oversight

Gulf War Illnesses: Procedural and Reporting Improvements Are Needed in DOD's Investigative Processes

Published by the Government Accountability Office on 1999-02-26.

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

                  United States General Accounting Office

GAO               Report to the Honorable Lane Evans,
                  Ranking Minority Member, Committee
                  on Veterans Affairs, House of
                  Representatives

February 1999
                  GULF WAR
                  ILLNESSES
                  Procedural and
                  Reporting
                  Improvements Are
                  Needed in DOD’s
                  Investigative Processes




GAO/NSIAD-99-59
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      National Security and
      International Affairs Division

      B-279127

      February 26, 1999

      The Honorable Lane Evans
      Ranking Minority Member
      Committee on Veterans Affairs
      House of Representatives

      In response to your request, we have reviewed the operations of the Department of Defense’s
      Office of the Special Assistant for Gulf War Illnesses. This report focuses on the thoroughness
      of this Office’s investigations into and reporting on veterans’ potential exposure to chemical or
      biological agents during the Persian Gulf War.

      We are sending copies of this report to the Chairmen and Ranking Minority Members of the
      House Committee on Appropriations, the House Committee on Government Reform and
      Oversight, the Senate Committee on Appropriations, and the Senate Committee on
      Governmental Affairs and to the Director, Office of Management and Budget. We will make
      copies available to others on request.

      If you or your staff have any questions concerning this report, please contact me on
      (202) 512-5140. Major contributors to this report are listed in appendix IV.

      Sincerely yours,




      Mark E. Gebicke
      Director, Military Operations
        and Capabilities Issues
Executive Summary


             Many servicemembers who served in the Persian Gulf War have
Purpose      subsequently experienced health problems such as fatigue, muscle and
             joint pain, gastrointestinal complaints, headaches, memory loss, and sleep
             disturbances. Whether these health problems are related to these
             servicemembers’ exposures to chemical, biological, or environmental
             agents during their Gulf War service has been a topic of much controversy.
             To ensure that all issues related to Gulf War illnesses were
             comprehensively addressed, the Department of Defense (DOD) established
             the Office of the Special Assistant for Gulf War Illnesses (OSAGWI) in
             November 1996.

             To determine whether DOD is diligently addressing issues related to Gulf
             War illnesses, the Ranking Minority Member of the House Committee on
             Veterans Affairs asked GAO to examine selected OSAGWI operations.
             Specifically, GAO’s objectives were to (1) describe DOD’s progress in
             establishing an organization to address Gulf War illnesses issues and
             (2) evaluate the thoroughness of OSAGWI’s investigations into and reporting
             on incidents of veterans’ potential exposure to chemical or biological
             warfare agents during the Gulf War.


             More than 100,000 Gulf War veterans have participated in health
Background   examination programs established by DOD and the Department of Veterans
             Affairs (VA). Of those examined, nearly 90 percent 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
             warfare agents that Iraq may have used during the Gulf War. Other causes,
             such as stress, smoke from oil well fires, reactions to pesticides or
             vaccines, and exposure to depleted uranium munitions, have also been
             suggested as causes of these illnesses. Research to better identify the
             causes is ongoing but will not be completed for years.

             Following the Gulf War, DOD claimed that chemical weapons were not
             present in the Gulf War theater. However, the Central Intelligence Agency
             disclosed in 1995 that chemical weapons were found at an ammunition
             storage site at Khamisiyah, Iraq. Following an investigation, DOD
             acknowledged in July 1997 that U.S. troops might have been exposed to a
             chemical warfare agent at Khamisiyah when demolitions were used there
             to destroy Iraqi rockets. Other incidents involving potential chemical
             warfare agent exposures have been cited by veterans in testimonies before
             various congressional committees. Consequently, some have called into
             question DOD’s credibility on Gulf War illnesses issues.



             Page 2                                       GAO/NSIAD-99-59 Gulf War Illnesses
Executive Summary




In November 1996, DOD established OSAGWI to restore public confidence in
DOD’s efforts to deal with Gulf War illnesses issues. OSAGWI has focused its
efforts on (1) establishing effective two-way communications with
veterans and veterans groups, (2) investigating and reporting on incidents
of possible chemical warfare agent exposures, and (3) applying lessons
learned from the Gulf War experience to better protect U.S.
servicemembers on a contaminated battlefield.

Each OSAGWI investigation into possible exposures of servicemembers to
chemical warfare agents results in a summation document called a case
narrative. The case narrative, a document updated as new evidence
becomes known, contains all important investigative facts and OSAGWI’s
assessment—in terms of “definitely,” “likely,” “indeterminate,” “unlikely,”
or “definitely not”—of the likelihood that servicemembers were exposed
to chemical or biological warfare agents. The standard OSAGWI used for its
assessments was whether all available facts would lead a reasonable
person to conclude that a chemical or biological warfare agent was or was
not present. At the time GAO began its evaluation, OSAGWI had issued eight
case narratives. OSAGWI pursued these cases first because they involved
incidents that were the most prominent and controversial.

GAO evaluated six of these eight investigations. GAO did not review the case
narrative about the alleged exposure at Khamisiyah because it was already
being heavily reviewed by other organizations, such as the Presidential
Advisory Committee on Gulf War Veterans’ Illnesses and the Senate
Committee on Veterans Affairs’ Special Investigation Unit. GAO also did not
review the Possible Chemical Agent on SCUD Missile Sample case
narrative because it appeared to be less controversial than the other case
narratives. In conducting its evaluations, GAO (1) traced each statement in
these reports 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 report,
(3) contacted key sources of information 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 of
possible exposures to chemical warfare agents.




Page 3                                        GAO/NSIAD-99-59 Gulf War Illnesses
                   Executive Summary




                   DOD  has made progress in carrying out its mandate to comprehensively
Results in Brief   address Gulf War illnesses-related issues. It has assisted veterans through
                   its outreach program by clearing large backlogs of veterans’ inquiries,
                   using a toll-free hot line, setting up a Web site, and publishing a newsletter.
                   In addition, it has assisted veterans in obtaining medical examinations and
                   other services at DOD and VA facilities. Through the course of its
                   investigations and other work, OSAGWI has identified needed improvements
                   in DOD’s equipment, policies, and procedures and has worked with various
                   DOD agencies to implement changes designed to provide better protection
                   to U.S. servicemembers on a contaminated battlefield. OSAGWI generally
                   applied appropriate investigative procedures and techniques in conducting
                   its work. However, GAO found that three of the six case narratives it
                   reviewed contained weaknesses such as failures to follow up with
                   appropriate individuals to confirm key evidence, to identify or ensure the
                   validity of some evidence, to include some important information, and to
                   interview some key witnesses. In the remaining three cases, OSAGWI
                   conducted its investigations without evidence of these weaknesses. In all
                   six cases, OSAGWI missed an opportunity to perform more complete
                   investigations because it did not take advantage of potentially valuable
                   sources of relevant information in DOD and VA clinical databases. GAO does
                   not know whether the investigatory and reporting weaknesses it found in
                   its review of these six cases might also exist in the cases that OSAGWI later
                   investigated.

                   Despite these weaknesses, GAO agreed with OSAGWI’s conclusions about the
                   likelihood of the presence of chemical warfare agents in five of the six
                   cases it reviewed. The one exception involved a potential exposure of U.S.
                   Marine Corps personnel to a chemical warfare agent during a minefield
                   breaching operation. OSAGWI concluded that exposure in this case was
                   “unlikely.” However, GAO found that OSAGWI had overlooked some
                   information it had in its possession and also did not include all relevant
                   information in its case narrative. After reviewing the overlooked
                   information and considering all relevant information OSAGWI had in its files,
                   GAO believes that OSAGWI should reassess the likelihood of exposure in this
                   case. There is potential that this case could be more appropriately
                   assessed as “indeterminate.”

                   GAO believes that the lack of effective quality assurance policies and
                   practices in OSAGWI’s investigating and reporting processes contributed to
                   the weaknesses noted. Although OSAGWI has taken steps to improve its
                   quality assurance procedures, certain features should be incorporated to




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                            Executive Summary




                            ensure that all of its investigations are thoroughly conducted and
                            accurately reported.



Principal Findings

DOD Has Made Progress in    DOD  established OSAGWI to repair the credibility problems it faced regarding
Establishing an             its past efforts to address Gulf War illnesses issues. It provided OSAGWI
Organization to Address     with an operating authority much broader than its predecessor, the
                            Persian Gulf Illnesses Investigation Team, namely, to coordinate all
Gulf War Illnesses Issues   aspects of DOD’s programs concerning Gulf War illnesses. Compared with
                            its predecessor, OSAGWI represents a significant increase in resources
                            directed toward investigations and outreach efforts. For example, in 1996,
                            the Persian Gulf Illnesses Investigation Team operated with a staff of 12
                            persons and a budget of $4.1 million. In contrast, OSAGWI had a staff of 200
                            persons as of October 9, 1998, and a fiscal year 1998 budget of
                            $29.4 million. In addition, while the Persian Gulf Illnesses Investigation
                            Team reported to the Assistant Secretary of Defense for Health Affairs,
                            OSAGWI reports directly to the Deputy Secretary of Defense.


                            DOD has made progress in addressing Gulf War illnesses issues. To improve
                            communications with veterans, OSAGWI has established the means to
                            receive input from and provide information to veterans. 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
                            received 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. OSAGWI also refers veterans to various sources of
                            medical services. Finally, OSAGWI communicates directly with veterans that
                            are affected by its investigations. 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’s mission requires that it advise the Secretary of Defense on
                            changes needed in military equipment, policies, and procedures in order to
                            better protect servicemembers during operations on a contaminated




                            Page 5                                        GAO/NSIAD-99-59 Gulf War Illnesses
                          Executive Summary




                          battlefield. OSAGWI has 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. For example, OSAGWI was instrumental in prompting the Deputy
                          Secretary of Defense to issue a requirement that the military services
                          review their depleted uranium training programs. These programs are
                          important in addressing potential health problems related to the use of
                          depleted uranium in armor and ammunition. We did not review the impact
                          this activity has had on making changes within DOD. However, in
                          October 1998, OSAGWI established a directorate to focus on ensuring that
                          lessons learned are implemented.


Investigative and         GAO found procedural, investigative, or reporting problems in three of the
Reporting Procedures      six cases it reviewed. These weaknesses were not evident in the other
Have Various Weaknesses   three cases. Specifically, it found that 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 GAO to agree with the conclusions in OSAGWI
                          case narratives concerning the presence of chemical warfare agents in all
                          but one of the six cases GAO 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, GAO found that this case narrative did not include
                          some key information contained in OSAGWI files. Specifically, 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. Also, 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 the
                          overlooked information and considering all relevant information OSAGWI
                          had in its files, GAO concluded that reassessment is needed and that the
                          probability of exposure might more appropriately be assessed as
                          “indeterminate.”

                          The other two of the three cases in which GAO found investigative or
                          reporting weaknesses involved (1) a possible exposure of a
                          servicemember to a mustard agent and (2) a possible exposure of
                          servicemembers to chemical agents in Al Jubayl, Saudi Arabia. In the case



                          Page 6                                       GAO/NSIAD-99-59 Gulf War Illnesses
Executive Summary




involving the potential exposure of a servicemember to a mustard agent
during an inspection of an Iraqi bunker complex, OSAGWI did not follow up
adequately to confirm whether an in-theater urinalysis test was
administered. GAO found insufficient evidence to support the existence of
such a test. Moreover, OSAGWI 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 case supported OSAGWI’s conclusion that exposure to a chemical
warfare agent was “likely.” In the case involving potential exposure to
chemical agents in Al Jubayl, Saudi Arabia, GAO found that the available
evidence generally supported OSAGWI’s conclusions. However, OSAGWI did
not include important information that would have made the case
narrative more complete. Had OSAGWI included this information, it would
have avoided any appearance that it had not completely reported what
was known from the investigation. Specifically, OSAGWI did not report 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 report also failed to mention that health problems affecting
many individuals associated with this incident were among the first Gulf
War illnesses-related incidents reported and the subject of several major
DOD investigations and studies.


For all six cases, GAO found that OSAGWI had not taken advantage of 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 its review of the case narratives, GAO noted weaknesses in OSAGWI’s
internal quality assurance practices that contributed to some of the
problems it found. In responding to GAO’s findings, OSAGWI officials said
that subsequent to the publication of these cases, they implemented
internal review and quality assurance procedures that should prevent such
shortcomings in future reports. This internal review mechanism has been
evolving since July 1997. It remains to be seen whether these procedures



Page 7                                       GAO/NSIAD-99-59 Gulf War Illnesses
                           Executive Summary




                           will effectively provide the quality assurances necessary for OSAGWI to
                           thoroughly investigate potential chemical, biological, and environmental
                           exposures and to maintain credibility with veterans.


                           To ensure that OSAGWI’s case narratives contain all the facts that have
Recommendations            surfaced to date, GAO recommends that the Secretary of Defense direct the
                           Special Assistant for Gulf War Illnesses to

                       •   revise the Marine Minefield Breaching, the Exposure to Mustard agent,
                           and the Al Jubayl case narratives to reflect the new and/or unreported
                           information identified by GAO and
                       •   determine whether OSAGWI’s conclusion in the Marine Minefield Breaching
                           case that exposure to chemical warfare agent was “unlikely” should be
                           changed to “indeterminate” in light of the additional information known
                           about this case.

