Chemical and Biological Defense:

DOD and VA Need to Improve Efforts to Identify and Notify Individuals Potentially Exposed during Chemical and Biological Tests

GAO-08-366: Published: Feb 28, 2008. Publicly Released: Feb 28, 2008.

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Tens of thousands of military personnel and civilians were potentially exposed to chemical or biological substances through Department of Defense (DOD) tests since World War II. DOD conducted some of these tests as part of its Project 112 test program, while others were conducted as separate efforts. GAO was asked to (1) assess DOD's efforts to identify individuals who were potentially exposed during Project 112 tests, (2) evaluate DOD's current effort to identify individuals who were potentially exposed during tests conducted outside of Project 112, and (3) determine the extent to which DOD and the Department of Veterans Affairs (VA) have taken action to notify individuals who might have been exposed during chemical and biological tests. GAO analyzed documents and interviewed officials from DOD, VA, the Department of Labor, and a veterans service organization.

Since 2003, DOD has stopped actively searching for individuals who were potentially exposed to chemical or biological substances during Project 112 tests, but did not provide a sound and documented basis for that decision. In 2003, DOD reported it had identified 5,842 servicemembers and estimated 350 civilians as having been potentially exposed during Project 112, and indicated that DOD would cease actively searching for additional individuals. However, in 2004, GAO reported that DOD did not exhaust all possible sources of information and recommended that DOD determine the feasibility of identifying additional individuals. In response to GAO's recommendation, DOD determined continuing an active search for individuals had reached the point of diminishing returns, and reaffirmed its decision to cease active searches. This decision was not supported by an objective analysis of the potential costs and benefits of continuing the effort, nor could DOD provide any documented criteria from which it made its determination. Since June 2003, however, non-DOD sources--including the Institute of Medicine--have identified approximately 600 additional names of individuals who were potentially exposed during Project 112. Until DOD provides a more objective analysis of the costs and benefits of actively searching for Project 112 participants, DOD's efforts may continue to be questioned. DOD has taken action to identify individuals who were potentially exposed during tests outside of Project 112, but GAO identified four shortcomings in DOD's current effort. First, DOD's effort lacks clear and consistent objectives, scope of work, and information needs that would set the parameters for its efforts. Second, DOD has not provided adequate oversight to guide this effort. Third, DOD has not fully leveraged information obtained from previous research efforts that identified exposed individuals. Fourth, DOD's effort lacks transparency since it has not kept Congress and veterans service organizations fully informed of the progress and results of its efforts. Until DOD addresses these limitations, Congress, veterans, and the American public can not be assured that DOD's current effort is reasonable and effective. DOD and VA have had limited success in notifying individuals potentially exposed during tests both within and outside Project 112. DOD has a process to share the names of identified servicemembers with VA; however, DOD has delayed regular updates to VA because of a number of factors, such as competing priorities. Furthermore, although VA has a process for notifying potentially exposed veterans, it was not using certain available resources to obtain contact information to notify veterans or to help determine whether they were deceased. Moreover, DOD had not taken any action with the civilian names, focusing instead on veterans since the primary impetus for the research has been requests from VA. DOD has refrained from taking action on civilians in part because it lacks specific guidance that defines the requirements to notify civilians. Until these issues are addressed, some identified veterans and civilians will remain unaware of their potential exposure.

Status Legend:

More Info
  • Review Pending-GAO has not yet assessed implementation status.
  • Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.
  • Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.
  • Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.
    • Review Pending
    • Open
    • Closed - implemented
    • Closed - not implemented

    Matters for Congressional Consideration

    Matter: To provide greater transparency and resolve outstanding questions related to DOD's decision to cease actively searching for the identification of individuals associated with Project 112, Congress may wish to consider requiring the Secretary of Defense to consult with and address the concerns of VA, veterans, and veterans service organizations; to conduct and document an analysis that includes a full accounting of information known, and the related costs, benefits, and challenges associated with continuing the search for additional Project 112 participants; and to provide Congress with the results of this analysis.

    Status: Closed - Not Implemented

    Comments: Congress has declined to take the actions suggested by GAO.

    Matter: To ensure that civilians who were potentially exposed to chemical or biological substances as a result of tests conducted or sponsored by DOD are aware of their circumstances, Congress may wish to consider requiring the Secretary of Defense, in consultation with the Secretary of Labor, to develop specific guidance that defines the requirements, roles and responsibilities, and mechanisms to notify civilians who have been potentially exposed to chemical or biological substances.

