee on Gulf War Veterans’ Illnesses: Interim
                                        Report (Washington, D.C.: U.S. Government Printing Office, Feb. 1996); Presidential Advisory
                                        Committee on Gulf War Veterans’ Illnesses: Final Report (Washington, D.C.: U.S. Government Printing
                                        Office, Dec. 1996).



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                   veterans confirmed the need for effective medical surveillance
                   capabilities. Research efforts to determine the causes of what has become
                   known as veterans’ Gulf War illnesses have been hampered due to
                   incomplete medical surveillance data on (1) the names and locations of
                   personnel deployed to the Persian Gulf, (2) exposure of personnel to
                   environmental health hazards, (3) changes in the health status of
                   personnel deployed in the theater, and (4) records of immunizations and
                   other health services provided to the individuals while deployed. In
                   essence, the data available were poorly suited to support epidemiological3
                   and health outcome studies related to veterans’ Gulf War illnesses.


                   DOD  has initiated actions to improve its medical surveillance for
Results in Brief   deployments since the Gulf War. A joint medical surveillance policy,
                   currently under development since late 1994, calls for a comprehensive
                   DOD-wide medical surveillance capability to monitor and assess the effects
                   of deployments on servicemembers’ health. Provisions of the draft policy
                   address the medical surveillance problems experienced during the Gulf
                   War; however, its success in resolving the problems cannot be assessed
                   until the directive and implementing instruction are finalized and applied
                   to a deployment. DOD officials expect the policy to be finalized by
                   September 1997. After the policy is issued, the services and responsible
                   offices are to develop detailed implementing instructions.

                   DOD  has also implemented two comprehensive medical surveillance
                   plans—one for Operation Joint Endeavor in Bosnia-Herzegovina, Croatia,
                   and Hungary and the other for the current deployment in Southwest Asia.
                   These plans address the medical surveillance problems experienced
                   during the Gulf War and specifically call for identifying servicemember
                   deployment information, monitoring environmental health and disease
                   threats, doing personnel medical assessments, maintaining a centralized
                   collection of medical assessment data, and employing certain medical
                   record-keeping requirements.

                   Recognizing that this is DOD’s first attempt, its success in implementing the
                   medical surveillance plan for Operation Joint Endeavor has been mixed.
                   Although the plan provided for enhanced medical surveillance compared
                   to the Gulf War, our review disclosed the following problems, all of which
                   offer DOD and the services lessons to be learned as they continue to
                   develop their medical surveillance capabilities:


                   3
                    Epidemiology is the scientific study of the incidence, distribution, and control of disease in a
                   population.



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                       •   Deployment information. The personnel database used for tracking which
                           Air Force and Navy personnel were deployed is considered inaccurate by
                           DOD personnel.
                       •   Medical assessments. Many Army personnel who should have received
                           postdeployment medical assessments did not receive them. Of
                           618 personnel in 12 selected Army units whose medical records we
                           reviewed, 24 percent did not receive in-theater postdeployment medical
                           assessments, 21 percent did not receive home station postdeployment
                           medical assessments, and 32 percent did not receive a tuberculin test.

                           When postdeployment medical assessments are done, they are frequently
                           done late. Personnel in the 12 selected Army units who received home
                           station postdeployment medical assessments received them on average
                           nearly 100 days after they left theater instead of within 30 days as required
                           by the plan. Similarly, personnel receiving the tuberculin tests received
                           them on average 142 days after they left theater. The tuberculin test was
                           required to be done soon after 90 days of the servicemember’s departure
                           from the theater.

                           The centralized database for collecting both in-theater and home unit
                           postdeployment medical assessments is incomplete for many Army
                           personnel. The database omitted 12 percent of the in-theater medical
                           assessments done and 52 percent of the home unit medical assessments
                           done for the 618 servicemembers whose records we reviewed.

                       •   Medical record-keeping. Many servicemembers’ medical records we
                           reviewed, maintained by medical units in Germany, were incomplete
                           regarding in-theater postdeployment medical assessments done, medical
                           servicemembers’ visits during deployment, and documentation of
                           personnel receiving the tick-borne encephalitis vaccine.


                           For over 2 years, DOD officials have been working to develop a DOD-wide
DOD’s Draft Joint          joint medical surveillance directive and instruction that establish policy
Medical Surveillance       and assign responsibility for improving DOD’s medical surveillance for
Policy                     deployments. The intent of the policy is to expand the concept of medical
                           surveillance during deployments to a more comprehensive approach for
                           monitoring and assessing the health consequences related to
                           servicemembers’ participation in deployments.

                           We reviewed this draft policy and found that it addresses the types of
                           medical surveillance problems experienced during the Gulf War—the lack



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    of personnel deployment information and medical assessments, the failure
    to monitor environmental and disease health threats, and the failure to
    meet record-keeping requirements. Specifically, the draft policy
    instruction assigns responsibilities as follows:

•   Assigns to the Defense Manpower Data Center (DMDC) the responsibility
    for collecting and maintaining information, available for dissemination on
    a daily basis, on each servicemember deployed to a theater, the length of
    time the servicemember was deployed, and the exact location within the
    theater of that member’s unit.
•   Specifies that the Commander in Chief (CINC) and the Joint Task Force
    (JTF) Surgeon deploy technically specialized units with the capability and
    expertise required to identify infectious and environmental diseases, make
    health hazard assessments, and do advanced diagnostic testing.
•   Requires the military services and the CINCs to conduct predeployment
    medical assessments, to include assessing mental health and drawing
    blood samples.
•   Requires the CINC Surgeon and the JTF Surgeon to conduct postdeployment
    medical assessments at the time of redeployment or within 30 days of final
    departure, to include assessing mental health and drawing blood samples.
    For both the predeployment and the postdeployment medical
    assessments, the policy calls for the assessment forms to be forwarded to
    a single office within DOD for centralized collection purposes and to allow
    future analyses.
•   Directs the CINC Surgeon and the JTF Surgeon to ensure that medical
    records are accurately kept and health-related events are documented
    during deployment. Specifically suggested are records of predeployment
    and postdeployment assessments and all health interventions (which
    would include all immunizations).

    The draft directive and implementing instruction are currently under
    review by various offices within DOD. DOD officials expect the directive and
    instruction to be issued by September 1997. The responsible offices are
    required to develop the necessary implementing documents within
    180 days of the directive’s effective date.




