Gulf War Illnesses: Evaluation of DOD's Investigative Processes

Published by the Government Accountability Office on 1999-07-13.

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

      United States

GAO   General Accounting Office
      Washington, D.C. 20548

      National Security and
      International AfTairs Division


      July 13,1999

      The Honorable Warren B. Rudman
      Presidential Special Oversight Board
       for Department of Defense Investigations
       of Gulf War Chemical and Biolog&al Incidents

      Subject: Gulf War Illnesses: Evaluation of DOD’s Investigative Processes

      Dear Mr. Chairman

      We are pleased to appear before your Board today to discuss our report dealing with the
      Department of Defense’s Office of the Special Assistant for Gulf War Illnesses. Enclosed is a
      copy of my prepared statement.
                                 \    We will make copies available to others upon request.

      If you, members of the Board, or your staff have questions concerning my statement, please
      contact me on (202) 512-5140. Major contributors to this statement were William Cawood
      and Steve Fox.

      Sincerely yours,

      Mark E. Gebicke
      Director, National Security Preparedness

                                                                       GAOMXAD-QQ219R Gulf War Ilhesses
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                                      BIOLOGICAL INCIDENTS

Mr. Chairman and Members of the Board:

We are pleased to be here to discuss our February 1999 report on the Department of Defense’s
(DOD) Office of the Special Assistant for Gulf War Illnesses (OSAGWI).’ This report dealt with (1)
DOD’s progress in establishing an organization to address Gulf War illnesses issues and (2) the
thoroughness of OSAGWI’s investigations into and reporting on servicemembers’ potential exposure
to chemical or biological agents during the Persian Gulf War. The report was prepared at the request
of the Ranking Minority Member of the House Committee on Veterans Affairs.

Today, I plan to first provide a brief summary and then provide some background information and
more details about our specific findings.


In the face of severe criticism by veterans and others on the handling of Gulf War illnesses issues,
DOD established OSAGWI in November 1996. Since then, DOD has made progress in addressing
issues related to Gulf War illnesses. It has (1) signiscantly increased the emphasis and resources
committed to determinin g the cause(s) of Gulf War veterans’ health problems, (2) improved
communications with veterans, and (3) identified chemical and biological warfare force protection
issues requiring attention.

In reviewing six of the eight case narratives that OSAGWI had published at the time of our review,
we found that OSAGWI generally followed its established investigation methodology and used
appropriate investigative procedures and techniques. However, we found significant weaknesses in
the scope and quality of OSAGWI’s investigations in three cases that were not evident in the other
three. These weaknesses included failures to (1) follow up with appropriate individuals to cor&irm
key evidence, (2) identify and ensure the validity of key physical evidence, (3) include important
information in the case narratives, and (4) interview key witnesses.

Despite these weaknesses, the preponderance of evidence led us to agree with OSAGWI’s
conclusions about the likelihood of the presence of chemical warfare agents in five of the six cases
reviewed. The one exception involved OSAGWI’s conclusion that a potential exposure of U.S.
Marine Corps personnel to a chemical agent during a mine breaching operation was “unlikely.” We
believe this conclusion needs reassessment because OSAGWI overlooked some important
information it had regarding this case. OSAGWI also considered, but did not include, other relevant
information in this case narrative.

 Gulf War Illnesses: Procedural and Reuortine Immovements Are Needed InD0 D’s Inves&ptive Processes CGAO/NSIADQ9-59.Feb. 26,

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In all six cases OSAGWI missed an opportunity to perform more complete investigations because it
did not use potentially valuable sources of relevant information in DOD and Department of Veterans
Affairs (VA) clinical databases. We noted that the lack of effective quality assurance policies and
practices in OSAGWI’s investigating and reporting processes contributed to the weaknesses we

With that overview, let me set the stage on OSAGWI’s origin and mission-and how we did our review.


Of the more than 100,000 Gulf War veterans who have participated in DOD or VA health examination
programs, many have reported a wide array of health complaints and disabling conditions. Some
veterans suspect that their health problems may be linked to chemical or biological agents, but a
variety of other causes have also been suggested. Following the war, DOD claimed that chemical
weapons were not present in the Gulf War theater. However, it later acknowledged that some U.S.
troops might have been exposed to chemical agents. Veterans cited other incidents of potential

DOD established OSAGWI in 1996 to restore public confidence in its efforts to deal with Gulf War
illnesses issues. Its primary missions are to (1) establish effective communications with veterans
and veterans groups, (2) investigate and report on incidents of possible chemical or biological
exposures, and (3) apply lessons learned from the Gulf War experience to better protect U.S.
servicemembers on a contaminated battlefield.