                           To enhance the thoroughness of OSAGWI’s investigative and reporting
                           practices, GAO recommends that the Secretary of Defense direct the
                           Special Assistant 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 and
                       •   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
                           conclusions have been fully substantiated by the facts, and all logical leads
                           have been pursued.

                           More detailed recommendations are found on pages 44 and 45.


                           GAO   asked DOD and VA to comment on a draft of this report.
Agency Comments
and GAO’s Evaluation       DOD generally concurred with the report. In response to GAO’s findings and
                           recommendations, DOD agreed to revise OSAGWI’s reports to include new or
                           unreported data identified by GAO’s efforts and to use this information in
                           reassessing case narrative findings. DOD also stated that follow-up
                           investigations were either planned or under way regarding the Marine
                           Minefield Breaching, Reported Mustard Agent Exposure, and Al Jubayl



                           Page 8                                        GAO/NSIAD-99-59 Gulf War Illnesses
Executive Summary




case narratives. While DOD agreed to update the Marine Minefield
Breaching 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 both disagreed with GAO’s recommendation that OSAGWI
incorporate the use of DOD and VA clinical databases into its evaluations.
Their disagreement was based on their concern 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 needed to be examined and analyzed for what they can
contribute to understanding the illnesses of Gulf War veterans.

GAO continues to believe that the VA and DOD databases could provide
relevant information to investigators about whether individuals that 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. GAO agrees that information
for these databases cannot be used to establish a causal association as
described by DOD and VA and did not intend that this information should be
used for such purposes.

DOD agreed that independent reviewers are critical to a thorough and
acceptable report on its investigations. DOD commented that this was the
reason it established its current multilevel review process. This is now
being supplemented by the President’s Special Oversight Board, which is
examining OSAGWI cases in detail.

DOD and VA general comments are addressed in more detail in chapter 3.
DOD and VA comments in their entirety and our evaluation of them are
included in appendixes I and II, respectively.




Page 9                                       GAO/NSIAD-99-59 Gulf War Illnesses
Contents



Executive Summary                                                                                  2


Chapter 1                                                                                         12
                       Establishment of the Persian Gulf Illnesses Investigation Team             12
Introduction           OSAGWI’s Mission and Implementation Strategy                               14
                       Objective, Scope, and Methodology                                          15


Chapter 2                                                                                         18
                       DOD Increases Emphasis on Determining Cause of Gulf War                    18
OSAGWI Has Made          Veterans’ Health Problems
Progress in            OSAGWI Has Improved Communications With Veterans                           19
                       OSAGWI Has Identified Chemical and Biological Warfare Force                20
Addressing Issues        Protection Issues Requiring Attention
Related to Gulf War
Illnesses
Chapter 3                                                                                         22
                       OSAGWI’s Investigations and Reporting Procedures Have Various              22
Some Case Narratives     Weaknesses
Have Investigative     OSAGWI Did Not Use DOD and VA Medical Databases in                         39
                         Conducting Its Investigations for Cases We Reviewed
and Reporting          Three Case Narratives Appear to Have Been Appropriately                    41
Weaknesses               Investigated
                       OSAGWI Has Made Changes to Improve Its Investigative and                   42
                         Reporting Processes
                       Conclusions                                                                43
                       Recommendations                                                            44
                       Agency Comments and Our Evaluation                                         45


Appendixes             Appendix I: Comments From the Department of Defense                        48
                       Appendix II: Comments From the Department of Veterans Affairs              60
                       Appendix III: OSAGWI Reports and Active Investigations                     64
                       Appendix IV: Major Contributors to This Report                             66


Table                  Table I.1: OSAGWI Published Case Narratives, Information                   64
                         Papers, and Environmental Exposure Reports




                       Page 10                                     GAO/NSIAD-99-59 Gulf War Illnesses
Contents




Abbreviations

ASP        Ammunition Supply Point
CCEP       Comprehensive Clinical Evaluation Program
DOD        Department of Defense
EPMU       Environmental and Preventive Medicine Unit
NMCB       Naval Mobile Construction Battalion
OSAGWI     Office of the Special Assistant for Gulf War Illnesses
VA         Department of Veterans Affairs


Page 11                                      GAO/NSIAD-99-59 Gulf War Illnesses
Chapter 1

Introduction


                         Many Persian Gulf War veterans have complained of illnesses since the
                         war’s end in 1991. Over 100,000 of the approximately 700,000 Gulf War
                         veterans have participated in health examination programs established by
                         the Department of Defense (DOD) and the Department of Veterans Affairs
                         (VA). Many of those examined reported health complaints, including
                         fatigue, muscle and joint pain, gastrointestinal problems, headaches,
                         depression, neurologic and neurocognitive impairments, memory loss,
                         shortness of breath, and sleep disturbances. Many veterans claim that their
                         medical symptoms, some of them debilitating in nature, were not present
                         before their service in the Persian Gulf War. Some veterans suspect that
                         their health problems may be linked to chemical or biological warfare
                         agents that Iraq may have used during the Gulf War.

                         Various organizations have researched the causes of Gulf War
                         illnesses—the source of much controversy over the past 7 years. By the
                         end of 1996, DOD and the VA together had funded 82 research projects
                         related to Gulf War illnesses. Despite these efforts, it remains unclear why
                         some Gulf War veterans became ill following their service in the Persian
                         Gulf War. It also remains unclear whether the rates of reported illnesses
                         for veterans that deployed to the Gulf are higher overall than the rates for
                         those that did not deploy or than the rates for the civilian or military
                         population as a whole. Also unexplained are differences in the frequency
                         of symptoms reported by reserve units and active duty units and any
                         correlations between the location of units and the occurrence of particular
                         illnesses. Research designed to answer these and many other Gulf War
                         illnesses-related questions will not be completed for years. Of the 151
                         current federally sponsored research projects, less than 25 percent have
                         been completed, and many are not scheduled for completion until after
                         2000.


                         Prompted by the continuing controversy over Gulf War illnesses, President
Establishment of the     Clinton, in 1995, ordered DOD and other federal agencies to reexamine
Persian Gulf Illnesses   whether possible exposure to chemical or biological agents occurred
Investigation Team       during the Gulf War. In March 1995, the Deputy Secretary of Defense
                         established the Persian Gulf Illnesses Investigation Team within the Office
                         of the Assistant Secretary of Defense for Health Affairs to explore this
                         question. The Investigation Team was established as DOD began to lose
                         credibility among veterans and veterans’ groups in its efforts to determine
                         the causes of Gulf War illnesses and to support the problems experienced
                         by veterans. The 12-member team included intelligence officers, an Army
                         Chemical Corps officer, a pilot, a chemist, a physician, and a criminal



                         Page 12                                      GAO/NSIAD-99-59 Gulf War Illnesses
Chapter 1
Introduction




investigator. Beginning in 1991, senior Defense officials had taken the
position, in testimony before the Congress and in press interviews, that
Iraq did not use chemical or biological weapons during the Persian Gulf
War and that no U.S. forces were exposed to chemical or biological agents.
DOD officials maintained this position as late as 1994. This position came
under attack because both U.S. and foreign detection teams had reported
that chemical warfare agents were present on the battlefield. In 1995 and
1996, Central Intelligence Agency and U.N. reports established that during
the Gulf War, Iraq had stored rockets filled with sarin, a deadly chemical
warfare agent, at an ammunition storage site located at Khamisiyah, Iraq,
about 60 miles from Kuwait’s border. In June 1996, DOD announced that
U.S. troops at Khamisiyah in March 1991 were likely to have destroyed a
bunker of rockets containing chemical agents. By July 1997, DOD
acknowledged that U.S. troops near Khamisiyah may have unknowingly
been exposed to low levels of sarin when they used demolitions to destroy
these rockets.

In the midst of this controversy, DOD became dissatisfied with the results
of the Investigation Team’s efforts. The Investigation Team did not have
the resources needed to accomplish its mission. For example, it was
unable to follow up on more than 1,200 toll-free calls received on DOD’s hot
line with Gulf War veterans. In addition, its operation was criticized in the
December 1996 report by the Presidential Advisory Committee on Gulf
War Veterans’ Illnesses.1 The report cited, for example, the Investigation
Team’s failure to take advantage of its unique access to classified and
routine military records to fully investigate and help answer the public’s
questions about veterans’ possible exposure to chemical and biological
warfare agents.

A DOD team asked by the Deputy Secretary of Defense to evaluate DOD’s
responses to Gulf War illnesses concluded that DOD’s work in this area
needed a broader focus, a strategy for systematically examining the
various theories concerning the nature and causes of Gulf War illnesses,
and a method of effectively communicating DOD’s findings to U.S. veterans
and the public. On November 12, 1996, the Deputy Secretary of Defense
established the Office of the Special Assistant for Gulf War Illnesses
(OSAGWI).




1
 Final Report, Presidential Advisory Committee on Gulf War Veterans’ Illnesses, December 31, 1996,
pp. 44-45.



Page 13                                                     GAO/NSIAD-99-59 Gulf War Illnesses
                     Chapter 1
                     Introduction




                     The goal of restoring public confidence in DOD shaped the mission and
OSAGWI’s Mission     organizational focus of OSAGWI. OSAGWI’s mission was broadly defined as
and Implementation   ensuring that (1) veterans of the Gulf War are appropriately cared for,
Strategy             (2) DOD is doing everything possible to understand and explain Gulf War
                     illnesses, and (3) DOD puts into place all required military doctrine and
                     personnel and medical policies and procedures to minimize any future
                     problems from exposure to chemical and biological warfare agents and
                     other environmental hazards.

                     Although OSAGWI’s mission statement charges it with ensuring that veterans
                     are appropriately cared for, specific responsibility for providing health
                     care to servicemembers still on active duty and for conducting the health
                     research program continues to reside with the Office of the Assistant
                     Secretary of Defense for Health Affairs. Similarly, VA remains the primary
                     health care provider for those who have left military service. OSAGWI
                     officials told us, however, that they assist servicemembers and veterans
                     with health care matters related to Gulf War illnesses by providing them
                     with referrals to sources of health care or helping them with the
                     registration and examination processes associated with DOD’s
                     Comprehensive Clinical Evaluation Program or the VA’s Persian Gulf
                     Registry. OSAGWI also works with the Assistant Secretary of Defense for
                     Reserve Affairs to (1) help ensure that reservists receive all entitled
                     benefits and (2) recommend changes to legislation or rules where needed.

                     At the time of our review, OSAGWI believed that its core activity involved
                     investigating and reporting on incidents of possible exposure to chemical
                     and biological warfare agents and investigating related military operations
                     during the Gulf War. After OSAGWI has completed its investigation of an
                     incident, the investigator writes a summation document called a case
                     narrative. The purpose of OSAGWI’s case narratives is essentially to get all of
                     the facts before the American people about what OSAGWI has learned from
                     its investigation of an incident. The case narrative, a document updated as
                     new evidence becomes known, is to contain all important investigative
                     facts and OSAGWI’s assessment—in terms of “definitely,” “likely,”
                     “indeterminate,” “unlikely,” or “definitely not”—of the likelihood that
                     servicemembers were exposed to chemical or biological warfare agents.
                     The standard OSAGWI used for its assessments was whether all available
                     facts would lead a reasonable person to conclude that a chemical or
                     biological warfare agent was or was not present.

                     As of January 1, 1999, OSAGWI had published a total of 19 reports—13 case
                     narratives, 2 environmental exposure reports, and 4 information papers. At



                     Page 14                                        GAO/NSIAD-99-59 Gulf War Illnesses
                        Chapter 1
                        Introduction




                        that time OSAGWI also had 27 active investigations under way. Appendix III
                        lists OSAGWI reports and their dates of publication as well as OSAGWI’s active
                        investigations.


                        On July 8, 1997, the Ranking Minority Member of the House Committee on
Objective, Scope, and   Veterans Affairs asked us to examine OSAGWI operations. Specifically, we
Methodology             were asked to (1) describe DOD’s progress in establishing an organization
                        to address Gulf War illnesses issues and (2) evaluate the thoroughness of
                        OSAGWI’s investigations into and reporting on veterans’ potential exposure
                        to chemical or biological agents during the Gulf War. We did not review
                        OSAGWI activities to coordinate and monitor research on the causes of Gulf
                        War illnesses because this subject is addressed by other reviews. To
                        determine DOD’s progress in establishing an organization to address Gulf
                        War illnesses issues, we obtained briefings from OSAGWI officials covering
                        the range of activities performed to fulfill their mission objectives and
                        reviewed associated documentation.