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                           While DOD was still developing its joint medical surveillance policy for
DOD’s                      deployments, the Assistant Secretary of Defense for Health Affairs issued,
Implementation of a        in January 1996, a medical surveillance plan for U.S. forces deploying to
Medical Surveillance       Bosnia-Herzegovina, Croatia, and Hungary under Operation Joint
                           Endeavor. This medical surveillance plan encompassed the concepts
Plan in Operation          under consideration in the draft joint policy, was developed by a triservice
Joint Endeavor             working group, and was coordinated by the Joint Staff with the services. It
                           was designed to reflect the lessons learned from the Gulf War and to
                           address the potential health risks in the Bosnian theater. According to DOD
                           officials, this DOD-wide, centrally managed medical surveillance plan was
                           the first DOD had developed for a deployment of U.S. forces. The strategy
                           for implementing the plan was determined by the service Surgeons
                           General, the Joint Staff, and the European Command Surgeon.

                           Using the four major elements of a military medical surveillance system
                           described earlier, we examined DOD’s and the services’ implementation of
                           the Operation Joint Endeavor medical surveillance plan.


Identifying Deployed       The ability to identify the population at risk is an essential part of an
Servicemembers and         effective military medical surveillance system. It is important to know
Tracking Their Movements   which servicemembers deployed to the theater and where they were
                           located within the theater during the deployment. This information is
in Theater                 needed to facilitate monitoring and analysis of how changes in the
                           servicemembers’ health status is related to various environmental,
                           biological, chemical, or other health threats. Our review indicated that DOD
                           continues to experience problems with its capability to track the
                           population at risk during deployments.

                           In researching the Persian Gulf War illnesses, the Institute of Medicine and
                           the Presidential Advisory Committee reported that inaccurate information
                           on the location of servicemembers in the theater presented problems in
                           identifying exposures to various health threats. Both recommended that
                           DOD improve its ability to track the location of units in the theater. DOD
                           established systems to identify the location of units during the Gulf War;
                           however, the research groups reported that their use for epidemiological
                           studies was limited because the systems did not provide information at the
                           individual servicemember level. During the Gulf War, servicemembers
                           frequently did not remain with their units.

                           DOD established a system, used in Operation Joint Endeavor, to identify
                           which servicemembers deployed to the theater. The services are required



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                              to supply deployment data to the DMDC in Monterey, California, which is
                              responsible for maintaining a database on those servicemembers who are
                              deployed.

                              In determining the extent to which the services had done the required
                              postdeployment medical assessments, we used the Army’s deployment
                              data and did not find any errors about which servicemembers had
                              deployed.4 However, DOD officials expressed their concerns about the
                              accuracy of the deployment database for Air Force and Navy personnel.
                              Air Force officials told us that the Air Force had supplied information to
                              DMDC on servicemembers it planned to deploy. These servicemembers
                              were added to the DMDC database, but many never actually deployed. We
                              were also told that the Navy’s personnel deployment data were inaccurate
                              because elements of two construction battalions (at least 200
                              servicemembers) that deployed to Operation Joint Endeavor do not
                              appear in the DMDC database. DOD officials told us that they have also
                              frequently heard concerns about the accuracy of the deployment database
                              and met in mid-March 1997 with representatives from the services, DMDC,
                              and other offices to discuss ways to correct the problems.

                              While the DMDC database provides information on which units and which
                              personnel within those units deploy to a theater, DOD has not yet
                              developed a system for accurately tracking the movement of individual
                              servicemembers in units within the theater. This capability is important for
                              accurately identifying exposures of servicemembers to health hazards in
                              the theater.


Capability to Assess and      A military medical surveillance program should contain mechanisms for
Test for Health Hazards       identifying the potential health and environmental hazards that deploying
and Monitor Their             troops will encounter in the theater. Such information can then be used to
                              develop effective preventive countermeasures and identify those exposed
Occurrence During             to these threats. During the Gulf War, DOD did little prospective monitoring
Deployments                   of environmental health threats in the theater and had no systematic
                              means of tracking and centrally reporting the occurrence of diseases and
                              nonbattle injuries during the war.

Environmental Health Threat   In its 1996 report, the Institute of Medicine recommended that, in
Assessments                   preparing for deployments, DOD should monitor the environment for
                              possible health threats and prepare for rapid response and investigation

                              4
                               While we did not find any instances where Army servicemembers shown in the deployment database
                              as deploying under Operation Joint Endeavor did not, in fact, deploy, we did not examine whether
                              additional servicemembers may have deployed who were not included in the deployment database.



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and collect accurate data on exposures to those threats in the theater of
operations.

Prior to deployments, DOD identifies diseases/illnesses common to the
environment in the theater and informs medical personnel and deploying
troops on ways to avoid or protect themselves from these
diseases/illnesses. According to DOD officials, a predeployment assessment
of potential health hazards in the Operation Joint Endeavor theater
indicated that diseases such as tick-borne encephalitis, hemorrhagic fever,
typhus, and lyme disease could be problems. A tick-borne encephalitis
vaccine was offered to those military personnel who might be in danger of
contracting the disease because of their proximity to ticks. In addition,
troops were advised on ways to best protect themselves from the other
diseases, and medical personnel were instructed to be particularly alert for
symptoms that might indicate that a servicemember had one of the
diseases/conditions. Of the potential diseases/illnesses identified, only one
case of hemorrhagic fever was diagnosed, and the patient was successfully
treated.

The establishment in 1994 of the U.S. Army Center for Health Promotion
and Preventive Medicine (USACHPPM) has been a major enhancement to
DOD’s ability to perform environmental monitoring and tracking since the
Gulf War. This capability was augmented in October 1995 with the
establishment of the 520th Theater Army Medical Laboratory. This
laboratory is a deployable public health laboratory that can provide
environmental sampling and analysis in theater. The sampling results can
then be used to determine what specific preventive measures and
safeguards should be taken to protect troops from harmful exposures and
to develop procedures to treat anyone exposed to health hazards.