    Status: Closed - Not Implemented

    Comments: Congress has declined to take the actions suggested by GAO.

    Recommendations for Executive Action

    Recommendation: To ensure a sound and documented process for DOD's decision regarding the identification of individuals associated with Project 112, the Secretary of Defense should direct the Office of the Under Secretary of Defense for Personnel and Readiness to conduct and document an analysis that includes a full accounting of information known, and the related costs, benefits, and challenges associated with continuing the search for additional Project 112 participants, and to provide Congress with the results of this analysis. In developing the analysis, DOD should consult with and address the identified concerns of VA, veterans, and veterans service organizations.

    Agency Affected: Department of Defense

    Status: Closed - Not Implemented

    Comments: In commenting on the draft report, DOD did not agree with the recommendation to conduct and document an analysis that includes a full accounting of information known, and the related costs, benefits, and challenges associated with continuing the search for additional Project 112 participants, and to provide Congress with the results of this analysis. DOD stated that it believes it made a full accounting of its efforts available to Congress in 2003, that it has not received any credible leads that would allow DOD to continue its research, and that it currently knows of no other investigative leads that would meaningfully supplement what it believes to be a total picture of Project 112. However, as discussed in our May 2004 report, we identified a number of credible leads that could possibly result in additional Project 112 information. In addition, as discussed in this report, almost 600 additional individuals who were potentially exposed during Project 112 (more than a 10 percent increase) have been identified by non-DOD sources since DOD's 2003 report to Congress and its decision to cease actively searching for additional exposures. In light of the increasing number of individuals who have been identified since DOD provided its report to Congress in 2003 and ceased its active search for additional individuals, until the department provides a more substantive analysis that supports its decision to cease active searches for additional individuals potentially exposed during Project 112 tests, Congress and veterans may continue to question the completeness and level of commitment to this effort. Because DOD disagreed with our recommendation and had not adequately addressed our May 2004 recommendation to determine the feasibility of addressing unresolved issues associated with Project 112, we added a Matter for Congress to consider directing the Secretary of Defense to conduct such an analysis.

    Recommendation: To ensure that DOD's current effort to identify individuals who were potentially exposed during chemical and biological tests outside of Project 112 are more efficient, effective, and transparent, and to ensure that its databases contain accurate information, the Secretary of Defense should direct the Office of Under Secretary of Defense for Acquisition, Technology, and Logistics to, in coordination with the Office of the Under Secretary of Defense for Personnel and Readiness and the Secretary of Veterans Affairs, modify the guidance about the scope of work for its current effort, such as the statement of work and concept of operations plan, to clearly define consistent, reasonable, and acceptable goals and objectives, and the type and amount of information that will need to be collected to meet these goals and objectives.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: DOD rewrote the task order's statement of work in July 2008, the concept of operations plan in October 2008, and the implementation plan in February 2009. We believe these corrective actions meet the intent of our recommendations, and DOD is better positioned to know whether it has accomplished the project's goals and produced its desired results.

    Recommendation: To ensure that DOD's current effort to identify individuals who were potentially exposed during chemical and biological tests outside of Project 112 are more efficient, effective, and transparent, and to ensure that its databases contain accurate information, the Secretary of Defense should direct the Office of Under Secretary of Defense for Acquisition, Technology, and Logistics to implement effective internal controls and oversight practices, such as periodic site visits, regular assessments of the contactor's efforts, and quality assurance reviews of the information provided by the contractor.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: In a September 2010 update on the status of the recommendation, DOD stated that the contractor was now providing the office overseeing the task order with monthly reports of its efforts. DOD also stated that a representative from the DOD office overseeing the contractor attends monthly meetings between the contractor and the DOD office that maintains the database as an additional quality control over the information that the contractor provides. In addition, DOD stated that it was now conducting quarterly site visits to the locations where the contractor was conducting its work. We believe these corrective actions meets the intent of our recommendation, and DOD is better positioned to determine (1) that resources spent on the contractor's research are more effectively and efficiently used, (2) the accuracy of the information provided by the contractor, and (3) whether the task order needs to be modified to focus DOD's resources and the contractor's research efforts to those tasks that will best meet its objectives. For example, the contractor has changed some of the locations where it plans on conducting its research because some of the initial sites were showing no benefits to DOD's efforts.