                        OSAGWI  had issued eight case narratives at the time we began our review. It
                        pursued these eight cases first because they involved incidents that were
                        the most prominent and controversial at the time. To evaluate the
                        thoroughness of OSAGWI’s investigations and reporting on veterans’
                        possible exposures to chemical or biological warfare agents, we reviewed
                        six of these eight case narratives. The case narratives we selected for
                        review were (1) “Reported Mustard Agent Exposure”; (2) “U.S. Marine
                        Corps Minefield Breaching”; (3) “Fox Detections in an Ammunition Supply
                        Point (ASP) Orchard”; (4) “Al Jubayl, Saudi Arabia”; (5) “Al Jaber Air Base”;
                        and (6) “Reported Detection of Chemical Agent, Camp Monterey, Kuwait.”
                        We did not review the case narrative about the alleged exposure to
                        chemical warfare agents at Khamisiyah, Iraq, because it was already being
                        heavily reviewed by other organizations, such as the Presidential Advisory
                        Committee on Gulf War Veterans’ Illnesses and the Senate Committee on
                        Veterans Affairs’ Special Investigation Unit. We also did not review the
                        “Possible Chemical Agent on SCUD Missile Sample” case narrative
                        because it appeared to be less controversial than the other case narratives.

                        In reviewing each case narrative, we generally used as criteria OSAGWI’s
                        methodology, which had itself been derived from the United Nations and
                        other international community protocols for investigating chemical
                        warfare incidents. This methodology included (1) substantiating the
                        incident by searching for documentation from operational, intelligence,
                        and environmental logs; (2) documenting the medical reports related to



                        Page 15                                        GAO/NSIAD-99-59 Gulf War Illnesses
Chapter 1
Introduction




the incident; (3) interviewing appropriate people; (4) obtaining
information available to external organizations; and (5) assessing the
results. We also used the criterion that the case narrative should
accurately and fully disclose all materially significant information relevant
to the investigation of the incident in order to avoid any appearance that
OSAGWI was selectively reporting what had actually happened.


We initially traced each statement in the published case narrative to its
underlying supporting document to identify the accuracy and
completeness of the text in the narrative. For those statements missing
adequate supporting documentation, we requested that OSAGWI provide us
with the appropriate documentation. We also reviewed additional
documentation collected by the OSAGWI investigators in performing the
investigation, even though some of this documentation might not have
been cited in the published narrative. We looked for any inconsistencies in
information that was not addressed in the published narrative. In addition,
for the selected case narratives, we contacted 71 individuals interviewed
by OSAGWI that were key sources of information and requested that they
verify the accuracy and completeness of both the OSAGWI case narrative
and the OSAGWI write-up of the investigator’s discussions. We also
contacted some key participants not originally interviewed by OSAGWI to
determine whether other relevant information was available that might
affect OSAGWI’s assessment of possible exposures to chemical warfare
agents. Finally, we contacted several Gulf War veterans organizations,
including the following: the American Legion; the Disabled American
Veterans; the Veterans of Foreign Wars; the National Gulf War Resource
Center; GulfWatch; the Desert Storm Justice Foundation; the Operation
Desert Storm/Shield Association; the Gulf War Veterans of Long Island,
New York; and the Chronic Illnesses Net for Persian Gulf Veterans. We
asked them to provide us with any information they had that refuted or
added to the OSAGWI information. We did not systematically approach
veterans’ groups to obtain their assessments of overall OSAGWI
effectiveness because this was beyond the scope of our review.

To further verify the case narratives, we interviewed officials and obtained
pertinent documentary evidence from officials at the following locations:
OSAGWI, located in Falls Church, Virginia; the U.S. Army Chemical and
Biological Defense Command at Aberdeen, Maryland; the U.S. Army
Chemical Center and School at Ft. McClellan, Alabama; the Office of the
Surgeon General of the Navy, Washington, D.C.; the Naval Health Research
Center, San Diego, California; the Department of Veterans Affairs,
Washington, D.C.; the Deployment Surveillance Team, which operates the



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Introduction




Comprehensive Clinical Evaluation Program, Falls Church, Virginia; and
the U.S. Army Gulf War Declassification Project, Falls Church, Virginia.

We conducted our review from September 1997 to January 1999 in
accordance with generally accepted government auditing standards.




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OSAGWI Has Made Progress in Addressing
Issues Related to Gulf War Illnesses

                       In the face of severe criticism by veterans, veterans groups, and others of
                       its handling of Gulf War illnesses issues, DOD committed additional
                       resources to its efforts to determine the cause of veterans’ health
                       problems. With greater resources and a much broader mandate than its
                       predecessor, OSAGWI has made significant progress in reestablishing
                       communications between DOD and veterans. In addition, OSAGWI is actively
                       engaged in identifying improvements DOD needs to make to protect
                       servicemembers on contaminated battlefields.


                       DOD is investing significantly more resources for OSAGWI’s investigations
DOD Increases          and outreach efforts than it did for the Persian Gulf Illnesses Investigation
Emphasis on            Team. In 1996, the Investigation Team operated with a staff of 12 persons
Determining Cause of   and a budget of $4.1 million. In contrast, as of October 9, 1998, OSAGWI had
                       a staff of about 200 persons and a fiscal year 1998 budget of $29.4 million.
Gulf War Veterans’     In addition, OSAGWI was given much broader authority than the
Health Problems        Investigation Team. Finally, OSAGWI reports directly to the Deputy
                       Secretary of Defense; the Investigation Team reported to the Assistant
                       Secretary of Defense for Health Affairs.

                       OSAGWI  officials said that with an adequate budget and sufficient operating
                       authority within DOD, they were generally unconstrained in their efforts to
                       pursue OSAGWI’s mandate. According to these officials, OSAGWI’s operations
                       have been fully funded, and OSAGWI has had largely unrestricted access to
                       personnel, files, and other data necessary for its work. For example,
                       OSAGWI has had full access to classified information from the military
                       services and intelligence agency sources. To date, OSAGWI has over
                       12 million pages of classified information in its computerized database and
                       approximately 500,000 additional pages of classified data in hard-copy
                       format.

                       The Special Assistant (the head of OSAGWI) has been free to staff OSAGWI
                       according to his needs. This authority has made it possible for him to
                       obtain the expertise needed for OSAGWI’s investigations. From the start,
                       OSAGWI management decided to make extensive use of contractors to
                       quickly obtain personnel with specific expertise and maintain the
                       flexibility to change the mix of staffing as needed. By October 9, 1998, 173
                       (87 percent) of OSAGWI’s personnel were contractor employees. As needed,
                       OSAGWI has obtained specialized expertise from individuals in various
                       governmental agencies, such as the Central Intelligence Agency, the
                       Defense Intelligence Agency, and the Army’s Chemical and Biological




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                      OSAGWI Has Made Progress in Addressing
                      Issues Related to Gulf War Illnesses




                      Defense Command.1 OSAGWI also has the authority to contract with private
                      organizations to perform specialized functions.


                      A key element of OSAGWI’s attempt to regain credibility with veterans,
OSAGWI Has            veterans’ organizations, and the public was to improve communications
Improved              with them. OSAGWI recognized that major improvements were needed from
Communications With   earlier DOD efforts to listen to veterans’ concerns and incorporate the
                      information they provided into DOD’s investigations and help provide
Veterans              health referral services to veterans. Our review confirmed that OSAGWI has
                      made significant progress in establishing communications with veterans
                      and others.

                      OSAGWI established an E-mail address and encouraged veterans and others
                      to use both this and the DOD toll-free hotline to communicate with OSAGWI
                      regarding Gulf War illnesses issues. Within the first year of operation, it
                      received almost 1,200 letters and 2,700 E-mail messages. OSAGWI staff
                      contacted over 3,900 veterans through personal telephone calls, which
                      included the vast majority of the Investigation Team backlog of
                      unanswered calls from 1,200 veterans. According to OSAGWI, as of
                      January 1, 1999, it had received 2,850 letters and 4,906 E-mail messages
                      and answered 2,803 and 4,866, respectively. OSAGWI used a staff specifically
                      trained to deal with Gulf War veterans’ concerns, obtain information from
                      veterans, provide information about OSAGWI activities, and make referrals
                      for those needing medical support from DOD or VA.

                      OSAGWI   uses a variety of methods to disseminate information on its
                      operations. For example, it uses a Web site called GulfLINK on which it
                      publishes its case narrative reports, information papers, and much of the
                      supporting documentation used in its investigations. OSAGWI reports that
                      this site typically receives over 60,000 inquiries each week. OSAGWI also
                      publishes a bimonthly newsletter called GulfNEWS. Over 12,000
                      individuals receive the newsletter. OSAGWI’s leadership and staff have met
                      with veterans at 18 town hall meetings and made appearances at 41
                      national veterans conventions. In addition, OSAGWI officials frequently meet
                      with veterans and military service organizations to discuss Gulf War
                      illnesses topics of interest to them.

                      Finally, OSAGWI communicates directly with veterans that are affected by
                      its investigations. After OSAGWI completes an investigation and publishes


                      1
                      The Chemical and Biological Defense Command was later renamed the Soldier and Biological
                      Chemical Command.



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                          OSAGWI Has Made Progress in Addressing
                          Issues Related to Gulf War Illnesses




                          the corresponding case narrative, it sends to each affected veteran a letter
                          that contains a synopsis of the investigation’s results. For example,
                          following its investigation of the potential chemical warfare agent
                          exposure in Khamisiyah, Iraq, OSAGWI sent letters to 97,837 veterans
                          concerning the possibility that they might have been exposed to low levels
                          of sarin, a chemical warfare agent.


                          According to OSAGWI officials, OSAGWI must go beyond investigating and
OSAGWI Has                reporting on possible veterans’ exposures to chemical or biological
Identified Chemical       warfare agents and identify ways to better protect servicemembers from
and Biological            nontraditional battlefield threats. From its investigations and reports on
                          possible veterans’ exposures to chemical, biological, or environmental
Warfare Force             agents, OSAGWI has identified force protection issues that need
Protection Issues         improvement. These lessons learned generally fall into the following three
                          categories: how to build trust and confidence in DOD, how to better
Requiring Attention       account for what happened on the battlefield, and how to better protect
                          servicemembers on the battlefield. Specific examples of the lessons
                          learned include the need for

                      •   institutionalizing a veterans’ outreach capability after OSAGWI is
                          disestablished;
                      •   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 commands;
                      •   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 detections;
                      •   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.

                          OSAGWI is presently working with DOD agencies to implement the lessons
                          learned. Discussions by the Special Assistant with the Director of the Joint
                          Staff and the military service Chiefs of Staff resulted in revised Joint Staff
                          policy concerning record-keeping by joint commands. OSAGWI was also
                          instrumental in developing a DOD-initiated requirement for the military



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OSAGWI Has Made Progress in Addressing
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services to review their depleted uranium training programs. We did not
review what impact OSAGWI’s lessons learned have had toward making
changes within DOD. Until recently, OSAGWI had no office for monitoring
and measuring the extent to which OSAGWI lessons learned were being
acted upon. In October 1998, the Special Assistant created a new OSAGWI
directorate to focus attention on ensuring that lessons learned are
effectively communicated to and implemented by the responsible DOD
agencies.




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Some Case Narratives Have Investigative
and Reporting Weaknesses

                       We reviewed six of the eight case narratives OSAGWI had published at the
                       time we began our review to evaluate the thoroughness and accuracy of
                       OSAGWI’s investigations. OSAGWI generally followed its investigation
                       methodology and used appropriate investigative procedures and
                       techniques. However, we found significant weaknesses in the scope and
                       quality of OSAGWI’s investigations for three of the six cases: the Reported
                       Exposure to Mustard Agent, the Marine Minefield Breaching, and the Al
                       Jubayl, Saudi Arabia, case narratives. Also, OSAGWI did not use DOD or
                       Department of Veterans Affairs medical databases on Gulf War illnesses in
                       conducting any of the six investigations. Despite the weaknesses we
                       noted, in all but one case—the Marine Minefield Breaching case—we
                       found no basis to question OSAGWI’s determinations of the likelihood that
                       chemical warfare agents were present.

                       Except for failing to take advantage of the VA and DOD medical databases,
                       we did not find significant weaknesses in the remaining three cases: the
                       Camp Monterey, the Al Jaber Airfield, and the ASP Orchard case narratives.
                       In investigating these cases, OSAGWI followed its methodology, identified
                       and interviewed important witnesses, appropriately used information from
                       other key sources, included all important information in the case
                       narratives, and accurately presented the information found. These
                       investigations were performed in a generally thorough manner, and the
                       evidence collected by OSAGWI supported its assessments.

                       OSAGWI  officials told us that they have revised their internal review
                       processes for conducting and reporting investigations. They said that
                       (1) improvements to these processes have evolved since the publication of
                       the six case narratives we reviewed, (2) some of the process revisions
                       were influenced by the findings we reported as our review progressed, and
                       (3) enhancements to their processes would considerably minimize the
                       recurrence of similar weaknesses in future case narratives.


                       Our review of the six selected case narratives disclosed some weaknesses
OSAGWI’s               in the investigations and in the accuracy and completeness of OSAGWI’s
Investigations and     reporting. OSAGWI’s investigations were usually conducted in accordance
Reporting Procedures   with the established methodology. OSAGWI also generally identified and
                       interviewed the appropriate witnesses, obtained relevant evidence and
Have Various           information, accurately documented witness testimonies, and otherwise
Weaknesses             generally used appropriate investigative techniques and procedures.
                       However, we found that three of the six selected case narratives still
                       contained significant investigative and reporting problems. The types of



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                       Some Case Narratives Have Investigative
                       and Reporting Weaknesses




                       problems varied. In three of the six case narratives, we found investigative
                       problems such as failures to (1) follow up with appropriate individuals to
                       confirm key evidence, (2) identify or ensure the validity of key physical
                       evidence, (3) include important information, and (4) interview key
                       witnesses. Following is a more detailed description of the three case
                       narratives containing most of these weaknesses.