Early in the planning for Operation Joint Endeavor, the Armed Forces
Medical Intelligence Center identified potential environmental health
threats in Bosnia-Herzegovina as coming primarily from exposures to air,
water, and soils contaminated by hazardous industrial waste. In
recognition of these potential threats, the Army laboratory was sent to
Bosnia-Herzegovina to assist deployed preventive medicine units and to
monitor environmental health hazards. While the laboratory was preparing
for the mission, USACHPPM deployed an advance monitoring team to the
theater in January 1996 to begin sampling the soil and water in the Tuzla
area, where most of the U.S. forces were to be located. The laboratory
arrived on-site in February 1996 and began conducting more extensive air,
water, soil, and other environmental monitoring. In June 1996, USACHPPM



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                             augmented the laboratory’s efforts with additional air monitoring stations
                             at nine regional locations in the theater where troops were concentrated.
                             Through January 14, 1997, 2,564 air, water, and soil samples were taken,
                             from which more than 112,000 reportable analyses were done. The results
                             of the sampling indicated that no significant health risks were posed from
                             the water, air, or soil in the theater but that prudent field sanitation
                             measures should be taken.

                             The information USACHPPM obtains through its air, soil, and water sampling
                             is entered into a database, which is then linked with DMDC’s information on
                             the units deployed to the theater. Using mapping data obtained from the
                             National Imaging and Mapping Agency, USACHPPM analysts can then
                             identify which units, if any, are in the most danger of exposure to
                             environmental contaminants. Using this method, which was developed in
                             response to the Gulf War oil fires, and which USACHPPM refers to as its
                             Geographical Information System, DOD can calculate the degree of risk to
                             specific units at specific theater locations and recommend preventive
                             actions, as necessary. Also, on a retrospective basis, USACHPPM can also
                             identify which units in the theater might have been exposed to other types
                             of health threats, such as chemical, biological, or contagious disease
                             threats. However, the troop location information is available only down to
                             the unit level; information on specific locations of individuals within given
                             units is still not available.

Monitoring of Diseases and   During the Gulf War, DOD did not systematically track, monitor, and report
Nonbattle Injuries           the types and numbers of diseases and nonbattle injuries experienced by
                             servicemembers. Recognizing that such information would be useful, DOD’s
                             Joint Staff mandated in January 1993 that weekly reports on the rates of
                             diseases and nonbattle injuries be provided to appropriate commanders
                             during all deployments. This is being done during Operation Joint
                             Endeavor. A major purpose of the program is to detect diseases and
                             nonbattle injuries before they become major outbreaks and thereby limit
                             the services’ capabilities to carry out their missions.

                             The weekly reports are categorized into 15 different areas such as
                             respiratory problems, orthopedic injuries, and unexplained fevers.
                             Miscellaneous/administrative visits can also be reported to track
                             immunizations, prescription refills, physical examinations, laboratory
                             tests, and follow-up visits. The data are summarized into theater-wide
                             illness and injury trends so that preventive measures can be identified and
                             forwarded to appropriate theater/field commanders to alert them to any
                             abnormal trends or to actions that should be taken.



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                              DOD officials believe the predeployment assessment of environmental
                              health hazards, the environmental sampling, and the medical surveillance
                              monitoring done during Operation Joint Endeavor have enabled better
                              tracking and medical troop surveillance than that available during the Gulf
                              War. In addition, they believe the capabilities now available through
                              USACHPPM and the Army laboratory, capabilities that were not available
                              during the Gulf War, have greatly improved DOD’s ability to monitor and
                              track environmental threats and exposures.


Ability to Identify Changes   Military medical surveillance should include the identification of changes
in Servicemembers’ Health     in the health status of servicemembers during and after a deployment.
Status During Deployment      Baseline information on the status of servicemembers’ health before they
                              deploy is highly desirable in determining whether their health status
                              changed during a deployment. Predeployment and postdeployment
                              medical assessments, including blood samples, provide for a comparison
                              from which postdeployment epidemiological analyses can be done.
                              Collecting and maintaining a centralized database of such medical
                              assessment data also facilitate such analyses.

                              During the Gulf War, the absence of data on servicemembers’ health,
                              including both baseline health information and postdeployment health
                              status information, greatly complicated the epidemiological research done
                              by the Institute of Medicine and the Presidential Advisory Committee
                              following the war.

Predeployment Medical         DOD’s medical surveillance plan did not require the collection of baseline
Assessments                   health status information on servicemembers who deployed during
                              Operation Joint Endeavor. Rather, the services were required to follow
                              their existing service requirements for ensuring that all personnel were
                              medically fit for deployment.

                              Initially, in developing the medical surveillance plan, DOD officials
                              considered collecting a predeployment blood sample for all deploying
                              servicemembers. However, this approach was not followed, according to
                              DOD officials, because (1) DOD already had blood samples that had been
                              drawn during the services’ periodic testing for the Human
                              Immuno-deficiency Virus (HIV), (2) many servicemembers had already
                              deployed when the collection was being discussed, and (3) the collection
                              of blood samples would have been logistically difficult. DOD officials
                              considered the blood samples drawn for the HIV testing to be acceptable
                              baseline samples.



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                         Our review, however, found that predeployment blood samples were not
                         available for many servicemembers who deployed under Operation Joint
                         Endeavor and that many of the blood samples, in the repository for
                         servicemembers who deployed, were quite old. More specifically, data
                         from USACHPPM, which oversees the blood repository, show that
                         predeployment blood samples are not available for 2,476 (9.3 percent) of
                         the 26,621 servicemembers who had deployed to Bosnia-Herzegovina as of
                         March 12, 1996. Also, the data show that the last blood samples for 9,266
                         (38.4 percent) of the 24,145 predeployment blood samples were more than
                         24 months old. Moreover, the data show that the last blood samples for
                         1,544 (6.4 percent) of the predeployment blood samples were more than
                         5 years old. DOD’s draft medical surveillance policy requires a new blood
                         sample to be drawn prior to a servicemember’s deployment when the last
                         blood sample is over a year old. Therefore, the age of these blood samples
                         raises questions as to their reliability as predeployment baseline samples.

Postdeployment Medical   Postdeployment medical assessments were required for servicemembers
Assessments              who deployed to Bosnia-Herzegovina, Croatia, and Hungary. However,
                         based on our review of documentation in both the Deployment
                         Surveillance Team’s database and the servicemembers’ medical records
                         we reviewed, we concluded that the required assessments were not done
                         for many Army personnel. Moreover, in those instances where
                         postdeployment medical assessments were done, they were done much
                         later than required.

