document: On January 6, 1993, the Institute of Medicine published a report that discussed secret U.S. chemical weapons programs during World War II. The report found that an estimated 60,000 military personnel participated as human experimental subjects in tests of exposure to mustard agents and lewisite and unknown numbers of additional servicemembers may have been exposed to these substances through their participation in the production, transportation, and/or storage of these chemical substances. On February 18, 1993, we issued a report that found VA lacked information about individuals who were exposed during secret DOD chemical tests. After Members of Congress, the President of the United States, and the Secretary of Defense exchanged a series of letters about this issue in 1993, the Deputy Secretary of Defense issued an agencywide memo that released all individuals from any nondisclosure restrictions that might have been placed on them, tasked the secretaries of the military departments to undertake efforts to declassify and provide to VA as soon as possible information about individuals who were potentially exposed, and directed OUSD (P&R) to establish a task force to monitor the status of DOD’s efforts. As a result, OUSD (P&R), the military services, and VA developed the Chemical Weapons Exposure Study Task Force to identify DOD personnel exposed to chemical substances during testing, training, transport, production, and storage. By conducting site visits and other research efforts, the task force identified approximately 6,400 servicemembers and civilians who were potentially exposed to mustard, lewisite, and other chemical substances. The office created a database with information about these individuals (hereafter referred to as OUSD (P&R) database) and, according to OUSD (P&R), sent certificates of commendation to more than 700 individuals for whom it could find contact information. In addition to its own research, OUSD (P&R), on behalf of the task force, issued a task order for a contractor to analyze, extract, and develop a database of information on all volunteers and/or other subjects potentially exposed to live chemical or biological substances. The contractor developed a database and issued a series of reports that identified the locations of human exposures to chemical substances, including those resulting from tests and a variety of other activities such as transportation, production, storage, and disposal. Congress continued to look into this issue during 1994 through a series of hearings and a staff report that was prepared for the U.S. Senate’s Committee on Veteran Affairs. The issue of servicemembers being used as human subjects during DOD’s chemical and biological tests received high-level attention again in 2000, when the acting Secretary of Veterans Affairs wrote a letter to the Secretary of Defense requesting assistance in obtaining information about a series of then-classified chemical and biological tests under DOD’s Project 112 program. OASD (HA) officials consequently initiated some actions to identify potentially exposed individuals. Subsequently, DOD, VA, and Congress exchanged a series of correspondence about the need to identify individuals who were potentially exposed during these tests. Eventually, the Defense Authorization Act for FY 2003 required DOD to submit to Congress and the Secretary of Veterans Affairs a comprehensive plan for the review, declassification, and submittal to VA of all DOD records and information on Project 112 that are relevant to the provision of benefits by the Secretary of Veterans Affairs to members of the armed forces who participated in that project. During this effort, DOD identified 5,842 servicemembers and estimated that 350 civilians had been potentially exposed during Project 112 tests, and this information was entered into a Project 112 database. The act further required the Comptroller General to evaluate the plan and its implementation. The Defense Authorization Act for FY 2003 also required DOD to work with veterans and veterans service organizations to identify DOD projects or tests outside of Project 112 that may have exposed members of the armed forces to chemical or biological substances. In June 2004, we reported that DOD had not yet begun its investigation to identify such projects or tests and recommended that the Secretary of Defense direct the appropriate office(s) to finalize and implement a plan for identifying DOD projects and tests conducted outside of Project 112 that might have exposed servicemembers to chemical or biological substances and ensure that the plan addresses the scope, reporting requirements, milestones, and responsibilities for those involved in completing this effort. According to an OASD (HA) official, OASD (HA) made an informal agreement with OUSD (AT&L) to undertake this effort since OASD (HA) did not have the resources to conduct an investigation itself or to fund a contractor to do the research. In September 2004, OUSD (AT&L)’s chemical and biological defense office issued a task order to fulfill this provision of the legislation. The research being done as a result of this task order is ongoing as of December 2007. In June 2003, after having identified several thousand servicemembers and hundreds of civilians as having been potentially exposed to chemical or biological substances during Project 112, DOD stopped actively searching for additional individuals. According to a knowledgeable DOD official, this decision was made without a sound and documented cost-benefit analysis. The Defense Authorization Act for FY 2003 required DOD to review records and information necessary to identify members of the armed forces who were or may have been exposed to chemical or biological substances as a result of Project 112. Subsequently, in June 2003, DOD issued a report to Congress that stated that 5,842 servicemembers and an estimated 350 civilians might have been exposed during Project 112 tests. The report also indicated that DOD had ceased its active search for individuals potentially exposed during Project 112 tests and that it would investigate any new information that may be presented as well as share any additional or changed information with VA and the public. In 2004, we reported that DOD performed a reasonable investigation of servicemembers who were potentially exposed to the substances used during Project 112 tests. However, we found that DOD had not exhausted all possibilities for identifying additional servicemembers and civilian personnel who had been potentially exposed. Therefore, we recommended that DOD determine the feasibility of addressing these unresolved issues. In response to our 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 any objective analysis of the potential costs and benefits of continuing the effort. Instead, this decision was made by officials in OASD (HA) who had a working knowledge of Project 112 tests and the contents of chemical and biological test record repositories. These officials concluded that the record repositories that had been searched contained the majority of Project 112 documents; therefore, they believed that the bulk of exposures related to Project 112 tests had already been identified. Furthermore, the officials decided that the application of resources necessary to continue searching for Project 112 exposures would result in a diminishing return on their investment. The Office of Management and Budget has stated that a good cost-benefit analysis should include a statement of the assumptions, the rationale behind them, and a review of their strengths and weaknesses. This could include a full accounting of information known, related costs, benefits, and challenges of continuing to search for additional Project 112 participants. Moreover, our prior work has shown that there are elements integral to a sound