Case Narrative on      This case narrative addresses the reported exposure of an individual
Reported Exposure to   soldier to mustard agent while he was exploring an Iraqi bunker. OSAGWI
Mustard Agent          assessed this incident as a “likely” exposure. OSAGWI’s assessment of this
                       case has been highly controversial. Some veterans organizations and
                       others believe that the evidence presented in OSAGWI’s case narrative and
                       the Army’s presentation of the Purple Heart medal to this soldier for his
                       injuries warranted an assessment of “definite” exposure. However, we
                       found that this case was affected by many investigative and evidentiary
                       problems. Some of these are more closely associated with shortcomings in
                       DOD procedural practices during the Gulf War than with how OSAGWI did its
                       investigation. Despite the problems identified, we believe that OSAGWI’s
                       original assessment of “likely” exposure remains appropriate for this case.

Incident Synopsis      According to OSAGWI’s case narrative, the soldier (an Army armored cavalry
                       scout) was exploring enemy bunkers in southeastern Iraq near Kuwait’s
                       border on March 1, 1991. He entered one bunker through a tight
                       passageway and twice brushed against the bunker’s doorway and wall.
                       About 8 hours later, he began to experience a stinging pain on the skin of
                       his left upper arm. Three hours later, blisters had formed there. About 15
                       hours after the exposure, the company medic checked the soldier’s
                       blisters and suspected a heater burn. Eight hours later, after more blisters
                       had formed on the soldier’s arm, aid station medical personnel suspected
                       he might be a casualty of blister agent, treated him, and evacuated him to
                       the company support battalion. There, an Army physician photographed
                       the blisters and confirmed the diagnosis of exposure to a blister agent.

                       An Army chemical officer also observed the soldier’s blisters and
                       examined his clothing. He observed a wet spot on the soldier’s coveralls.
                       The officer took the coveralls to a Fox vehicle for testing.1 From its tests
                       on March 2, 1991, the Fox vehicle reportedly confirmed the presence of a

                       1
                        The Fox Nuclear Biological and Chemical Reconnaissance Vehicle was the most sophisticated and
                       technically complex piece of chemical detection equipment that the United States used during the
                       Persian Gulf War. It was designed to provide an initial alert to warn personnel of the possible presence
                       of dangerous chemicals and subsequently to provide detailed confirmation by means of an on-board
                       mass spectrometer.



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mustard chemical warfare agent. After this positive test, the soldier’s
coveralls were buried at the scene in Iraq as contaminated waste.

On March 3, 1991, a senior medical officer (a physician and an expert in
chemical warfare agents who was also at the time the Commander of the
U.S. Army Medical Research Institute of Chemical Defense) examined the
soldier’s blisters and concluded that they had been caused by exposure to
a liquid mustard agent. This officer based his diagnosis largely on (1) the
latent period of 8 hours between exposure and the first symptoms, which
is characteristic of mustard exposure and (2) the absence of any other
known chemical compounds present on the battlefield that have this
characteristic.

On March 4, 1991, following an order from chemical officers at the division
level to confirm the positive results from the first day of Fox vehicle
testing, tests on the soldier’s flak vest were performed by two Fox
vehicles—apparently because the vest had not been buried along with the
coveralls. Initially, both Fox vehicles registered the potential presence of
chemical warfare agents, but only one was apparently able to confirm the
presence of mustard agent. At the bunker complex where the soldier was
injured, a Fox vehicle also initially detected a chemical warfare agent but
was unable to confirm the presence of mustard or any other chemical
warfare agent.

The case narrative reported that an in-theater analysis of the soldier’s
urine tested positive for thiodiglycol, a breakdown product of mustard
agent. It also reported that a second urinalysis was performed by the U.S.
Army Medical Research Institute of Chemical Defense at Aberdeen
Proving Ground, Maryland. This analysis found no evidence of
thiodiglycol. Clothing samples were also sent to the U.S. Army Chemical
Research, Development and Engineering Center for analysis. Tests of
these items also revealed no evidence of any chemical warfare agent.
However, the negative test results from one of the urinalyses were not
considered unusual due to the low level of the exposure.

OSAGWI  based its assessment of “likely” exposure primarily on the
following factors: (1) the medical assessments of two physicians who
examined the soldier—a senior medical officer and a physician who had
recently been trained to identify chemical warfare agent injuries; (2) the
latent period of 8 hours between the soldier’s exposure and his first
symptoms, which is consistent with exposure to mustard agent; and




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                         Some Case Narratives Have Investigative
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                         (3) the positive detections of mustard agent made in-theater from analyses
                         of the soldier’s clothing and urine.

Our Review of OSAGWI’s   We agree with OSAGWI’s assessment that exposure to a chemical agent was
Investigation            “likely.” However, we found several investigative procedural problems
                         with this case, primarily concerning insufficient follow-up with witnesses,
                         failure to interview key officials about tests conducted on the soldier’s
                         clothing, and uncertainties about the identity and validity of key physical
                         evidence sent to the United States for testing.

                         First, information we discovered causes us to question the existence of the
                         soldier’s positive in-theater urinalysis for mustard agent. OSAGWI based the
                         existence of this test on an Army Central Command message reporting a
                         positive in-theater test for thiodiglycol. However, OSAGWI was unable to
                         find any documented test results from this urinalysis, and OSAGWI
                         investigators did not perform sufficient follow-up with the involved
                         individuals to verify that this test had actually taken place.

                         In discussing what OSAGWI knew about the positive in-theater urinalysis, we
                         learned that OSAGWI had not interviewed either the senior medical officer
                         or the officer who wrote the message describing the positive in-theater
                         analysis during its investigation. Instead OSAGWI relied upon the senior
                         medical officer’s testimony to the Presidential Advisory Committee, his
                         medical journal article, and his review of OSAGWI’s draft case narrative.
                         However, this procedure failed to identify important information. In early
                         1998, our subsequent interviews with the senior medical officer and
                         OSAGWI’s interviews with him revealed that he was unaware of the
                         existence of any in-theater urinalysis involving the soldier. He also stated
                         that, because of his position in the theater as the head of a team of
                         scientists responsible for assessing any chemical casualties, he would have
                         known about the existence of any positive urinalysis performed there. We
                         then contacted the officer who had written the Army Central Command
                         message and asked him about his basis for reporting the positive
                         urinalysis. He told us that his message was based on 3rd Armored Division
                         reports that the senior medical officer had found thiodiglycol in the
                         soldier’s urine specimen. The available evidence is thus contradictory and
                         insufficient to establish that this test actually occurred.

                         Second, the results of the tests conducted on March 2, 1991 (the first day
                         of testing), for mustard agent on the soldier’s clothing cannot be
                         confirmed with the available documentation, and OSAGWI did not interview
                         some key officials involved in the case about the tests. According to the



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Commander of the Fox vehicle involved, the Fox tests on the soldier’s
clothing conducted on March 2, 1991, indicated the presence of blister
agent on the soldier’s coveralls. However, the Fox printout of the test
results was apparently lost. We located and interviewed the Fox test
operator involved, who told us that several tests were conducted on the
soldier’s clothing that day and that there was one positive confirmation for
mustard agent. During our review, OSAGWI found a printout from one of
these tests in its files, but it was negative for chemical agent. We noted
that this printout had not been logged into OSAGWI’s document receipt
system. We also noted that OSAGWI had never interviewed the Fox vehicle
Commander in person or the operator who conducted the tests. OSAGWI
relied upon information provided by E-mail from the Commander of the
Fox vehicles involved because he was then stationed in Germany and
could not easily be interviewed in person. OSAGWI said it did not interview
the test operator because it could not locate him.

On the second day of Fox testing, the Fox Commander returned with both
the original and a second Fox vehicle to confirm the positive test results
from the first day of Fox testing of the soldier’s clothing. One of the Fox
vehicles was unable to confirm the presence of mustard agent on the
soldier’s flak vest because of a high concentration of oil products on the
vest.2 The other Fox vehicle, whose detailed confirmatory procedure was
videotaped by a crewmember but for which the printout is unavailable, did
show the presence of mustard agent. DOD sent the printout from the
original Fox vehicle and the videotape from the second one to the U.S.
Army Chemical and Biological Defense Command at Aberdeen Proving
Ground, Maryland, for analysis. A Command expert found that the
surviving printout did not confirm the presence of chemical warfare agent
when the detailed confirmatory procedure was performed. However, after
examining the printout and viewing the videotape, this official concluded
that the incident had involved an actual mustard agent detection.

We found other procedural discrepancies that raise questions regarding
this case. First, DOD did not adequately identify or ensure the validity of
important physical evidence. We noticed a difference between the
inventory of items that the Commander of the Fox vehicles had reportedly
packaged for shipment back to the United States for analysis and the items
that were received at the U.S. Army Chemical Research, Development and
Engineering Center. The Commander reported on his inventory list that he
did not include samples from the soldier’s coveralls since they were
unavailable; however, the Center’s inventory showed receipt of such

2
 This was confirmed by analysis of the available printout from these Fox vehicle tests.



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                           Some Case Narratives Have Investigative
                           and Reporting Weaknesses




                           samples. When we interviewed the Commander, he told us that he
                           believed the sample material was in fact from the Commander’s own
                           protective suit that he wore during the Fox vehicle testing. These
                           discrepancies raise the possibility that either someone recovered the
                           soldier’s coveralls and then repackaged the contents for shipment to the
                           United States or that at least some of the clothing sent back to the United
                           States for testing was not the soldier’s. The circumstances surrounding the
                           testing of the soldier’s clothing in-theater thus remain unclear. It is
                           impossible to determine whether the samples are actually from this
                           soldier.

                           In discussing the investigative weaknesses we found, the OSAGWI lead
                           investigator told us that this investigation had begun under the
                           Investigation Team before OSAGWI was established and that the case was
                           carried over to OSAGWI. She said that the case’s outcome appeared to be
                           obvious on the surface—particularly since the soldier had received a
                           medical diagnosis indicating exposure to mustard agent. She said that the
                           investigation process at OSAGWI has matured since this case narrative was
                           published. She also said that OSAGWI would do more cross-checking of the
                           facts if this investigation were being done today.

                           Despite the investigation’s shortcomings, we believe that OSAGWI’s
                           assessment of “likely” exposure to a chemical warfare agent in this case is
                           reasonable. The senior medical officer’s clinical diagnosis that the soldier’s
                           injuries were caused by exposure to mustard agent is significant in that
                           this expert in chemical warfare agents made his assessment
                           contemporaneously at the time of the injury and continues to believe that
                           the latent period of 8 hours from exposure to the first symptoms supports
                           his diagnosis. In addition, an expert at the U.S. Army Chemical and
                           Biological Defense Command, after reviewing the Fox vehicle printout and
                           viewing a videotape of another Fox vehicle conducting tests, concluded
                           that this incident involved a valid detection of mustard agent. However, we
                           believe the lack of confirmation of exposure through urinalysis or retained
                           confirmatory printouts from the Fox vehicles involved prevents OSAGWI’s
                           exposure assessment in this case from being classified as “definitely.”


Marine Minefield           This case narrative addresses reports that U.S. Marines might have been
Breaching Case Narrative   exposed to chemical warfare agents while breaching minefield barriers on
                           the first day of Operation Desert Storm’s ground war. OSAGWI concluded
                           that the presence of chemical warfare agents was “unlikely” during this
                           incident, in part because it found that no mechanism was present for



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                    delivering such agents. However, we found that OSAGWI overlooked
                    information indicating that a means for delivering chemical warfare agents
                    might have been present, and that the case narrative does not include
                    other relevant information indicating that chemical warfare agents might
                    have been present. We believe that these shortcomings are sufficient to
                    cause a reasonable person to question OSAGWI’s assessment.

Incident Synopsis   On February 24, 1991, the first day of Operation Desert Storm’s ground
                    war, Marine Corps forces breached two rows of minefields that stretched
                    for miles near the border between Saudi Arabia and Kuwait. As they
                    passed through the first row of minefields, two Fox vehicles (one assigned
                    to units of the 1st Marine Division and another assigned to the 2nd Marine
                    Division) indicated potential detections of chemical agents. The detection
                    by the 1st Division’s Fox vehicle was described as a trace detection of
                    such a small magnitude that no official report of the detection was made
                    and no Fox printout was kept to document the detection. OSAGWI
                    concluded that the presence of chemical warfare agents in the 1st Division
                    area was “unlikely.”

                    The detection by the 2nd Division’s Fox vehicle, however, indicated the
                    potential presence of mustard, sarin, and lewisite—all chemical warfare
                    agents. In this instance, the Fox vehicle printouts were kept, but because
                    of the hostile environment, the Fox vehicle was not stopped to perform a
                    more detailed confirmation procedure to conclusively determine whether
                    chemical warfare agents were present.