                         For those deployed under Operation Joint Endeavor, two postdeployment
                         medical assessments were to be done—one assessment was to be done in
                         theater shortly before the servicemembers redeployed to their home
                         station and the other at the home station within 30 days of leaving the
                         theater. The assessments consist of the servicemember’s responses to a
                         series of questions to be answered by the servicemember covering the
                         member’s general health status. After completion by the servicemember, a
                         health care provider was required to review the responses to the questions
                         and refer the servicemember for further evaluation, if appropriate. At the
                         time of the in-theater postdeployment medical assessment, medical
                         personnel were required to collect a blood sample and send it to the
                         central blood repository in the United States. If this blood sample was not
                         collected during the in-theater postdeployment medical assessment
                         process, it was to be collected at the time of the home unit
                         postdeployment medical assessment. Postdeployment requirements also
                         included administering a battery of mental health questionnaires designed
                         to identify servicemembers needing further psychological evaluation.



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Tuberculin skin tests were also required at the servicemembers’ home
stations soon after 90 days of departure from the theater. Tuberculosis
was considered a potential health threat in the theater.

Our review of the Deployment Surveillance Team’s database for the 6,624
Army personnel in our universe requiring medical assessments indicated
that 43 percent of the personnel had not received the required in-theater
postdeployment medical assessment, 82 percent had not received the
home unit postdeployment medical assessment, and 41 percent did not
have a postdeployment blood sample drawn.5 Only 429 (6.5 percent)
servicemembers met all three requirements—the in-theater and home unit
postdeployment medical assessments and a postdeployment blood sample
drawn and in storage. We also found that 1,889 (28.5 percent) had not met
any of the three requirements. The Deployment Surveillance Team’s
database does not collect information on the extent to which the
tuberculin tests are done at the home unit.

During our review of the medical documentation for 618 servicemembers
in 12 selected Army units requiring postdeployment medical assessments,
we found no evidence that the required medical assessments were
conducted for many servicemembers.6 More specifically, as shown in
table 2, about 24 percent did not receive the in-theater postdeployment
medical assessment, 21 percent did not receive the home unit
postdeployment medical assessment, 34 percent did not have a
postdeployment blood sample drawn, and 32 percent did not receive the
required tuberculin test.




5
 The Deployment Surveillance Team’s database may understate the extent to which the in-theater and
home unit postdeployment medical assessments were conducted based on the results of our review of
medical records for selected Army units.
6
 Documentation reviewed included data in both the Deployment Surveillance Team database and the
servicemember’s permanent medical record. Our analysis reflects the existence of in-theater and home
unit postdeployment medical assessments in either the Deployment Surveillance Team database or the
servicemembers’ medical records.



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Table 2: Medical Assessments for
Selected Army Units (as of Feb. 6,                                      No
1997)                                                            in-theater   No home       No blood            No
                                                       Records     medical unit medical      sample      tuberculin
                                     Unit             reviewed assessment assessment          drawn            test
                                     A                     63           12           27           11            42
                                     B                     80            9           13           10            14
                                     C                     66           58           10           59            16
                                     D                     36            7           11           12             9
                                     E                     49            5           16           25            17
                                     F                     48           14            4           33             4
                                     G                     43            7            1             7           12
                                     H                     55            6           17             1           37
                                     I                     46            4            6             4           17
                                     J                     52            4            6           12            11
                                     K                     48           12           13           13            15
                                     L                     32            7            3           22             3
                                     Total                618          145          127          209           197
                                     Percentage                       23.5         20.6          33.8         31.9

                                     Of the 618 servicemembers whose medical records we reviewed, only 206,
                                     or one-third, had met all four requirements—the in-theater medical
                                     assessment, the home unit medical assessment, the tuberculin test, and a
                                     postdeployment blood sample drawn. Conversely, 20 (about 3 percent) of
                                     the 618 servicemembers had not met any of the four requirements.

                                     Different reasons were cited for lack of (1) in-theater medical assessments
                                     and (2) unit medical assessments and the tuberculin tests conducted at the
                                     home unit. According to Army medical officials in Germany, the in-theater
                                     problem was due to the lack of a centralized out-processing mechanism
                                     for redeploying personnel; whereas the home unit problem was due to unit
                                     commanders not giving enough emphasis to the medical assessment
                                     requirements. More specifically, the U.S. Army Europe (USAREUR) Surgeon
                                     attributed the lack of in-theater medical assessments for Army personnel
                                     redeploying to their home units before August 1996 to the lack of a fully
                                     functioning central out-processing point for redeploying personnel to
                                     ensure that they received the required assessments. Beginning in
                                     August 1996, all Army personnel redeploying to their home unit from
                                     Bosnia-Herzegovina, Croatia, and Hungary were required to go through an
                                     intermediate staging base in Hungary, where medical assessments were
                                     done. For redeployments, the USAREUR Surgeon believes that compliance
                                     with the requirement for in-theater medical assessments would be higher



                                     Page 13                                   GAO/NSIAD-97-136 Defense Health Care
                                       B-275801




                                       after the staging base became operational. We did not validate whether
                                       these improvements, in fact, occurred.

                                       Officials with several medical units responsible for the Army units we
                                       reviewed told us that they have no direct authority over the unit personnel
                                       to require them to obtain the postdeployment medical assessments or
                                       tuberculin tests. They must rely on unit commanders to require their
                                       personnel to go to the medical clinic for the assessments.

                                       Further, home unit medical assessments and the tuberculin test, when
                                       done, were frequently done much later than required. The home unit
                                       postdeployment medical assessments are required to be conducted within
                                       30 days of servicemembers’ departure from the theater. The 30-day time
                                       frame was established to ensure that the required medical assessments are
                                       done soon after servicemembers return to their home unit and, from an
                                       epidemiological standpoint, if medical problems exist, to be better able to
                                       associate the medical problems to the members’ service while deployed.
                                       As shown in table 3, most of the home unit medical assessments that were
                                       completed for the selected 12 Army units were done much later than the
                                       30 days required—averaging 98 days following departure from the theater.
                                       Similarly, the tuberculin tests, required to be done soon after 90 days of
                                       the members’ departure from the theater, if done, were done later—an
                                       average of 142 days.

