Gulf War Illnesses:

Procedural and Reporting Improvements Are Needed in DOD's Investigative Processes

NSIAD-99-59: Published: Feb 26, 1999. Publicly Released: Mar 19, 1999.

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Pursuant to a congressional request, GAO provided information on the: (1) Department of Defense's (DOD) progress in establishing an organization to address Gulf War illnesses issues; and (2) thoroughness of DOD's Office of the Special Assistant for Gulf War Illnesses' (OSAGWI) investigations into and reporting on incidents of veterans' potential exposure to chemical or biological warfare agents during the Gulf War.

GAO noted that: (1) DOD has made progress in carrying out its mandate to comprehensively address Gulf-War illnesses-related issues; (2) 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; (3) in addition, it has assisted veterans in obtaining medical examinations and other services at DOD and Department of Veterans Affairs (VA) facilities; (4) 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; (5) OSAGWI generally applied appropriate investigative procedures and techniques in conducting its work; (6) 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; (7) in the remaining three cases, OSAGWI conducted its investigations without evidence of these weaknesses; (8) 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; (9) 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; (10) 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; (11) the one exception involved a potential exposure of U.S. Marine Corps personnel to a chemical warfare agent during a minefield breaching operation; (12) OSAGWI concluded that exposure in this case was unlikely; (13) 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; (14) 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; and (15) GAO believes that the lack of effective quality assurance policies and practices in OSAGWI's investigating and reporting processes contributed to the weaknesses noted.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: A multilevel review process along the lines proposed by GAO has been implemented.

    Recommendation: To enhance the thoroughness of OSAGWI's investigative and reporting practices, the Secretary of Defense should direct the Special Assistant for Gulf War Illnesses to 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.

    Agency Affected: Department of Defense

  2. Status: Closed - Implemented

    Comments: DOD concurred and will follow this process. On January 31, 2001, DOD updated the concerned case narrative (Al Jubayl, Saudi Arabia). The updated narrative included the relevant medical information.

    Recommendation: To enhance the thoroughness of OSAGWI's investigative and reporting practices, the Secretary of Defense should direct the Special Assistant for Gulf War Illnesses to include relevant medical information in its case narratives where it is needed to fully explain incidents of possible exposure to chemical agents to other potential causes of Gulf War Illnesses.

    Agency Affected: Department of Defense

  3. Status: Closed - Not Implemented

    Comments: OSAGWI disagrees with GAO's position on this matter. It does not think that it should routinely use these databases for assessments.

    Recommendation: To enhance the thoroughness of OSAGWI's investigative and reporting practices, the Secretary of Defense should 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.

    Agency Affected: Department of Defense

  4. Status: Closed - Implemented

    Comments: OSAGWI had advised GAO that it is going to reassess its position. OSAGWI completed all revisions to this case by August 2001. OSAGWI's review did not result in any major changes to the case conclusions or assessment.

    Recommendation: To ensure that OSAGWI's case narratives contain all relevant facts, the Secretary of Defense should direct the Special Assistant for Gulf War Illnesses to 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.

    Agency Affected: Department of Defense

  5. Status: Closed - Implemented

    Comments: OSAGWI concurred with every point in the recommendations. The Special Assistant agreed to make all changes pointed out by GAO. All information updates were completed by August 2001.

    Recommendation: To ensure that OSAGWI's case narratives contain all relevant facts, the Secretary of Defense should 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 or unreported information noted in GAO's report.

    Agency Affected: Department of Defense

  6. Status: Closed - Implemented

    Comments: OSAGWI has responded that it intends to share information with organizations involved in the Gulf War Illnesses research to include those GAO cited in its report. OSAGWI does not believe it has not practiced due diligence in circulating its findings among the various organizations involved in this issue. OSAGWI did not contact the Naval Health Research Center regarding the relationship between NMCB-24 and NMCN-40, and comparisons were performed under the center's Seabee study.

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

    Agency Affected: Department of Defense: Office of the Special Assistant for Gulf War Illnesses

 

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