                    One possible chemical warfare agent injury was reported during the
                    breaching: a 2nd Division Marine riding in an amphibious assault vehicle at
                    the time of the detection claimed his hands were burned, presumably by a
                    chemical warfare agent, as he closed the vehicle hatch after hearing the
                    Fox vehicle alert by radio. However, the validity of this reported injury
                    was controversial. Some witnesses supported the Marine’s claim that his
                    hands were blistered, but the examining physician stated that the Marine
                    had no injury of any kind.

                    In investigating the breaching incident, OSAGWI interviewed key
                    participants in the breaching operations, including members of the Fox
                    vehicle crews, chemical warfare specialists, some unit commanders, the
                    Marine who claimed to have been injured, other Marines from the injured
                    man’s unit, and the medical personnel who examined him. The
                    investigators also reviewed unit logs and other pertinent documentation,




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                         including classified data, and consulted with Fox vehicle and chemical
                         weapons technical experts.

                         On the basis of reviews of the 2nd Division Fox vehicles’ printouts by
                         three different laboratories, OSAGWI concluded that the Fox vehicle
                         detections were false alarms, probably caused by the high concentrations
                         of smoke from oil well fires and petroleum particles in the atmosphere.
                         OSAGWI further indicated that except for the possible injury to one Marine,
                         no other troops reported claimed chemical warfare agent injuries. In its
                         overall assessment of the incident, OSAGWI stated that the presence of
                         chemical warfare agent was “unlikely.” In supporting its assessment,
                         OSAGWI stated that since no chemical land mines were ever found in Kuwait
                         and since no artillery fire was encountered by the Marines who breached
                         the first row of mines, there was no delivery mechanism for chemical
                         warfare agents.

Our Review of OSAGWI’s   OSAGWI  overlooked a key piece of evidence and did not report other
Investigation            significant information in its case narrative. OSAGWI concluded that the
                         Marines had encountered no Iraqi artillery fire as they moved through the
                         first row of Iraqi minefields. This conclusion was based on comments
                         made by the commanding officer and others of the Marine company that
                         carried out the minefield breach where the 2nd Division Fox vehicle
                         reported the presence of a chemical warfare agent. However, our review
                         of OSAGWI files disclosed a Marine Corps unit log entry indicating that Iraqi
                         artillery and mortar fire was present during the first minefield breach. The
                         OSAGWI investigator told us that he had inadvertently overlooked this
                         information during his investigation. We also interviewed Marines who
                         told us that Iraqi artillery and mortar fire was present as they passed
                         through the first minefield. Consequently, we believe a delivery
                         mechanism for chemical warfare agent may have been present.

                         Also, the timing of events was significant. For example, the log entry
                         indicating that enemy artillery was encountered was made around
                         6:15 a.m. on February 24, 1991. The Fox vehicle detection was made at
                         6:22 a.m. of that same day. The Marine who claimed to be injured was
                         riding in an amphibious assault vehicle that was following the Fox vehicle.
                         He said his injury occurred just after he heard the Fox vehicle’s report of
                         the chemical warfare agent detection over the radio.

                         We also learned that the Commander of the 2nd Division’s Fox vehicle told
                         OSAGWI investigators that chemical detection paper taped to the outside of
                         the Fox vehicle was noted to have changed colors after passing through



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                           the first minefield (indicating possible contact with a chemical agent).
                           However, this information was not reported in OSAGWI’s narrative. The
                           OSAGWI investigator said that this information was omitted because
                           technical experts had told him that the detection paper could change
                           colors because of the heavy concentrations of petroleum products in the
                           air coming from the oil well fires the Iraqis had set. Furthermore, as
                           mentioned in the case narrative, three different laboratories had reviewed
                           the Fox vehicle printout and concluded that the detections were probably
                           false alarms. The narrative did not point out, however, that one of the
                           three laboratories had also said that it could not rule out the possibility of
                           the presence of a chemical warfare agent.

                           Finally, a classified document in OSAGWI’s files contained intelligence
                           evidence not included in the narrative that could support the possibility of
                           an Iraqi chemical attack. This information, some of which has since been
                           declassified, refers to a report indicating the end of a chemical attack on
                           February 24, 1991, the same date as this incident. OSAGWI was aware of this
                           information, but because of its vagueness, unknown origin, fragmentary
                           nature, and time of report (about 4 hours after the breaching event), it was
                           not given much weight during OSAGWI’s analysis. We agree that the
                           potential impact of this evidence is unclear. However, when combined
                           with the other information we have cited, it provides additional cause for
                           further investigation by OSAGWI, regardless of its potential for association
                           with this case.

                           We believe that OSAGWI’s assessment of “unlikely” in this case is subject to
                           question. While the information we found does not conclusively prove that
                           chemical warfare agents were present, it does increase the potential that
                           some might have been present. In our opinion, the weaknesses we found
                           in this case narrative are sufficient to warrant OSAGWI’s reconsideration of
                           its assessment. We discussed our findings with OSAGWI investigators and
                           officials, and they agreed that this information needs to be evaluated.
                           OSAGWI officials told us they would include this information in their
                           follow-up investigation of the minefield breaching incident and would
                           address the questions we raised.


Al Jubayl, Saudi Arabia,   Regarding this case narrative about three significant events occurring in
Case Narrative             the Al Jubayl area during the Persian Gulf War, OSAGWI concluded that the
                           presence of chemical warfare agents was “unlikely” for one of the events
                           and “definitely did not occur” in the remaining two. We believe that the
                           available evidence generally supports OSAGWI’s assessment, but OSAGWI is



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                         still performing work regarding alternate explanations for some events
                         affecting this case. However, we also found that OSAGWI did not include
                         important information in this case narrative regarding the unusually high
                         levels of post-war veterans’ complaints of medical symptoms they
                         associated with the incidents involved in this case. Furthermore, OSAGWI
                         did not adequately identify and coordinate some of this information that
                         could potentially provide evidence to help resolve research questions
                         concerning whether there is a correlation between high levels of reported
                         Gulf War illnesses symptoms and duty during the Gulf War at Al Jubayl.

Incident Synopsis        Al Jubayl is the largest of eight planned industrial cities in Saudi Arabia. It
                         consists of an industrial zone and port facilities, as well as residential and
                         other noncommercial areas. The Al Jubayl area was developed during the
                         early 1980s along what was then essentially undeveloped coast line and
                         was designed to take advantage of Saudi Arabia’s vast oil resources. Al
                         Jubayl played a crucial role during the Gulf War—many U.S. and coalition
                         military units either passed through or were stationed there.

                         OSAGWI’s case narrative addresses three separate events that allegedly
                         involved exposure to chemical agents in the Al Jubayl area: the “loud
                         noise” event and alerts on January 19 through 21, 1991; an Iraqi SCUD
                         missile attack on February 16, 1991; and a noxious fumes event on
                         March 19, 1991, which some U.S. military personnel claim caused them to
                         experience medical problems and turned portions of the T-shirts they
                         were wearing from brown to purple.

                         The need for OSAGWI to investigate these events was underscored by
                         concerns about Gulf War illnesses expressed in a May 1994 report of the
                         U.S. Senate’s Banking, Housing, and Urban Affairs Committee (known as
                         the Riegle Committee) by veterans of Naval Mobile Construction Battalion
                         24 (NMCB-24). NMCB-24 was a reserve “Seabee” or military construction
                         battalion of 724 enlisted persons and 24 officers. During Operation Desert
                         Shield/Desert Storm, NMCB-24 was stationed alongside NMCB-40, an active
                         duty “Seabee” battalion. Both units occupied Camp 13, a housing and
                         billeting area located in the Al Jubayl industrial zone that was commanded
                         by the senior officer of NMCB-40.

The “Loud Noise” Event   OSAGWI found that the “loud noise” event actually referred to several loud
                         explosive-like noises and related events occurring between January 19 and
                         21, 1991. As stated in the OSAGWI narrative and confirmed by our review,
                         early on January 19, a very loud noise like an explosion was heard
                         throughout the Al Jubayl area. Units in the area subsequently reported



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additional explosions, went on alert, and conducted tests for the presence
of a chemical warfare agent. A variety of confusing and contradictory
actions subsequently occurred. All NMCB-24 tests for chemical warfare
agent were officially reported as negative, but one member of this unit
alleged that he had obtained positive test results for a chemical warfare
agent in two of three attempts. British units in the vicinity initially
reported positive tests for a chemical warfare agent, but detection teams
sent to investigate these reports were unable to confirm any such agents.
Some eyewitnesses from NMCB-24 reported a large fireball that illuminated
the sky and medical symptoms such as runny noses, burning sensations,
blisters, and numbness. They stated that those experiencing symptoms
reported for medical attention within the next few days. However, other
NMCB-24 personnel said that although they were unprotected during these
events, they experienced no such symptoms. After reviewing NMCB-24’s
medical logs, neither OSAGWI nor we found any records indicating that
medical attention for these symptoms was sought on or shortly after
January 19, 1991. OSAGWI and our interviews with the NMCB-24 Commander,
medical personnel, and senior noncommissioned officers similarly
revealed no evidence that any medical attention was sought.

OSAGWI  found, and we confirmed, that many coalition aircraft were
engaged in the air war on the day in question, and Air Force records show
that two coalition aircraft flew over the Al Jubayl area at supersonic speed
during the early hours of January 19, 1991. OSAGWI concluded that the loud
noise and related events were due to sonic booms from these aircraft. It
also concluded that the presence of chemical or biological warfare agents
was “unlikely” because (1) DOD records show that no SCUD missiles were
launched toward Saudi Arabia by Iraq on January 19, (2) no verifiable tests
in the Al Jubayl area were positive for chemical warfare agents, and (3) no
records were found of any individual receiving treatment for symptoms
associated with exposure to chemical or biological warfare agents.

On January 20-21, 1991, air raid sirens and explosions were heard again in
the Al Jubayl area, but available records reviewed by OSAGWI, and checked
by us, indicated that chemical detection tests were again negative. OSAGWI
again concluded that the presence of chemical or biological warfare
agents was “unlikely” because (1) records show a SCUD missile aimed at
Dhahran was intercepted and destroyed at high altitude by a Patriot air
defense missile at approximately the same time as this incident, (2) there
is no record of an impact site in the Al Jubayl area, and (3) no records
were found of anyone receiving medical treatment for symptoms
associated with exposure to chemical or biological warfare agents.



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The SCUD Missile Attack    A second possible exposure of veterans to chemical and biological warfare
                           agents in the Al Jubayl area occurred as the result of an Iraqi SCUD missile
                           attack early in the morning of February 16, 1991. The OSAGWI narrative
                           explains that U.S. national sensors detected this missile early in flight and
                           provided warning of the launch. The missile landed in the waters of Al
                           Jubayl harbor, and the site of impact was quickly found and marked by
                           Coast Guard and Navy boat crews. Later that day, a Navy explosive
                           ordnance disposal team surveyed the marked area with an underwater
                           television system and located missile debris on the harbor’s bottom.
                           Divers confirmed that the missile had broken apart and that the site
                           contained an intact SCUD warhead, guidance section, rocket motor, and
                           miscellaneous components. Recovery of the smaller SCUD components
                           began on February 19 and concluded with the warhead on March 2. During
                           the recovery operation, tests were conducted, but no evidence was found
                           indicating the presence of chemical or biological agents. The Joint
                           Captured Material Exploitation Center then took custody of the SCUD
                           components, which were subsequently shipped to the Army Missile
                           Command in Huntsville, Alabama. The Command’s evaluation of the
                           recovered SCUD missile components confirmed that the warhead did not
                           contain chemical or biological warfare agent.

                           Some eyewitnesses to this event reported that the SCUD missile was
                           intercepted and shot down by a Patriot missile and during this process
                           could have dispersed chemical or biological warfare agents over Al Jubayl.
                           A Patriot battery was defending Al Jubayl at the time. However, OSAGWI
                           found and we confirmed that this battery was not operational for
                           maintenance reasons at the time of the attack and therefore was not able
                           to engage the SCUD. OSAGWI concluded in its case narrative that while an
                           Iraqi SCUD missile had hit the waters of Al Jubayl harbor, it had not
                           detonated, had caused no damage or injuries, had tested negative for
                           chemical warfare agents, and therefore was definitely not armed with
                           chemical warfare agents.

The Purple T-Shirt Event   The third known possibility of exposure to chemical agents at Al Jubayl
                           occurred on March 19, 1991, when personnel from NMCB-24 were exposed
                           to unidentified airborne noxious fumes. These fumes affected nine
                           persons working in three separate groups. They experienced acute
                           symptoms such as burning throats, eyes, and noses and difficulty in
                           breathing. In addition, portions of the brown T-shirts being worn by these
                           individuals turned purple, as did some of the individuals’ combat boots.
                           Seven persons composing two of the groups immediately sought medical
                           attention and returned to work with no further symptoms after showering



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                         and changing clothes. The two persons in the third group did not seek
                         medical assistance and continued to work. The nine persons involved
                         stated that they had experienced a choking sensation when a noxious
                         cloud enveloped them. None saw the origin of the cloud, but all believed it
                         had come from one of the industrial plants located nearby.