Table 3: Timeliness (average days
from departure from theater) for the                                               Average days
Army’s Home Unit Postdeployment                                         Home unit medical
Medical Assessments and Tuberculin                                     assessment (30-day     Tuberculin test (90-day
Tests for Selected Army Units          Unit                                  requirement)               requirement)
                                       A                                            178.8                      173.9
                                       B                                             95.1                      109.0
                                       C                                            212.0                      236.9
                                       D                                             76.8                      113.6
                                       E                                             33.9                      131.2
                                       F                                             58.9                      133.6
                                       G                                             11.4                      104.5
                                       H                                             48.1                      125.0
                                       I                                             17.3                      106.9
                                       J                                             85.0                      123.3
                                       K                                            178.8                      159.2
                                       L                                            169.2                      166.1
                                       Average for all units                         98.6                      142.0




                                       Page 14                                   GAO/NSIAD-97-136 Defense Health Care
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Such delays in doing the home unit medical assessments, particularly if the
assessment also involves the drawing of a postdeployment blood sample,
pose concerns regarding epidemiological analyses. With such delays, it is
much more difficult to isolate which health problems were attributable to
members’ service during deployments and which were contracted after
their return to home stations. Also, the delay in doing the assessments
could delay the referral of the servicemember for further evaluation and
treatment based on this medical assessment.

Our review of medical records may have resulted in more medical
assessments being done than would otherwise have occurred. In fact, we
were told that our planned review of medical records in Germany, which
was announced in December 1996, encouraged certain units to complete
their home unit postdeployment medical assessments and tuberculin tests
in anticipation of our arrival. Four of the 12 units (units A, C, K, and L)
completed over 80 percent of the required home unit postdeployment
medical assessments and tuberculin tests in January and February 1997,
even though the servicemembers had returned to their home units
5 to 8 months earlier. This delay explains much of the timeliness problems
experienced by these units discussed earlier. As shown in table 4, the
percentage of Army personnel who did not have the home unit
postdeployment medical assessment and the tuberculin test was much
higher as of December 31, 1996, before our medical records
review—increasing from 20.6 percent to 44.5 percent for home unit
postdeployment medical assessments and from 31.9 percent to
58.7 percent for tuberculin tests.




Page 15                                   GAO/NSIAD-97-136 Defense Health Care
                                      B-275801




Table 4: Medical Assessments for
Selected Army Units (as of Dec. 31,                                               No home unit
1996)                                                                                  medical
                                      Unit                 Records reviewed        assessment    No tuberculin test
                                      A                                  63                 57                  50
                                      B                                  80                 13                  14
                                      C                                  66                 51                  59
                                      D                                  36                 11                  12
                                      E                                  49                 16                  46
                                      F                                  48                  8                  20
                                      G                                  43                  1                  13
                                      H                                  55                 17                  37
                                      I                                  46                  6                  17
                                      J                                  52                 15                  26
                                      K                                  48                 48                  39
                                      L                                  32                 32                  30
                                      Total                             618                275                 363
                                      Percentage                                          44.5                58.7

Centralized Collection of             A complete and accurate database is needed to effectively monitor the
Assessment Data                       extent to which required medical assessments are done. The medical
                                      surveillance plan includes provisions for the centralized collection and
                                      maintenance of a database for the in-theater and home unit
                                      postdeployment medical assessments done for servicemembers deployed
                                      under Operation Joint Endeavor. The medical units processing the
                                      in-theater and home unit medical assessments are required to send copies
                                      of the assessment forms to DOD’s Deployment Surveillance Team. The
                                      team uses the data to prepare statistical reports on how well the medical
                                      assessment program is being implemented.

                                      We tested the completeness of the surveillance team’s centralized
                                      database for the in-theater and home unit postdeployment medical
                                      assessments conducted for the 618 servicemembers whose medical
                                      records we reviewed. We found that the database was incomplete for both
                                      assessments—understating considerably the number of home unit medical
                                      assessments done. More specifically, the database omitted 57 (12 percent)
                                      of the 473 in-theater medical assessments done and 174 (52 percent) of the




                                      Page 16                                  GAO/NSIAD-97-136 Defense Health Care
                        B-275801




                        332 home unit medical assessments done for the 618 service members
                        whose medical records we reviewed.7


Complete and Accurate   Complete and accurate medical records documenting all medical care for
Medical Records         the individual servicemember are essential for the delivery of high quality
                        medical care. They are also important for epidemiological analyses
                        following military deployments.

                        The Presidential Advisory Committee and the Institute of Medicine
                        reported problems concerning the completeness and accuracy of medical
                        record-keeping during the Gulf War. During the Gulf War, interactions
                        between the deployed forces and medical care providers in the theater
                        were frequently not recorded in servicemembers’ permanent medical
                        records. This problem was particularly common for immunizations given
                        in the theater. The Institute of Medicine characterized DOD’s and the
                        Department of Veterans Affairs’ medical records systems as fragmented,
                        disorganized, and incomplete.

                        Under the Operation Joint Endeavor medical surveillance plan,
                        postdeployment in-theater and home unit medical assessment forms are
                        required to be included in servicemembers’ permanent medical records.
                        Similarly, Army regulations require documentation in servicemembers’
                        permanent medical records of all immunizations received in theater and
                        visits made by servicemembers to health units such as battalion aid
                        stations.8 Because the tick-borne encephalitis vaccine is classified by the
                        Food and Drug Administration as an investigational drug, specific
                        requirements apply for documenting its use in servicemembers’ medical
                        records.

                        We tested the completeness of the permanent medical records for selected
                        Army active duty servicemembers who had deployed under Operation
                        Joint Endeavor. Our review disclosed that many of the medical records
                        were incomplete regarding documentation reflecting that (1) in-theater
                        medical assessments were conducted, (2) servicemembers had received
                        the tick-borne encephalitis vaccine, and (3) visits had been made by


                        7
                         Our analyses reflected the completeness of the database as of January 21, 1997, for in-theater medical
                        assessments completed before September 1, 1996, and for home unit medical assessments completed
                        before December 1, 1996. This provided a minimum of almost 2 months for the medical assessment
                        forms to be sent from Germany and incorporated into the Deployment Surveillance Team’s database.
                        8
                         A battalion aid station, which is integral to all combat battalions, provides forward battlefield medical
                        care such as immediate emergency treatment, evacuation and clinical stabilization of sick and injured
                        servicemembers, and routine outpatient medical care.



