Gulf War Illnesses:
Evaluation of DOD's Investigative Processes
NSIAD-99-219R, Jul 13, 1999
GAO discussed its February 1999 report on the Department of Defense's (DOD) Office of the Special Assistant for Gulf War Illnesses (OSAGWI), focusing on: (1) DOD's progress in establishing an organization to address Gulf War illnesses issues; and (2) the thoroughness of OSAGWI's investigations into and reporting on servicemembers' potential exposure to chemical or biological agents during the Persian Gulf War.
GAO noted that: (1) in the face of severe criticism by veterans and others on the handling of Gulf War illnesses issues, DOD established OSAGWI in November 1996; (2) since then, DOD has made progress in addressing issues related to Gulf War illnesses; (3) it has: (a) significantly increased the emphasis and resources committed to determining the cause of Gulf War veterans' health problems; (b) improved communications with veterans; and (c) identified chemical and biological warfare force protection issues requiring attention; (4) in reviewing six of the eight case narratives that OSAGWI had published at the time of GAO's review, GAO found that OSAGWI generally followed its established investigation methodology and used appropriate investigative procedures and techniques; (5) however, GAO found significant weaknesses in the scope and quality of OSAGWI's investigations in three cases that were not evident in the other three; (6) these weaknesses included failures to: (a) follow up with appropriate individuals to confirm key evidence; (b) identify and ensure the validity of key physical evidence; (c) include important information in the case narratives; and (d) interview key witnesses; (7) despite these weaknesses, the preponderance of evidence led GAO to agree with OSAGWI's conclusions about the likelihood of the presence of chemical warfare agents in five of the six cases reviewed; (8) the one exception involved OSAGWI's conclusion that a potential exposure of Marine Corps personnel to a chemical agent during a mine breaching operation was unlikely; (9) GAO believes this conclusion needs reassessment because OSAGWI overlooked some important information it had regarding this case; (10) OSAGWI also considered, but did not include, other relevant information in this case narrative; (11) in all six cases, OSAGWI missed an opportunity to perform more complete investigations because it did not use potentially valuable sources of relevant information in DOD and Department of Veterans Affairs clinical databases; and (12) GAO noted that the lack of effective quality assurance policies and practices in OSAGWI's investigating and reporting processes contributed to the weaknesses GAO found.