Each OSAGWI investigation into possible exposures to chemical or biological warfare agents results
in a summation document called a case narrative. This document is expected to contain all
important investigative facts as well as OSAGWI’s assessment of the likelihood that servicemembers
were exposed. The standard OSAGWI uses for its assessments is whether all available facts would
lead a reasonable person to conclude that a chemical or biological warfare agent was or was not

In reviewing the six case narratives, we (1) traced each statement in the case narratives to its
underlying supporting documentation in OSAGWI files, (2) reviewed OSAGWI documentation
associated with the incident to determine if all relevant information was included in the case
narrative, (3) contacted key sources of intormation to verify the accuracy and completeness of the
information these sources provided to OSAGWI, (4) independently sought other sources of
information, and (5) contacted key participants not originally interviewed to determine if relevant
information was available that might affect OSAGWI’s assessment.

With that backdrop, let me get into our findings in more detail.

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In the past few years, DOD has clearly exerted increased emphasis on determining the cause(s) of
Gulf War veterans’ health problems. Since OSAGWI was established, the-staff assigned to deal with
Gulf War illnesses issues has increased from 12 to about 200 in 1998. The operating budget also
increased from $4.1 million to $29.4 million in the same time frame.

To improve communications with veterans, OSAGWI has cleared a large backlog of veterans’
inquiries, used a toll-free hot line, established an internet web site, begun publishing a newsletter,
and assisted veterans in obtaining medical examination and other services at DOD and VAfacilities.
Within its first year of’operation, OSAGWI successfully cleared a backlog of 1,200 veterans’ inquiries
through personal telephone calls and received an additional 1,200 letters and 2,700 e-mail messages.
By January 1,1999, OSAGWI had reiteived 2,850 letters and 4,906 e-mail messages. OSAGWI officials
met with the public and veterans at 18 town hall meetings and appeared at 41 national veterans’
conventions. Its internet site reportedly receives over 60,000 inquiries each week, and over 12,000
individuals receive OSAGWI’s bimonthly newsletter. Moreover, after OSAGWI completes an
investigation and publishes the corresponding case narrative, it sends to each directly affected
veteran a letter that contains a synopsis of the investigation’s results.

OSAGWI also identified several areas needing improvement on the basis of its experience in
investigating and reporting on possible chemical, biological, or environmental exposures. OSAGWI
is working with DOD and other executive branch agencies to implement these lessons learned.
Specific examples of the lessons learned include the need for

    improving systems for tracking troop movements during a conflict so that accurate data is
    available to show where individuals or units were located on the battlefield at any point in time;

    improving wartime records development and post-war records management systems and
    addressing issues such as the lack of a uniform records management program for joint

    improving chemical and biological warfare agent detection equipment to make it less prone to
    false alarms and requiring doctrinal changes to collect and retain detector-produced printouts of

    implementing techniques to better safeguard the health of deployed troops, such as deploying
    forward field laboratories early and taking samples to determine whether contamination may
    have occurred subsequent to the use of depleted uranium ammunition; and

    improving and implementing depleted uranium training programs.

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We found procedural, investigative, or reporting problems in three of the six cases we reviewed that
were not evident in the other three cases. Specifically, OSAGWI investigators sometimes failed to
follow up with appropriate individuals to confirm key evidence, identify or ensure the validity of key
evidence, include important information, and interview key witnesses. Despite these weaknesses,
the preponderance of evidence led us to agree with the conclusions in OSAGWI case narratives
concerning the presence of chemical warfare agents in all but one of the six cases reviewed.

This one exception involved a potential exposure of U.S. Marine Corps personnel during a minefield
breaching operation. OSAGWI concluded that an exposure in this case was “unlikely.” However,
this case narrative did not include some key information contained in OSAGWI files. Specifically, we
found the following.

m OSAGWI had information regarding the presence of artillery fire that contradicted one of its
  primary determinations-that no artillery fire or chemical mines were present and therefore no
  means of chemical warfare agent delivery existed.

n       OSAGWI did not include information that chemical detection paper attached to a vehicle used in
        the operation changed color, indicating the potential presence of a chemical warfare agent.

After reviewing all relevant information OSAGWI had in its files, we concluded that OSAGWI needed
to reassess this case, taking into consideration this added information.

The other two cases in which we found investigative or reporting weaknesses involved a possible
exposure of (1) a servicemember to a mustard agent during an inspection of an Iraqi bunker complex
and (2) servicemembers to chemical agents in Al Jubayi, Saudi Arabia.

In the mustard agent case, OSAGWI did not follow up adequately to confirm whether an in-theater
urinalysis test was admimstered. We found insufficient evidence to support the existence of such a
test. Moreover, OSAGWl did not establish whether clothing tested for chemical warfare agent in this
case actually belonged to the individual allegedly exposed. Finally, OSAGWI reached its conclusion
without interviewing some key witnesses. Despite these weaknesses, the evidence in this csse
supported OSAGWI’s conclusion that exposure to a chemical warfare agent was “likely.”