                        Page 17                                                     GAO/NSIAD-97-136 Defense Health Care
B-275801




servicemembers to battalion aid stations. All of these documentation
problems pertain to medical care in the theater.

Regarding postdeployment medical assessments, we found that 91
(19 percent) of the 473 servicemembers with a postdeployment in-theater
medical assessment and 9 (1.8 percent) of the 491 servicemembers with a
postdeployment home unit medical assessment did not have the
assessments documented in their medical records.

USAREUR Surgeon officials attributed these documentation problems to the
practice of allowing servicemembers to hand-carry the in-theater
assessment forms to their home unit for insertion to their permanent
medical records. The officials said the assessment forms were frequently
lost. We noted that such documentation problems occurred less frequently
for the home unit medical assessments because they were done at the
home unit and as such did not need to be forwarded from the theater to
the servicemembers’ home units.

During the deployment to Bosnia, servicemembers deploying to regions
with a threat of tick-borne encephalitis were given the choice of being
vaccinated with an investigational drug vaccine.9 To determine whether
the medical records included documentation of servicemembers receiving
the vaccine, we obtained a list from the U.S. Army Medical Research
Institute of Infectious Diseases (USAMRIID)10 of servicemembers that
received the vaccine and reviewed 588 medical records of servicemembers
in selected Army units shown as having received the vaccine. As shown in
table 5, 141 (24 percent) of these servicemembers’ permanent medical
records did not document the vaccinations.




9
 An investigational drug is a new drug, antibiotic drug, or biological drug or product that has not been
licensed by the Food and Drug Administration for general use in the United States. As such, the Food
and Drug Administration regulates its use.
10
    USAMRIID maintains a list of servicemembers that received the tick-borne encephalitis vaccine.



Page 18                                                    GAO/NSIAD-97-136 Defense Health Care
                                       B-275801




Table 5: Documentation of Tick-Borne
Encephalitis Vaccinations in                               Number taking the
Servicemembers’ Permanent Medical                               vaccine per      No documentation     Percentage not in
Records                                Unit                      USAMRIID        in medical records    medical records
                                       I                                   96                   29                 30.2
                                       M                                   55                   19                 34.6
                                       N                                  135                   22                 16.3
                                       O                                  176                    7                  4.0
                                       P                                  126                   64                 50.8
                                       Total                              588                  141                 24.0

                                       To test the completeness of the permanent medical records for visits made
                                       to battalion aid stations by servicemembers while deployed to
                                       Bosnia-Herzegovina during Operation Joint Endeavor, we selected
                                       50 entries from the sign-in logs for three battalion aid stations and
                                       reviewed those members’ medical records for documentation of the visit.
                                       As shown in table 6, about 29 percent of the battalion aid station visits
                                       were not documented in the members’ permanent medical records.

Table 6: Documentation of Battalion
Aid Station Visits in Permanent                                   Number of
Medical Records                                                 battalion aid
                                                                station visits   No documentation     Percentage not in
                                       Unit                         reviewed     in medical records    medical records
                                       F                                   50                   12                 24.0
                                       M                                   50                   20                 40.0
                                       N                                   50                   12                 24.0
                                       Total                              150                   44                 29.3

                                       Army medical officials pointed out that servicemembers had deployed to
                                       the theater only with an abstract of their permanent medical records and
                                       that any medical documentation generated in the theater should have been
                                       routed back to the servicemembers’ home units for inclusion in their
                                       medical records, but in many instances, this did not occur. They also
                                       mentioned that permanent medical records are still essentially kept in a
                                       paper-based system and are therefore subject to having information
                                       misfiled or lost.

                                       To address medical documentation problems, the Presidential Advisory
                                       Committee recommended that DOD direct its attention toward
                                       computerizing its theater medical records. An Assistant Surgeon General
                                       of the Army also told us that he believes the solution to such
                                       documentation problems is the development of a deployable computerized



                                       Page 19                                     GAO/NSIAD-97-136 Defense Health Care
B-275801




patient record. DOD has a project underway with the goal to have a
paperless, filmless computerized medical record for every servicemember,
while on active duty, by fiscal year 2000. Further objectives of the project
are to standardize medical record-keeping DOD-wide; ensure that medical
record information is complete, accurate, and available when needed; and
prevent active duty members with disqualifying conditions from being
deployed. In addition, plans call for the computerized medical record to
document and update the baseline health status of each active duty
member, support the recognition of deployment-related illnesses, and
provide a mechanism for reporting the medical readiness of the active
duty force.

Recognizing that DOD’s paper-based medical records are not sufficient to
support the growing interest in epidemiology driven by the Gulf War
experience, the project officials recommended the development of some
type of electronic mechanism to capture health service data for each
active duty member at all echelons of care during military operations.
Several options for obtaining and recording the necessary information are
being considered, but the basic concept involves providing each
servicemember with a computerized card or tag that can receive and store
computerized health information. When the member reports to a medical
unit for care, the card can be updated with the member’s complaint,
diagnosis, and treatment (including X-rays). This information would be
collected by computer and reported to a central location by the medical
unit to allow for overall summarization of medical problems and
treatments in a given theater.

Long-term recommendations of project officials call for deploying a
triservice computerized patient record throughout DOD by fiscal year 2000.
Also recommended is the establishment of linkages to external systems
through the inclusion of a global positioning history for each individual.
Such a record could support the geographical location history developed
and being refined by USACHPPM and assist in prospective or retrospective
data analysis of factors such as chemical/biological risk exposures to
specific troops in the theater.




Page 20                                    GAO/NSIAD-97-136 Defense Health Care
                       B-275801




                       In December 1996, the CINC, U.S. Central Command, issued guidance that
DOD’s                  included medical surveillance requirements for all forces deployed in
Implementation of a    Southwest Asia. This guidance is similar to the medical surveillance plan
Medical Surveillance   for Operation Joint Endeavor. While implementation of the medical
                       surveillance plan for Southwest Asia began only recently in January 1997,
Plan in Southwest      a Joint Staff official told us the plan is being implemented. The official said
Asia                   that an epidemiology team and the Navy’s forward medical laboratory
                       were deployed to the theater to provide on-site medical surveillance. In
                       addition, the official said that predeployment and postdeployment medical
                       assessments are being conducted for the servicemembers in the
                       Southwest Asia theater. We did not test, however, the services’
                       implementation of the Southwest Asia medical surveillance requirements.