                         Evidence collected by OSAGWI regarding the source of the noxious fumes
                         was inconclusive. One eyewitness of the event said that he had seen
                         purple dust falling in the area that was coming from a smokestack at a
                         nearby fertilizer plant. The Navy’s Environmental and Preventive Medicine
                         Unit No. 2 (EPMU-2) conducted an environmental/occupational hazard
                         investigation and site visit to Al Jubayl in 1994. The resulting EPMU-2 study
                         did not determine the source of the irritant. It noted, however, that the
                         camp was located in a heavily industrialized area and that emissions from
                         a petrochemical plant or from a spill within the camp’s motor park could
                         have been the source of the irritant. The T-shirts and the boots that
                         changed color were given to unnamed U.S. military and Saudi officials.
                         However, the chain of custody cannot be identified, and no reports have
                         been found other than an informal telephone call to NMCB-24 shortly after
                         the incident indicating that “there was nothing to worry about.” The U.S.
                         Army Material Test Directorate and the Natick Research Development and
                         Engineering Center later conducted tests on the type of military T-shirts
                         involved. The Natick tests showed that these T-shirts do turn purple when
                         exposed to acids such as sulfuric (battery) acid or oxides from nitric acid.

                         OSAGWI  concluded that chemical warfare agents were definitely not
                         involved in the purple T-shirt event. OSAGWI reached this conclusion
                         because (1) the event occurred after the cessation of Gulf War hostilities,
                         (2) there was no record of hostile attack during the time period of the
                         event, and (3) the types of medical problems affecting the individuals
                         involved and their rapid recovery are not consistent with exposure to
                         chemical warfare agents.

Our Review of OSAGWI’s   As a result of our review of evidence, procedures, and other information
Investigation            obtained from OSAGWI and other sources regarding the Al Jubayl case
                         narrative, we generally concur that OSAGWI’s assessments of whether
                         chemical warfare agents were present are reasonable. The evidence
                         generally supports OSAGWI’s assessment that chemical warfare agents were
                         “definitely not” involved in the SCUD missile and purple T-shirt events.
                         The loud noise incident involved some contradictions in evidence or
                         testimony that we could not resolve, but our work confirmed the
                         credibility of the vast majority of the evidence used by OSAGWI. We noted



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the existence of another potential explanation of some of the events
involved in the loud noise incident. Some documents and other evidence
we acquired from a veterans’ organization indicate that an Iraqi aircraft or
a patrol boat might have been involved in an attempted chemical attack on
Al Jubayl at the time of this incident. OSAGWI is currently investigating this
version of events. However, pending the outcome of this continuing
investigation, we believe that the currently available evidence still
provides a reasonable level of support for OSAGWI’s conclusion that
exposure to chemical warfare agents was “unlikely” in this incident.

Although we concur with OSAGWI’s assessments in the Al Jubayl case, we
believe that the case narrative is not complete and could be misleading
because it does not mention the fact that many members of NMCB-24 have
reported unusually high levels of health problems since their service in the
Persian Gulf War. We also found that OSAGWI had not coordinated some
information developed during this investigation with the Naval Health
Research Center for inclusion in its Gulf War illnesses research on
Seabees.

OSAGWI’s Al Jubayl case narrative states that the methodology it used was
designed to investigate reports of exposure to chemical warfare agents
and to determine whether chemical weapons were used. OSAGWI officials
told us that in this case they had expanded their methodology to include a
considerable amount of information in the narrative regarding
environmental cleanliness factors affecting the Al Jubayl area. They said
they had done this in an effort to better explain the circumstances of the
case because some veterans had expressed concern over the hazardous
materials they could have been exposed to while they were in Al Jubayl.
The narrative thus contained much information explaining that (1) Saudi
environmental protection standards were equivalent to those of the U.S.
Environmental Protection Agency, (2) these standards were monitored
and maintained by the Saudis throughout Operation Desert Storm/Desert
Shield, and (3) Saudi monitoring records indicate no detections that
normal standards were exceeded on the date of the purple T-shirt incident.
The environmental data included in the narrative, much of which was
obtained by EPMU-2, thus indicated that Al Jubayl was no worse or better
than comparable industrialized sites in the United States.

We concur that OSAGWI’s decision to expand its stated methodology in
order to include this information was appropriate. As indicated at the
beginning of the narrative, OSAGWI’s charge is to investigate all possible
causes of Gulf War illnesses. However, most of the information presented



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    in this case narrative leads the reader to conclude that exposure to either
    chemical warfare agents or other chemical agents at Al Jubayl was
    “unlikely” and probably did not involve a health threat in the limited
    incident involving the purple T-shirts. The narrative mentions that some
    NMCB-24 veterans testified before the Congress (the Riegle Commission)
    but does not state why. The narrative text also contains no information
    regarding significant DOD actions taken to address the high incidence of
    post-war health problems reported by members of NMCB-24.

    DOD  has long been aware of health problems reported by NMCB-24. In 1992,
    DOD  began to identify clusters of military personnel who were complaining
    of medical symptoms they attributed to their Gulf War service. As a result,
    DOD initiated two field investigations. One of these, performed at the
    request of the Navy Surgeon General, was a study of illnesses reported by
    members and former members of NMCB-24 conducted during 1993-94 by the
    same unit (EPMU-2) that conducted the Al Jubayl environmental study.
    EPMU-2 personnel visited 6 of NMCB-24’s 12 detachments during this period,
    conducted a questionnaire study, performed medical examinations,
    reviewed military and other medical records, interviewed veterans and
    family members, and otherwise attempted to identify prevalent symptoms
    experienced by the members of NMCB-24 and diagnoses of their illnesses.
    Much of the information they collected was computerized and used to
    produce a series of tables and other statistical data relevant to Gulf War
    illnesses issues and included in EPMU-2’s final report. This report contained
    the following conclusions:

•   A significant number of NMCB-24 veterans of the Gulf War have
    experienced an array of nonspecific symptoms since returning from the
    Persian Gulf. More than 41 percent of the veterans from three of the six
    detachments experienced 10 or more symptoms.
•   No common syndrome or diagnosis was identified in these veterans.
•   The diagnoses identified were the same as those that might be expected in
    a group of the same age that had not served in the Persian Gulf War.
•   More research was needed.

    Our review of OSAGWI’s files, our visit to EPMU-2, our interviews of current
    and former EPMU-2 officials, and our review of all remaining EPMU-2
    documentation related to this study revealed additional information. For
    example, 44 of the 67 witnesses OSAGWI interviewed regarding the facts of
    the loud noise incident are now reporting health problems they attribute to
    their service during the Persian Gulf War. A former EPMU-2 physician
    directly involved in the EPMU-2 study told us that while he had no factual



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baseline for comparison, it appeared to him that the frequency of
symptoms found in NMCB-24 veterans was greater than the frequency to be
expected in the general population. This observation, along with the high
symptom rates, was one of the reasons the EPMU-2 report recommended
more research. NMCB-24 veterans have been involved in testimony before
the Congress regarding health problems they attribute to their service in
the Persian Gulf War, and the Naval Health Research Center in San Diego,
California, is currently performing a major, multiyear, Gulf War
illnesses-related epidemiological study involving the vast majority of the
Navy’s Seabees. NMCB-24 veterans have also been the subject of several
additional research studies related to Gulf War illnesses.

OSAGWI was aware of the existence of the EPMU-2 medical study and had a
copy on file that was originally obtained by its predecessor, the Persian
Gulf Illnesses Investigation Team, in 1996. However, no OSAGWI
investigators visited EPMU-2 to review files regarding this study. No
information regarding this study, the Naval Health Research Center
research project, or other epidemiological studies or research on Gulf War
illnesses was included in the case narrative. A high-ranking OSAGWI official
told us that OSAGWI investigators had been instructed to consider such
medical information as outside their charter for inclusion in the case
narratives. This official said that they had been so instructed because this
line of inquiry was more appropriately the responsibility of the Office of
the Assistant Secretary of Defense for Health Affairs and because OSAGWI
did not have the expertise to conduct or evaluate epidemiological studies
such as the one performed by EPMU-2.

We believe that much more information regarding the health complaints of
NMCB-24 veterans should have been included in the case narrative. OSAGWI
was aware of this information and could have included it without
conducting or evaluating epidemiological studies. Including information
developed by EPMU-2 regarding the environmental cleanliness of Al Jubayl
but excluding EPMU-2’s report and other information specifically related to
post-war health complaints by NMCB-24 veterans makes OSAGWI vulnerable
to an appearance of bias. Such omissions tend to reinforce the beliefs of
some that DOD is inappropriately withholding information.

We also found that some information developed by OSAGWI might have
significantly added to what is known about Gulf War illnesses issues
involving NMCB-24 had OSAGWI coordinated the information with the Naval
Health Research Center for use in its currently ongoing Seabee
epidemiological study. For example, as determined by OSAGWI and reported



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in the Al Jubayl case narrative, both NMCB-24 and NMCB-40 were located at
Camp 13 during Operations Desert Shield and Desert Storm. Complaints
by NMCB veterans regarding post-war medical problems they attribute to
Persian Gulf service are well known, having been the subject of several
congressional hearings, various research efforts, and other activities
addressing Gulf War illnesses issues. An OSAGWI official told us that
interviews with selected NMCB-40 personnel indicated that personnel from
this unit were not experiencing health problems of the same nature and
extent as those reported by NMCB-24 veterans.

Since NMCB-24 and NMCB-40 occupied the same camp at Al Jubayl, we
believe that a determination of whether NMCB-40 veterans are encountering
medical problems similar to those being reported by NMCB-24 veterans
would be of considerable interest to those concerned with resolving Gulf
War illnesses issues. The Naval Health Research Center study is obtaining
for analysis a wide range of Gulf War illnesses-related information from
current and former Seabees and plans to perform a multifaceted analysis
of the information collected.

In August 1998, Naval Health Research Center officials told us they had
coordinated with OSAGWI officials regarding the Seabee study on several
occasions but that OSAGWI officials had not informed them of the
relationship between NMCB-24 and NMCB-40. The study’s methodology
therefore did not include plans to specifically compare Gulf War illnesses
information obtained from veterans of these two units. They
acknowledged, however, that such comparisons could be conducted and
that they might provide useful information. They said they would be
willing to discuss adding such comparisons if OSAGWI officials requested
that they do so. We believe such comparisons, especially regarding the
extent and nature of post-war medical symptoms, might provide
information important to OSAGWI’s investigation and reporting of Gulf War
illnesses issues involving the Al Jubayl and other case narratives.

OSAGWI officials agreed that the Al Jubayl case narrative needed to be
modified to acknowledge the high rate of symptoms reported by members
of NMCB-24 and that they would modify the case narrative accordingly.
They also told us they would coordinate with the Naval Health Research
Center regarding new information that might be developed through
comparisons of NMCB-24 and NMCB-40 data in the Naval Health Research
Center Seabee study.




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                               DOD  and the VA maintain databases that contain self-reported health
OSAGWI Did Not Use             information and clinical information on thousands of Gulf War veterans.
DOD and VA Medical             Some of these veterans may have symptoms associated with Gulf War
Databases in                   illnesses. Although OSAGWI’s methodology calls for the use of the DOD and
                               VA databases in its investigations, we found it did not access them for the
Conducting Its                 six case narratives selected for our review. Therefore, OSAGWI missed an
Investigations for             opportunity to determine whether individuals involved in possible
                               exposure incidents were also reporting symptoms in the databases.
Cases We Reviewed              Information thus obtained could provide leads to help scope and guide the
                               nature of the investigation and potentially could be combined with other
                               evidence and research efforts conducted by DOD and others to help
                               evaluate whether chemical warfare agents might have been present.


Gulf War Illnesses             In response to the complaints of many military personnel that returned
Databases Maintained by        from the Gulf War with health problems they believed were related to their
DOD and VA                     deployment, DOD and VA created programs to track the health of Gulf War
                               veterans. Information collected in these programs is stored in databases
                               that describe the health status of a large group of Gulf War veterans who
                               have undergone a standardized examination process to document their
                               health.

DOD’s Comprehensive Clinical   The multiphase Comprehensive Clinical Evaluation Program (CCEP) was
Evaluation Program             implemented by DOD in June 1994 to provide a systematic clinical
                               evaluation for the diagnosis and treatment of active duty military
                               personnel who have medical complaints they believe could be related to
                               their service in the Persian Gulf. Phase I of the CCEP consists of a medical
                               history, physical examinations, and laboratory tests that are comparable to
                               an evaluation conducted during an inpatient internal medicine hospital
                               admission. CCEP participants are evaluated by a primary care physician at
                               their local medical treatment facility and receive specialty consultations if
                               deemed appropriate.

                               The primary care physician may refer patients to phase II for further
                               specialty consultations depending on the clinical findings of phase I.
                               Phase II evaluations consist of targeted, symptom-specific examinations;
                               laboratory tests; and consultations. During this phase, potential causes of
                               unexplained illnesses are assessed, including infectious agents,
                               environmental exposures, psychological factors, and vaccines. DOD
                               maintains a database that summarizes the clinical evaluations of CCEP
                               participants. The database shows self-reported complaints and symptoms
                               from everyone and physician diagnoses for examined participants. In



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                             addition, the database shows unit assignments, medical complaints,
                             diagnoses, and possible exposures of individuals who were part of units
                             during the Gulf War that may have come in contact with chemical warfare
                             agents or other environmental hazards. As of October 31, 1998, the CCEP
                             database contained health information on 34,963 service members who
                             had received clinical evaluations as a part of the program.