In the case involving three reported incidents with potential exposure to chemical agents in Al
Jubayl, Saudi Arabia, the available evidence generally supported OSAGWl’s conclusions that two of
the reported incidents did not occur and that the presence of chemical agents was 9mlikely” in the
other incident. However, OSAGWI did not include important information that would have made the
case narrative more complete-that many of the individuals associated with this case had reported
unusually high levels of health problems since their service during the Persian Gulf War. Without
this information, a reader could conclude that there was little basis for concern about exposure to
hazardous substances in this case. The case narrative also failed to mention that health problems
affecting many individuals associated with this incident were among the first Gulf War illnesses-
related in&&&s reported and the subject of several major DOD investigations and studies. Had

Page5                                                              GAO/NSIADgS-219R Gulf War lilmses
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OSAGWI included this information, it would have avoided any appearance that it had not completely
reported what was known from the investigation. Moreover, OSAGWI did not adequately identify
and coordinate some information developed during this investigation with the Naval Health Research
Center for inclusion in its Gulf War illnesses research on Navy personnel (Seabees) who were in that

For all six cases, we found that OSAGWI had not used DOD and VA clinical databases that contain
information on the health of thousands of Gulf War veterans who may have symptoms of the types
commonly associated.with Gulf War illnesses. Use of these databases is identified in OSAGWI’s
methodology for conducting investigations, and they were used by OSAGWI in some other
investigations. Their use might have provided leads regarding whether more investigative effort was
needed in cases where exposure to chemical warfare agents or other environmental hazards might
have occurred. During our review of the case narratives, we noted weaknesses in OSAGWI’s internal
quality assurance practices that contributed to some of the problems we found.


To ensure that OSAGWI’s case narratives contain all the facts that have
surfaced to date, we recommended that the Secretary of Defense direct the Special &sistant for Gulf
War Illnesses to
.   revise the marine minefield breaching, the mustard agent, and the Al Jubayl case narratives to
    reflect the new and/or unreported information we identified and
.   examine whether OSAGWI’s conclusion in the marine minefield breaching case should be
    changed in light of the additional information known about this case.

To enhance the thoroughness of OSAGWI’s investigative and reporting practices, we recommended
that the Secretary of Defense direct the Special Ass&ant for Gulf War Illnesses to

.   use the DOD and VA Gulf War clinical databases to assist in designing the nature and scope of all
    OSAGWI investigations;

= include relevant medical information in its case narratives where it is needed to fully explain
  incidents of possible exposure to chemical agents or other potential causes of Gulf War illnesses;
.   ensure that OSAGWI’s internal review procedures provide that (1) those reviewing an
    investigation and related report are independent of the team investigating the incident and (2)
    steps are in place that will lead the reviewers to thoroughly check that all relevant information
    obtained by the investigation teams has been included in the case narrative reports, all
    conchrsions have been fully substantiated by the facts, and all logical leads have been pursued.    .

We further recommended that OSAGWI contact the Naval Health Research Center regarding the
usefulness and desirability of comparing data between two units that served in the same area to
determine whether veterans from the units were reporting the same types and numbers of

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DOD generally concurred with the report and agreed to revise OSAGWI’s reports to include new or
unreported data identified by our review and to use this information in reassessing case narrative
findings. DOD stated that follow-up investigations were either planned or underway regardingthe
three cases where we noted weaknesses. While DOD agreed to update the marine minefield               -
breaching case narrative, it also noted that there were still inconsistencies regarding the presence of
artillery fire. DOD said that as part of its follow-up investigation, it would objectively consider all
information and detail more completely the artillery issue and its relevance to whatever final
assessment is made.

DOD and VA disagreed with our recommendation that OSAGWI incorporate the use of DOD and VA
clinical databases into its evaluations. Their disagreement was based on concerns that these
databases might be inappropriately used to establish a causal relationship between an event and the
medical findings of the registries. However, DOD agreed that the databases need to be examined
and analyzed for what they can contribute to understanding the illnesses of Gulf War veterans.

We agree that information from these databases should not be used to estabbsh a causal association
and did not intend that this information should be used for such purposes. However, we continue to
believe that these databases could provide relevant information to investigators about whether
individuals who were at or near a site under investigation are reporting health problems. This
information could then be combined with other information to help guide the nature and scope of
OSAGWI investigations.

DOD indicated that it would request the Naval Health Research Center to undertake the analytkal
comparison we had recommended. DOD also commented that independent reviewers are critical to
a thorough and acceptable report on its investigations. DOD added that this was the reason it had
established its current multilevel review process.

Mr. Chairman that concludes my prepared remarks. I will be happy to answer any questions you
may have about our report.


                                                                  GAO/NSIAD-99-219RGulf War Illnm
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