                       DOD officials told us that they delayed issuing a specific medical
                       surveillance plan for Southwest Asia because DOD was developing a joint
                       medical surveillance policy that would cover such deployments. However,
                       when the time required to develop a joint policy took longer than
                       expected, the Joint Staff encouraged the CINC (U.S. Central Command) to
                       issue specific medical surveillance requirements for the deployment.

                       Prior to the issuance of the December 1996 guidance, DOD had conducted
                       some medical surveillance activities, including environmental sampling, in
                       the Southwest Asia theater but had not required medical assessments and
                       postdeployment blood samples for servicemembers deployed there. We
                       believe that the delay in requiring medical assessments and
                       postdeployment blood samples raises concerns, given that U.S. forces
                       have been deployed to this region continuously since the end of the Gulf
                       War and many veterans who served in this region began to complain of
                       medical problems soon after the end of the conflict.


                       Overall, DOD has taken initiatives to overcome the medical surveillance
Conclusions and        problems experienced during the Gulf War. It is evident that positive steps
Recommendations        have been taken to establish a joint policy that will emphasize the
                       importance of medical surveillance and provide for a more uniform
                       approach for doing such surveillance in future deployments. DOD’s recent
                       experience in Operation Joint Endeavor, during which it tried to institute
                       corrective policies and processes to overcome problems experienced
                       during the Gulf War, provides lessons learned that DOD can apply in its
                       ongoing efforts to develop a DOD-wide joint medical surveillance policy.
                       However, the joint policy has been under development for over 2 years.




                       Page 21                                     GAO/NSIAD-97-136 Defense Health Care
                         B-275801




                         Some of the problems we found in implementing the medical surveillance
                         during Operation Joint Endeavor—the failure to assess all
                         servicemembers’ health in theater and after return to their home units and
                         to consistently document medical care provided in theater—raise serious
                         questions about DOD’s ability to effectively implement medical surveillance
                         policies during another high-conflict deployment like the Gulf War. We
                         recognize that complete record-keeping may be more difficult during times
                         of high intensity combat activities; however, complete record-keeping is
                         still necessary for an effective medical surveillance system.

                         In light of the problems discussed in this report, we recommend that the
                         Secretary of Defense direct the Assistant Secretary of Defense for Health
                         Affairs, along with the military services, the Joint Chiefs of Staff, and the
                         Unified Commands, as appropriate, to

                     •   complete expeditiously and implement a DOD-wide policy on medical
                         surveillance for all major deployments of U.S. forces, using lessons
                         learned during Operation Joint Endeavor and the Gulf War;
                     •   develop procedures to ensure that medical surveillance policies are
                         implemented to include emphasizing (a) the need for unit commanders to
                         ensure that all servicemembers receive the required medical assessments
                         in a timely manner and (b) the need for medical personnel to maintain
                         complete and accurate medical records; and
                     •   develop procedures for providing accurate and complete medical
                         assessment information to the centralized database.

                         We also recommend that the Secretary of Defense direct the Deputy Under
                         Secretary of Defense for Requirements and Resources to investigate the
                         completeness of information in the DMDC personnel deployment database
                         and take corrective actions to ensure that the deployment information is
                         accurate for servicemembers who deploy to a theater.


                         In commenting on a draft of this report, DOD agreed with the accuracy of
Agency Comments          the report. It agreed that substantial improvements in medical surveillance
and Our Evaluation       and record-keeping were needed based on the Gulf War experience and
                         that some improvements in these areas were applied in the deployment to
                         Bosnia. Likewise, DOD stated that it will apply the lessons from the Bosnia
                         deployment to refine its policy for future medical surveillance during
                         deployments.




                         Page 22                                     GAO/NSIAD-97-136 Defense Health Care
B-275801




DOD  concurred with each of our four recommendations and stated that
with the support of the services, the Chairman of the Joint Chiefs of Staff,
and the intelligence community, it will aggressively work to continue to
make improvements. For example, DOD stated that, in August 1997, it will
disseminate the DOD instruction and directive establishing a DOD-wide
policy on medical surveillance. DOD also indicated that it has reviewed its
master personnel database deficiencies and developed recommendations
to improve its ability to maintain accurate information on servicemembers
who deploy. DOD indicated that on February 10, 1997, a message was sent
to all unified commanders reemphasizing the importance of a
comprehensive medical surveillance program to ensure force readiness
and sustainment. DOD noted that it has standardized predeployment and
postdeployment questionnaires and has started an automation initiative to
enhance accuracy of the centralized database.

We believe these initiatives, if properly implemented, could greatly
enhance the medical surveillance program. However, DOD’s response did
not indicate what its specific procedures will be for institutionalizing these
efforts to ensure that all medical surveillance requirements will be met.
For example, further procedural improvements would be needed to
routinely monitor units’ compliance with the medical surveillance
requirements and periodically evaluate the accuracy and completeness of
the centralized database.

DOD’s   comments are presented in appendix II.


We are sending copies of this report to the Chairmen and Ranking
Minority Members, Senate and House Committees on Appropriations; the
Secretaries of Defense, the Army, the Navy, and the Air Force; and the
Chairman, Joint Chiefs of Staff. Copies will also be made available to
others upon request.

Please contact me at (202) 512-5140 if you or your staff have any questions
concerning this report. Major contributors to this report are listed in
appendix III.




Mark E. Gebicke
Director, Military Operations
  and Capabilities Issues

Page 23                                     GAO/NSIAD-97-136 Defense Health Care
Contents



Letter                                                                                            1


Appendix I                                                                                       26

Scope and
Methodology
Appendix II                                                                                      29

Comments From the
Department of
Defense
Appendix III                                                                                     33

Major Contributors to
This Report
Tables                  Table 1: Major Elements of a Military Medical Surveillance                2
                          System
                        Table 2: Medical Assessments for Selected Army Units                     13
                        Table 3: Timeliness for the Army’s Home Unit Postdeployment              14
                          Medical Assessments and Tuberculin Tests for Selected Army
                          Units
                        Table 4: Medical Assessments for Selected Army Units                     16
                        Table 5: Documentation of Tick-Borne Encephalitis Vaccinations           19
                          in Servicemembers’ Permanent Medical Records
                        Table 6: Documentation of Battalion Aid Station Visits in                19
                          Permanent Medical Records

