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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Highlights

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.

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Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Defense 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.
Closed – Implemented
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.
Department of Defense 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.
Closed – Implemented
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.
Department of Defense 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.
Closed – Not Implemented
OSAGWI disagrees with GAO's position on this matter. It does not think that it should routinely use these databases for assessments.
Department of Defense 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.
Closed – Implemented
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.
Department of Defense 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.
Closed – Implemented
A multilevel review process along the lines proposed by GAO has been implemented.
Office of the Special Assistant for Gulf War Illnesses 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.
Closed – Implemented
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.

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