    Recommendation: To ensure that DOD's current effort to identify individuals who were potentially exposed during chemical and biological tests outside of Project 112 are more efficient, effective, and transparent, and to ensure that its databases contain accurate information, the Secretary of Defense should direct the Office of Under Secretary of Defense for Acquisition, Technology, and Logistics to coordinate and communicate with other entities that previously identified exposed individuals to leverage existing information, including institutional knowledge and documents.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: In our February 2008 report, Chemical and Biological Defense: DOD and VA Need to Improve Efforts to Identify and Notify Individuals Potentially Exposed during Chemical and Biological Tests (GAO-08-366), we stated that the DOD chemical and biological defense office that was responsible for overseeing the department's effort at that time did not fully leverage the work of other entities, including the Office of the Under Secretary of Defense for Personnel and Readiness (OUSD (P&R)), which had led a joint DOD-Department of Veterans Affairs effort to find exposed service members during the 1990s. During this period, OUSD (P&R) personnel involved with the research became very knowledgeable about the issues, collected boxes of information, and issued various reports. According to OUSD (P&R) officials, however, officials in OUSD (AT&L)'s chemical and biological defense office had not met with any of the personnel with institutional knowledge or examined any of the documents that OUSD (P&R) still maintained. Since OUSD (P&R)'s reports identified locations of exposures, officials in OUSD (AT&L)'s chemical and biological defense office could have used this information as another source to help validate and prioritize the repository sites proposed by the contractor for its current effort, and to eliminate potential redundancy. As such, we recommended and DOD agreed that the chemical and biological defense office should coordinate and communicate with other entities that previously identified exposed individuals to leverage existing information. Based on this recommendation, the chemical and biological office has met with the OUSD (P&R) office several times since the winter of 2009. During the meetings, the chemical and biological office found between 12 to 19 file boxes of records that OUSD (P&R) gleaned and gathered in the early 1990s. We believe this corrective action meets the intent of our recommendation, and that the DOD chemical and biological office overseeing DOD's efforts is able to leverage this information to make more informed decisions and assure the Congress and other concerned individuals that the department is trying to identify potentially exposed service members.

    Recommendation: To ensure that DOD's current effort to identify individuals who were potentially exposed during chemical and biological tests outside of Project 112 are more efficient, effective, and transparent, and to ensure that its databases contain accurate information, the Secretary of Defense should direct the Office of Under Secretary of Defense for Acquisition, Technology, and Logistics to make its efforts transparent with regular updates to Congress, the public, and veterans service organizations.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: In response to this recommendation, DOD took a series of actions to make its efforts more transparent. For example, in September 2008, DOD launched an updated internet site that provides interested persons with information on what happened during Project 112 and other chemical and biological tests. We believe this action addresses the finding identified in our report and that the internet site will provide more current information to veterans and other interested individuals. In addition, according to an August 2010 DOD inspector general report on the status of the GAO report's recommendations, DOD has distributed fact sheets to congressional committees, veterans service organizations, and the Department of Veterans Affairs; participated in a series of interviews; posted a two-minute informational video on DOD's health affairs web site; and briefed veterans service organizations. We believe these corrective actions meet the intent of our recommendation, and they have made DOD's research efforts more transparent to Congress, the public, and veterans service organizations.

    Recommendation: To ensure that DOD has taken appropriate action in its efforts to notify servicemembers who were potentially exposed, the Secretary of Defense should direct the Office of the Under Secretary of Defense for Personnel and Readiness to take appropriate action to address the factors--such as competing priorities and database management weaknesses--affecting DOD's ability to forward the names of potentially exposed individuals to VA in a timely and effective manner.

    Agency Affected: Department of Defense

    Status: Closed - Implemented

    Comments: In an August 2010 DOD inspector general report on the status of the GAO report's recommendations, DOD stated that it is providing updated information to VA on a quarterly basis. We believe this corrective action meets the intent of our recommendation, and that this action should lead to VA obtaining the names and exposure information of potentially exposed service members in a timelier manner.

    Recommendation: To ensure that all veterans who have been identified as having been potentially exposed to chemical or biological substances have been notified, the Secretary of Veterans Affairs should take steps to increase its use of available resources, such as the Internal Revenue Service, to implement a more efficient and effective process for obtaining contact information for living veterans.

    Agency Affected: Department of Veterans Affairs

    Status: Closed - Implemented

    Comments: In August 2010, the Department of Veterans Affairs told us that the department's "Veterans Benefits Administration (VBA) had begun requesting contact information from IRS for Veterans who were identified by DoD as chemical and biological test participants. In June 2010, VBA provided IRS a list of Veterans' names and Social Security numbers and requested any known mailing addresses. VBA received the requested IRS data in July 2010. VBA will continue to request information from IRS as needed to reach test participants."

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