                        Abbreviations

                        CINC          Commander in Chief
                        DMDC          Defense Manpower Data Center
                        DOD           Department of Defense
                        HIV           Human Immuno-deficiency Virus
                        JTF           Joint Task Force
                        USACHPPM      U.S. Army Center for Health Promotion and Preventive
                                           Medicine
                        USAMRIID      U.S. Army Medical Research Institute of Infectious
                                           Diseases
                        USAREUR       U.S. Army Europe


                        Page 24                                 GAO/NSIAD-97-136 Defense Health Care
Page 25   GAO/NSIAD-97-136 Defense Health Care
Appendix I

Scope and Methodology


             For this report, we interviewed officials and obtained pertinent
             documentary evidence from officials at the Office of the Assistant
             Secretary of Defense for Health Affairs; the Joint Staff; and the Offices of
             the Surgeons General at Army, Navy, and Air Force Headquarters in
             Washington, D.C. We also interviewed and obtained documents from
             officials at the Department of Defense’s (DOD) Deployment Surveillance
             Team and the Persian Gulf Illness Investigation Team at Falls Church,
             Virginia, and from the U.S. Army Center for Health Promotion and
             Preventive Medicine at Aberdeen Proving Ground, Maryland; the Institute
             of Medicine’s Medical Follow-up Agency; the Presidential Advisory
             Committee on Gulf War Veterans’ Illnesses; the Defense Manpower Data
             Center in Monterey, California; the U.S. European Command Surgeon’s
             Office; the U.S. Army Europe Surgeon’s Office; and the U.S. Air Force
             Europe Surgeon’s Office.

             To assess the extent to which the required medical assessments, described
             above, were conducted, we (1) obtained information from the DOD
             Deployment Surveillance Team’s database in Falls Church, Virginia, and
             (2) reviewed the medical records for active duty servicemembers in 12
             selected Army units in Germany who deployed to Operation Joint
             Endeavor.

             To determine the overall status of DOD’s efforts to implement its Operation
             Joint Endeavor medical surveillance policy, in January 1997, we requested
             the Deployment Surveillance Team to provide us with information from its
             database showing those servicemembers in units who deployed to and
             spent at least 30 days in the countries of Bosnia-Herzegovina, Croatia, and
             Hungary from the start of Operation Joint Endeavor and had returned to
             their home units by August 31, 1996. The cutoff date was selected to
             provide sufficient time for units to forward in-theater and home unit
             assessment forms and blood samples to the United States and have that
             information entered into the team’s database. The team then extracted
             data from its database showing which of these servicemembers had
             received the required assessments and had a postdeployment blood
             sample in storage at the central blood repository. This information showed
             each service’s overall compliance with the Operation Joint Endeavor
             medical surveillance assessment requirements.

             After obtaining this information, we decided to limit our review of
             servicemembers’ medical records to selected Army units because the
             Army is the largest participant of the services in Operation Joint Endeavor.
             To select the Army units from which we would review servicemembers’



             Page 26                                    GAO/NSIAD-97-136 Defense Health Care
Appendix I
Scope and Methodology




medical records, we requested the Deployment Surveillance Team to sort
the deployment data we had requested by unit, rank-ordered by the units
with the largest number of personnel requiring postdeployment medical
assessments, without regard to the unit’s rate of compliance with the
requirements. We then selected the 12 units in Germany with the largest
numbers of personnel requiring medical assessments. These selected units
provided a range of different types of units and were located in multiple
locations in central Germany. At the responsible medical unit for the
selected units, we requested the medical records for those
servicemembers on the Deployment Surveillance Team list who required
medical assessments to be done. We reviewed the medical records for
those servicemembers who were still in the unit and whose medical
records were not currently in use by the medical unit at the time of our
review. In reviewing these 618 medical records, we determined whether
the record included an (1) in-theater medical assessment form, (2) the
home unit medical assessment form, and (3) documentation that the
required tuberculin test had been done.

To determine whether servicemembers who had received the tick-borne
encephalitis vaccine had this documented in their medical records, we
obtained a list from the U.S. Army Medical Research Institute of Infectious
Diseases of all servicemembers who had received one or more doses of
the vaccine in units who deployed during Operation Joint Endeavor. From
this list, we selected five units located in Germany from the listing and
reviewed 588 servicemembers’ medical records to determine whether the
medical records documented the vaccinations.

To determine whether servicemembers’ visits to Army battalion aid
stations were documented in the members’ permanent medical records,
we selected three battalion aid stations that deployed to
Bosnia-Herzegovina during Operation Joint Endeavor and selected 50
entries from each battalion aid station’s sign-in patient logs. We then
reviewed the medical records of those servicemembers to determine
whether the visits had been documented.

To ensure that we did not overlook any of the appropriate documentation
in the medical records during our examinations, the unit medical staff
reviewed all of those records in which we could not find required
documentation and verified that our examination was accurate. We also
discussed reasons for missing documentation in the medical records with
officials at the responsible medical units in Germany for those units whose
medical records we reviewed.



Page 27                                   GAO/NSIAD-97-136 Defense Health Care
Appendix I
Scope and Methodology




We conducted our review from October 1996 to April 1997 in accordance
with generally accepted government auditing standards.




Page 28                                 GAO/NSIAD-97-136 Defense Health Care
Appendix II

Comments From the Department of Defense




              Page 29       GAO/NSIAD-97-136 Defense Health Care
                Appendix II
                Comments From the Department of Defense




Now on p. 22.




Now on p. 22.




                Page 30                                   GAO/NSIAD-97-136 Defense Health Care
                Appendix II
                Comments From the Department of Defense




Now on p. 22.




                Page 31                                   GAO/NSIAD-97-136 Defense Health Care
                Appendix II
                Comments From the Department of Defense




Now on p. 22.




                Page 32                                   GAO/NSIAD-97-136 Defense Health Care
Appendix III

Major Contributors to This Report


                        Sharon A. Cekala, Associate Director
National Security and   Donald L. Patton, Assistant Director
International Affairs
Division, Washington,
D.C.
                        Steve J. Fox, Evaluator-in-Charge
Norfolk Field Office    Lynn C. Johnson, Evaluator
                        William L. Mathers, Evaluator




(703176)                Page 33                                GAO/NSIAD-97-136 Defense Health Care
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