VA’s Persian Gulf Registry   The VA’s Persian Gulf Registry (VA Registry) was established in 1992. Any
                             Gulf War veteran may participate in the registry, even if that person has no
                             current health complaints. Like the CCEP, the registry consists of a
                             two-phase examination process. During phase I, the veteran completes a
                             standardized questionnaire on exposures during the Gulf War and health
                             complaints and undergoes a physical examination with laboratory testing.
                             Veterans who have health problems that remain undiagnosed after phase I
                             are referred to more extensive phase II medical evaluations.

                             VA maintains a database that summarizes the results of clinical evaluations
                             of registry participants. It contains information on symptoms and
                             complaints self-reported by veterans and diagnosed by physicians. It also
                             contains information on exposures, birth defects, and undiagnosed
                             illnesses. Like the DOD database, the registry database also contains
                             information on which units the participants were assigned to during the
                             Gulf War. As of July 31,1998, the VA Registry contained information on the
                             health conditions of 70,051 Gulf War veterans who had physical
                             examinations under the VA program.


Identifying Program          Each of the case narratives selected for our review describes possible
Participants Could Help      chemical exposure incidents that involve individuals acting alone or as a
OSAGWI Better Focus Its      part of larger units. Many of these individuals may have enrolled in either
                             the CCEP or the VA Registry. OSAGWI could use this data to identify whether
Investigative Efforts        individuals involved in the incidents described in the case narratives might
                             be experiencing health problems.

                             Several of the case narratives included in our review describe events that
                             could have been the subject of further analysis using the CCEP and VA
                             Registry. For example, OSAGWI’s ASP Orchard case narrative describes
                             chemical warfare agent alarms at an ammunition storage facility near an
                             orchard outside Kuwait City, Kuwait. OSAGWI collected information from
                             many of the personnel that inspected this facility and from a variety of
                             other sources, such as the Central Intelligence Agency and the Defense




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                        Some Case Narratives Have Investigative
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                        Intelligence Agency. OSAGWI concluded that the alarms were false and that
                        chemical warfare agents probably had not been stored at this facility.

                        However, for the six case narratives we reviewed, OSAGWI investigators did
                        not query the CCEP or the VA Registry in an attempt to determine whether
                        any of the several personnel that inspected the site or any of the hundreds
                        of other personnel encamped nearby had enrolled and had reported or
                        been diagnosed with health problems. Although it would not be definitive,
                        unusually high levels of participation accompanied by the reporting of
                        certain health problems and possible exposures might have led OSAGWI to
                        investigate further. Performing this investigative step would serve to
                        enhance the credibility of OSAGWI’s case narratives and would confirm
                        OSAGWI’s intention to investigate these events leaving no stone unturned.


                        We noted that OSAGWI’s investigative methodology includes the use of the
                        CCEP and the VA registry and that OSAGWI had used such an analysis in
                        investigating the Khamisiyah incident and in developing its Depleted
                        Uranium environmental exposure report issued on August 4, 1998. For
                        example, in performing the investigation on depleted uranium, OSAGWI
                        investigators queried the CCEP to determine whether an unusually high
                        proportion of the participants involved in the case had experienced kidney
                        damage—a possible medical effect of being exposed to depleted uranium.
                        According to OSAGWI, the analysis showed that these CCEP participants did
                        not suffer unusually high rates of kidney damage compared to the general
                        U.S. population.


                        Except for not using the DOD and VA medical databases, the Al Jaber Air
Three Case Narratives   Base, ASP Orchard, and Camp Monterey case narratives generally did not
Appear to Have Been     have the weaknesses we found in the other three cases. In investigating
Appropriately           these cases, OSAGWI followed its methodology, identified and interviewed
                        important witnesses, appropriately used information from other key
Investigated            sources, included all important information, and accurately presented the
                        information found. These investigations were performed in a thorough
                        manner, and the evidence collected by OSAGWI convincingly supported its
                        assessments.

                        The Camp Monterey case is a good example. In this case, soldiers of the
                        8th U.S. Army Infantry Division were moving wooden Iraqi crates
                        containing metal canisters out of a building in a bivouac area north of
                        Kuwait City, Kuwait, so that it could be used to house troops. One of the
                        canisters broke open, spilling a white powder-like substance and causing



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                        several soldiers to become ill. At the request of the local commander, two
                        Fox vehicles tested the spilled substance. Both Fox vehicles initially
                        reported detections of sarin, a deadly nerve agent, and this apparently led
                        to some initial reports that soldiers had been exposed to a nerve agent.
                        Later, mass spectrometer tests by these Fox vehicles confirmed that the
                        substance was actually a relatively harmless riot control agent rather than
                        sarin. OSAGWI found, and we confirmed, that after interviewing the
                        personnel present (including the Fox crews) and after reviewing Fox crew
                        and laboratory analyses of the Fox printouts, the initial alarm for sarin was
                        an error. Similarly, in both the Al Jaber and ASP Orchard cases, initial Fox
                        alarms for persistent chemical warfare agent could not be confirmed in
                        some instances even by repeated attempts by the same Fox vehicles.
                        OSAGWI concluded, and we agreed, that had the chemical warfare agents
                        been present, they would have been detected in the repeated tests.


                        We believe that inadequate quality control procedures within OSAGWI
OSAGWI Has Made         contributed to the investigative and reporting problems discussed in this
Changes to Improve      report. During our review of OSAGWI operations, we periodically briefed
Its Investigative and   OSAGWI officials on the nature and types of weaknesses we had found and
                        on our preliminary observations. OSAGWI officials agreed that they needed
Reporting Processes     to improve their investigations and their reporting of the investigation
                        results. They said that they have instituted several changes to their internal
                        quality assurance practices that they believe will considerably strengthen
                        their investigative and reporting processes.

                        According to OSAGWI officials, their current investigative and reporting
                        process has evolved over the 2 years since OSAGWI was established.
                        Consequently, certain enhancements are now in place that were not
                        present when the six case narratives we reviewed were published. More
                        specifically, OSAGWI now requires its investigators to prepare a written
                        investigation plan. The investigation plan must specify the information that
                        will be obtained, the direction the investigation will take, and the
                        schedule. The plan is expected to mirror the overall methodology adopted
                        by the division within the Investigation and Analysis Directorate for its
                        investigations. The division chief is to review the investigation plan and
                        provide feedback to the investigator on the scope and direction of the
                        investigation and the proposed schedule. Following approval of the plan
                        by the division chief, the investigator can begin the investigation.

                        Also, the process now includes a requirement for a team directional
                        guidance meeting when the investigation is 50- to 75-percent complete. At



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              this meeting, the investigator briefs a small group of analysts from within
              the investigator’s division on the investigation’s scope, direction, and
              findings to that point. The purpose of the meeting is to identify at an early
              stage any problems in the direction of the investigation and to identify any
              major information sources that are not being used.

              According to OSAGWI, each case investigation is now periodically reviewed
              by the Director of the Investigations and Analysis Directorate to allow the
              Director to adjust, as necessary, the scope of the investigation and the
              case narrative development. Furthermore, the peer review process for
              case narratives is now more robust because the peer review team,
              comprising experienced individuals, reviews the completed case narrative
              along with the source materials. The peer reviewers are responsible for
              ensuring that the text in the case narrative is supported by the source
              material and also for identifying portions of the text needing footnotes to
              source materials. In addition, an OSAGWI official said the internal review of
              case narratives by key individuals within the OSAGWI organization is more
              rigorous than it used to be. OSAGWI officials believe that these
              enhancements to their review processes will preclude the recurrence of
              the types of investigative and reporting weaknesses we found.


              The weaknesses in the scope and quality of OSAGWI’s investigations and in
Conclusions   reporting the results of these investigations in the Reported Exposure to
              Mustard Agent, Marine Minefield Breaching, and Al Jubayl case narratives
              are significant; however, we agree with OSAGWI’s assessments of the
              likelihood of the presence of chemical warfare agents in all but the Marine
              Minefield Breaching case narrative. In our opinion, the lack of effective
              quality assurance policies and practices within OSAGWI contributed to the
              weaknesses we noted. A stronger quality control mechanism for its
              investigations would provide greater assurance that all relevant facts are
              included and that the information presented is accurately and properly
              sourced. More consistent use of some types of medical information would
              also strengthen the rigor of OSAGWI’s investigations. By querying available
              medical databases for all cases, OSAGWI investigators might have been able
              to better determine whether personnel at or near the sites of incidents had
              reported or been diagnosed with unusual health problems, thus helping
              indicate whether increased investigative efforts regarding the potential
              presence of chemical warfare agents or other environmental hazards in
              these incidents might be appropriate.




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                      OSAGWI’s  changes to its internal review process appear to be positive steps
                      in ensuring the quality of investigations and the related case narrative
                      reports. Because OSAGWI initiated these changes after the case narratives
                      we reviewed were published, we could not determine their effectiveness in
                      ensuring the quality of OSAGWI investigations and reports. However, the
                      procedures should incorporate two features to enhance the credibility of
                      the review process. First, it is critical that those named to review OSAGWI’s
                      investigations are independent of the team investigating the incidents to
                      avoid the appearance of a conflict of interest. Second, it is important that
                      the procedures in place lead reviewers to thoroughly check to ensure that
                      all relevant information obtained by the investigation teams has been
                      included in the case narrative reports, that all important leads have been
                      pursued, and that the investigation team has reached conclusions that are
                      fully substantiated by the facts.

                      Information about the potential for differences in the occurrence of Gulf
                      War illnesses symptoms between NMCB-24 and NMCB-40 developed during
                      the Al Jubayl case investigation was not shared with the Naval Health
                      Research Center for consideration for inclusion in its ongoing Gulf War
                      illnesses research. We believe this information has potential for use in
                      helping DOD evaluate issues related to the high levels of health problems
                      reported by many of the Seabees stationed at Al Jubayl during the Gulf
                      War.


                      To ensure that OSAGWI’s case narratives contain all relevant facts, we
Recommendations       recommend that the Secretary of Defense direct the Special Assistant for
                      Gulf War Illnesses to

                  •   revise the Marine Minefield Breaching, Exposure to Mustard Agent, and Al
                      Jubayl, Saudi Arabia, case narratives to reflect the new and/or unreported
                      information noted in our report and
                  •   examine whether it should change its conclusion about the likelihood of
                      the presence of chemical warfare agents in the Marine Minefield Breaching
                      case from “unlikely” to “indeterminate” in light of the additional
                      information now known about this case.

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




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                         Some Case Narratives Have Investigative
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                     •   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; and
                     •   ensure that its 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
                         conclusions have been fully substantiated by the facts, and that all logical
                         leads have been pursued.

                         Because of the potential research value of information developed through
                         OSAGWI investigations, we further recommend that OSAGWI contact the
                         Naval Health Research Center regarding the usefulness and desirability of
                         comparing data between the veterans of NMCB-24 and NMCB-40 for purposes
                         such as helping to determine whether veterans of these two units are
                         reporting the same types and numbers of symptoms.


                         DOD  generally concurred with a draft of this report, agreeing to revise the
Agency Comments          case narratives we reviewed to include new or unreported data, and to
and Our Evaluation       reassess case narrative findings based upon any new evidence. In
                         particular, DOD agreed to update the Marine Minefield Breaching case to
                         reflect new information, conduct additional analysis on the issue of
                         artillery fire during the breaching operation, and reassess its conclusions
                         as appropriate.

                         DOD  disagreed with our proposed use of the CCEP and the VA Gulf War
                         Health Examination Registry in OSAGWI investigations. In commenting on
                         this report, DOD stated it was concerned that these databases might be
                         inappropriately used to establish a causal relationship between an event
                         and the medical findings of the registries. DOD therefore maintains it would
                         be inappropriate for case investigations, which were designed to report
                         simply on what happened on the battlefield, to make assumptions about
                         the significance or validity of the data in these databases without the
                         establishment of a causal association by scientific research. DOD also
                         stated concerns about preempting scientific research in this area and
                         drawing premature conclusions that would be fallacious. However, DOD
                         agreed that these databases need to be examined and analyzed for what
                         they can contribute to understanding the illnesses of Gulf War veterans,



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and noted that the Department has been involved in a number of research
and other analyses of these databases.

We agree that information from these databases should not be used by
investigators to establish a causal association and/or conclusions as
described by DOD, and did not intend that it should be used for this
purpose. We also agree that the establishment of Gulf War illnesses causal
relationships is most appropriately a research activity. However, we also
believe that the VA and DOD databases could potentially provide relevant
information to the investigator about whether individuals who were at or
near a site under investigation are reporting health problems, and that this
information could be appropriately used, when combined with other
information, to help guide the nature and scope of OSAGWI investigations.
For example, case investigators could use VA Registry and CCEP data,
particularly where it shows that large numbers of individuals at or near a
given site are reporting health problems, as an indicator for providing
investigative leads and for use in establishing the nature and scope of an
investigation. This does not mean, as implied in DOD’s comments, that such
use of these databases would entail routine inclusion of the reviewed data
in the published case narratives, their use as a replacement for research
activities, or that its use would result in interpretations of
non-scientifically based cause and effect relationships. We believe that
these databases can be used by investigators to help guide and scope their
efforts without entailing the types of misuse described by DOD. We
modified the final report text and recommendatons to clarify our position
regarding this finding.

DOD agreed that the Al Jubayl case narrative needed to be modified to
place the events of this incident in fuller context, and that this would
include that some servicemembers stationed at Al Jubayl, especially
members of NMCB-24, have reported high levels of health problems. DOD
also agreed to request that the Naval Health Research Center undertake an
analytical comparison regarding NMCB-24 and NMCB-40, and that
independent reviewers are critical to a thorough and acceptable report on
OSAGWI investigations.


VA also disagreed with our proposed use of the CCEP and the VA Gulf War
Health Examination Registry in OSAGWI investigations in its written
comments on a draft of this report. VA’s comments were similar to DOD’s
regarding this matter. VA also expressed doubts regarding the usefulness to
research of data comparisons involving NMCB-24 and NMCB-40.




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Additional discussion of DOD’s and VA’s comments and our evaluation is
included in appendixes I and II.




Page 47                                     GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I

Comments From the Department of Defense




             Page 48         GAO/NSIAD-99-59 Gulf War Illnesses
                 Appendix I
                 Comments From the Department of Defense




See comment 1.




                 Page 49                                   GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I
Comments From the Department of Defense




Page 50                                   GAO/NSIAD-99-59 Gulf War Illnesses
                       Appendix I
                       Comments From the Department of Defense




Now on pp. 8 and 44.




See comment 2.


Now on p. 8.




                       Page 51                                   GAO/NSIAD-99-59 Gulf War Illnesses
                          Appendix I
                          Comments From the Department of Defense




Now on pp. 8 and 44-45.




                          Page 52                                   GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I
Comments From the Department of Defense




Page 53                                   GAO/NSIAD-99-59 Gulf War Illnesses
                 Appendix I
                 Comments From the Department of Defense




Now on p. 45.




See comment 3.




                 Page 54                                   GAO/NSIAD-99-59 Gulf War Illnesses
                 Appendix I
                 Comments From the Department of Defense




Now on p. 25.


See comment 4.

See comment 5.




Now on p. 30.


See comment 6.




Now on p. 31.



See comment 7.




Now on p. 35.


See comment 7.
Now on p. 3.




                 Page 55                                   GAO/NSIAD-99-59 Gulf War Illnesses
                 Appendix I
                 Comments From the Department of Defense




See comment 8.




                 Page 56                                   GAO/NSIAD-99-59 Gulf War Illnesses
               Appendix I
               Comments From the Department of Defense




               The following are our comments on the Department of Defense’s (DOD)
               letter dated February 4, 1999.


               1. Our report states that the Office of the Special Assistant for Gulf War
GAO Comments   Illnesses (OSAGWI) case investigators did not attempt to use Comprehensive
               Clinical Evaluation Programs (CCEP) or Department of Veterans Affairs
               (VA) registry information in the six cases we reviewed. The report
               acknowledges OSAGWI’s use of the CCEP and VA registry regarding to the
               Khamisiyah incident and the Depleted Uranium Environmental Exposure
               Report.

               2. Our report recommends that OSAGWI examine whether to change its
               conclusion about the likelihood of exposure to a chemical agent in light of
               the additional information now known about this case. We agree that
               additional assessment is needed by OSAGWI to make this determination, and
               that some of the evidence regarding this incident is contradictory and
               otherwise in need of additional analysis. Until additional analysis is
               performed, it is not clear whether the likelihood of the presence of a
               chemical warfare agent in this case should be assessed as “unlikely” or
               “indeterminate.” However, we believe the new evidence tends to increase
               the possibility that an “indeterminate” assessment might be more
               appropriate.

               3. OSAGWI should have identified the potential research value of
               information it had in its files regarding the relationship between Naval
               Mobile Construction Battalion 24 (NMCB-24) and NMCB-40, and shared this
               information with researchers at the Naval Health Research Center for use
               in the Seabee study—a major Gulf War illnesses research project. We
               agree that this finding cannot be used by itself as sufficient evidence to
               show an overall lack of diligence by OSAGWI in sharing information from
               case investigations with researchers. However, the fact that neither we nor
               OSAGWI could find any evidence that an attempt was made to identify or
               coordinate this information in the Al Jubayl case does raise questions
               about the adequacy and effectiveness of OSAGWI procedures for identifying
               and referring this kind of information. The word “diligence” was removed
               from the final report.

               4. The sentence referring to how the OSAGWI investigator should have been
               alerted to the need for further investigation based on the absence of
               thiodiglycol in the urine sample has been deleted from the final report. We




               Page 57                                      GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I
Comments From the Department of Defense




agree that other inferences could also be drawn from the absence of
thiodiglycol in this analysis.

5. Information has been added to the final report regarding the senior
medical officer’s testimony, his medical journal article, and his review of
the narrative draft. However, OSAGWI was remiss in failing to interview the
senior medical officer, especially in view of the importance of this witness’
involvement in the case. This officer was still on active duty and stationed
in the Washington, D.C., area at the time of our review. OSAGWI could have
avoided some of the accuracy problems associated with this case narrative
had it interviewed this officer prior to publication of the narrative.

6. We agree that this message was fragmentary, incomplete, and leaves
many unanswered questions about its meaningfulness and reliability.
However, this message deserves further investigation because of its date
and reference to a chemical attack. In our opinion, the fact that the
message was received hours after the incident does not rule out the
possibility there could have been a delay between the time of the event
and the time the message was transmitted. Even if the message is shown
to be unassociated with the incident in question, its very nature justifies
further investigation by OSAGWI. OSAGWI officials agreed that they would
attempt to investigate further.

7. We agree with OSAGWI regarding the need for caution when interpreting
the relationship between an event, medical findings of the CCEP and VA
registries, and other medical information. Accordingly, the final report text
was modified regarding the term “direct linkage with post-war veterans’
complaints.”

We do not agree that the issue in point necessarily implies such
connotations. Our concern is simply that while the Al Jubayl narrative
contains much information to the effect that chemical warfare agents were
either “definitely not” or “unlikely” to have been present at Al Jubayl and
that the Al Jubayl area appeared environmentally clean during the Gulf
War, it fails to point out that (1) many servicemembers stationed there are
now reporting unusually high levels of health problems and (2) DOD has
conducted or is conducting several investigations and major research
projects addressing this issue. These important facts need to be mentioned
in the case narrative. If DOD is concerned about the possible misuse of
information regarding reported veterans’ illnesses, then the need for
caution regarding its use and research implications could also be included




Page 58                                       GAO/NSIAD-99-59 Gulf War Illnesses
Appendix I
Comments From the Department of Defense




in the case narrative. We trust that OSAGWI’s planned modifications to the
Al Jubayl case narrative will resolve this issue.

8. In response to this comment, we have changed the report in several
places to refrain from using the word “disclose.” However, in the case
narrative involving the Seabees, as well as in one other case, OSAGWI for
various reasons originally chose not to include information that we believe
should have been included.




Page 59                                       GAO/NSIAD-99-59 Gulf War Illnesses
Appendix II

Comments From the Department of
Veterans Affairs




Now on pp. 39-41.

Now on p. 39.




See comment 1.




                    Page 60   GAO/NSIAD-99-59 Gulf War Illnesses
                 Appendix II
                 Comments From the Department of
                 Veterans Affairs




Now on p. 45.

See comment 2.




See comment 3.




                 Page 61                           GAO/NSIAD-99-59 Gulf War Illnesses
               Appendix II
               Comments From the Department of
               Veterans Affairs




               The following are our comments on VA’s letter dated February 10, 1999.


               1. We are not suggesting that OSAGWI should use data from the DOD and VA
GAO Comments   registries to reach conclusions about causal relationships between
               participants’ health outcomes and the likelihood of their exposure to
               chemical warfare agents. We recognize that these databases contain the
               results of medical examinations for voluntary, self-selected individuals
               that if used for research purposes could be affected by participation bias.
               However, the databases contain information about whether the
               participants believe that they were exposed to various chemical or
               environmental hazards, their general health status, and the results of
               medical examinations performed by DOD or VA. It is also possible that some
               or many of these participants may have been at or near a site under
               investigation by OSAGWI. Consequently, the databases may contain
               potentially relevant information about individuals that were at a site under
               investigation by OSAGWI—information which OSAGWI did not access for the
               cases we reviewed. We are not suggesting that this information would
               necessarily change the course of the OSAGWI investigation; however, review
               of this information could possibly suggest additional investigative steps
               that should be undertaken.

               2. In our report, we recommend that OSAGWI contact the Naval Health
               Research Center regarding the usefulness and desirability of comparing
               data about veterans of NMCB-24 and NMCB-40. Center researchers told us
               that such a comparison might be useful. The point of our recommendation
               is that information developed in OSAGWI investigations that might have
               research usefulness should be forwarded to organizations performing the
               research. DOD agreed with this recommendation. Furthermore, it should be
               noted that the Seabee study is one of the research projects being
               performed under the management of the Research Working Group of
               Persian Gulf Veterans Coordinating Board (Project DOD-1E) and as such is
               one of the federally sponsored research projects addressing Gulf War
               illnesses. This project is using scientific methods for collecting data from
               both former and current Seabees and plans a multifaceted comparison of
               this data. We made no judgments regarding what the outcome of this work
               might be or how it might be reviewed by the epidemiology research
               community. However, we believe that all data or ideas for comparisons
               that might have applicability to Gulf War illnesses research should be
               forwarded for consideration by the appropriate research organization.
               Otherwise, an opportunity for learning more about Gulf War illnesses
               could be missed.



               Page 62                                       GAO/NSIAD-99-59 Gulf War Illnesses
Appendix II
Comments From the Department of
Veterans Affairs




3. OSAGWI’s own methodology for chemical incident investigations, which
was derived from the United Nations and the international community,
calls for obtaining information from the DOD and VA registries about the
medical condition of personnel involved in an incident under investigation.
We are not suggesting that OSAGWI establish a hypothesis from which it
could derive undisputed conclusions. We are suggesting that the DOD and
VA databases may contain potentially relevant information that could assist
OSAGWI in determining the scope and nature of its investigations.




Page 63                                      GAO/NSIAD-99-59 Gulf War Illnesses
Appendix III

OSAGWI Reports and Active Investigations


                                      Table I.1 lists reports published by OSAGWI. It is followed by a listing of
                                      active OSAGWI investigations.

Table I.1: OSAGWI Published Case
Narratives, Information Papers, and   Case name                                 Publication date
Environmental Exposure Reports (as    Khamisiyah                                April 15, 1997
of Jan. 1, 1999)
                                      Camp Monterey                             May 22, 1997
                                      Fox Information Paper                     July 29, 1997
                                      Marine Minefield Breaching                July 29, 1997
                                      Al Jubayl, Saudi Arabia                   August 13, 1997
                                      SCUD Piece                                August 13, 1997
                                      Exposure to Mustard Agent                 August 28, 1997
                                      Al Jaber Air Base                         September 25, 1997
                                      ASP/Orchard                               September 25, 1997
                                      M8A1 Information Paper                    October 30, 1997
                                      MOPP Information Paper                    October 30, 1997
                                      Medical Surveillance During ODS/DS        November 6, 1997
                                      Information Paper
                                      Tallil Air Base                           November 13, 1997
                                      Kuwaiti Girls’ School                     March 19, 1998
                                      An Nasiriyah SW                           August 4, 1998
                                      Czech/French Detections                   August 4, 1998
                                      Depleted Uranium Environmental Exposure   August 4, 1998
                                      Report
                                      11th Marines                              November 5, 1998
                                      Oil Well Fire Environmental Exposure Report November 5, 1998



Active OSAGWI                         Air Campaign Information Paper
Investigations (as of                 Al Muthanna
Jan. 1,1999)                          Biological Warfare
                                      CARC Paint Environmental Exposure Report
                                      Cement Factory
                                      Chemical Munitions Markings Information Paper
                                      Chemical Weapons Sites
                                      Edgewood Tapes
                                      Injured Marine
                                      Khamisiyah - Update
                                      M256 Information Paper
                                      Marine Breaching Followup
                                      Medical Record Keeping Information Paper




                                      Page 64                                          GAO/NSIAD-99-59 Gulf War Illnesses
Appendix III
OSAGWI Reports and Active Investigations




Medical Surveillance Information Paper
Muhammadiyat
Pesticides/Insecticides Environmental Exposure Report
Possible Terrorist Attack at Al Jubayl
Possible Post-War Chemical Warfare Use on Iraqis
Rafha M256 Detections
Inhibited Red Fuming Nitric Acid Information Paper
Retrograde Equipment Environmental Exposure Report
Sand Environmental Exposure Report
SCUD Information Paper
Ukhaydir
Vaccine Administration Information Paper
XM21 RSCAAL Detection
JCMEC-TEU Sampling Process Information Paper




Page 65                                    GAO/NSIAD-99-59 Gulf War Illnesses
Appendix IV

Major Contributors to This Report


                        Donald L. Patton
National Security and   William W. Cawood
International Affairs   Raymond G. Bickert
Division, Washington,   William J. Rigazio
D.C.
                        Steve J. Fox
Norfolk Field Office    Lynn C. Johnson
                        William L. Mathers




(703223)                Page 66              GAO/NSIAD-99-59 Gulf War Illnesses
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