cost-benefit analysis. For example, the analysis should include a thorough evaluation of the social benefits and costs of investments, identify objectives to ensure a clear understanding of the desired outcome, and include a list of the relevant impacts to ensure that all aspects are considered. DOD could not provide us with a quantitative analysis based on objective data or any documented criteria because OASD (HA) was not required to provide any support or basis for the decision. Since DOD’s June 2003 report to Congress and its decision to cease actively searching for additional exposures, additional individuals who may have been exposed as a result of Project 112 tests have been identified through various non-DOD sources, as shown in table 1. For example, the Institute of Medicine conducted a study on the long-term health effects of participation in the shipboard hazard and defense tests that were conducted as a subset of Project 112. This study identified 394 individuals who had been potentially exposed and who were previously unknown to DOD. According to DOD and Institute of Medicine officials, the additional names were discovered when the Institute of Medicine applied a more inclusive methodology in its research. In addition, our previous work in 2004 reported that DOD did not exhaust all possible sources of information during its investigation of Project 112 and our own research for that report resulted in the identification of 39 additional potentially exposed servicemembers. For example, DOD had limited success in identifying exposures during land-based tests because it was unable to find documentation, and it did not specifically search for individual civilian personnel in its investigation because it considered them to be outside of its scope. Furthermore, DOD officials have told us that veterans who participated in Project 112 tests have contacted DOD on their own initiative in search of information and documentation related to their exposures, which has resulted in 165 additional veterans being identified as having been potentially exposed during these tests. DOD’s current effort to identify individuals who may have been exposed to chemical or biological substances during activities outside of Project 112, discussed in the following section of this report, has also resulted in the discovery of information related to Project 112 tests. Specifically, the DOD contractor has found evidence that individuals who DOD already knew were potentially exposed to substances during at least one known Project 112 test were also potentially exposed during other Project 112 tests. In light of the increasing number of individuals who have been identified since DOD ceased actively searching, until DOD makes a sound and documented decision regarding the cost and benefits of actively searching for individuals potentially exposed during Project 112 tests, Congress and veterans may continue to question the completeness and accuracy of DOD’s effort. Although DOD has taken action to identify individuals who were potentially exposed during chemical or biological tests outside of Project 112, we identified several shortcomings in the current effort. Specifically, we found that DOD’s approach was hampered by (1) a lack of clear and consistent objectives, scope of work, and information needs; (2) management and oversight weaknesses; (3) a limited use of the work of other entities that previously identified exposed individuals; and (4) a lack of transparency in DOD’s efforts. In response to the Defense Authorization Act for FY 2003 and our May 2004 recommendation that DOD finalize and implement a plan to identify individuals who were potentially exposed during tests conducted outside of Project 112, DOD issued a task order in September 2004. The task order identified four sets of tasks that the contractor was to undertake to accomplish the task order’s objectives within 3 years—perform literature searches, conduct and review on-site data collections, data mine existing databases, and augment a database maintained by the contractor. The contractor has issued monthly reports on its work to OUSD (AT&L)’s chemical and biological defense office, which indicate that the contractor has taken action on each of these tasks. OUSD (AT&L)’s chemical and biological defense office and the contractor have agreed that the on-site reviews will be conducted at a total of 18 sites that were identified and prioritized based on established criteria, such as relevance and number of documents expected to be present. As of October 2007, the contractor has completed on-site data collection at 5 of these 18 sites, and as of December 2007 was collecting data at 3 additional sites. During its site visits, the contractor’s staff searches a variety of documents for information that pertains to human exposure to chemical or biological substances. The documents that are identified as having relevant information are then scanned into an electronic file and the information from those documents—such as the individual’s name, the substance to which the subject was exposed, and the activity that resulted in the exposure—is entered into a database. The contractor conducts a quality assurance review before this information is delivered to OASD (HA) officials. OASD (HA) officials told us that they perform a detailed review of this information, query the contractor to resolve errors or inconsistencies, and make modifications to the information provided by the contractor if they have received or read other information that they believe could add contextual sophistication. Once OASD (HA) officials complete their review of the information, it is added to the DOD chemical and biological test database that they maintain (hereafter referred to as the OUSD (AT&L) task order database). While the database information is not provided to OUSD (AT&L)’s chemical and biological defense office, the contractor’s monthly report to this office includes the number of identified individuals that the contractor has provided to OASD (HA). The task order identified specific locations for the contractor to review and was supposed to be completed in September 2007; however, the contractor was unable to complete its work within the 3-year schedule and has subsequently received a 3-year extension. This task order is valued at almost $4.5 million, and the estimated value of the extension is between $2.5 million and $3.7 million. Based on the project’s June 2007 concept of operations plan, which DOD developed as a result of this review, the contractor is expected to meet the project’s objectives and complete collection and analysis of information obtained from 18 data collection sites by September 2010. Since the remaining sites have been prioritized based on expected level of information and other criteria, DOD officials believe that the remaining data collection efforts could be completed more quickly. DOD’s current effort to identify individuals potentially exposed to chemical or biological substances lacks clear and consistent objectives, scope of work, and information needs, which affects DOD’s ability to know whether it has accomplished the project’s goals. First, the objectives of DOD’s current effort are inconsistent. The Defense Authorization Act for FY 2003, which was the genesis for DOD’s current effort, directed the Secretary of Defense to identify DOD projects or tests outside of Project 112 that may have exposed members of the armed forces to chemical or biological substances. However, the focus of the current effort has expanded to include other exposures, including those resulting from immunizations, transportation, storage, and occupational accidents. This occurred because the documents that are guiding this effort, including the project’s September 2004 statement of work and its June 2007 concept of operations plan, have been used interchangeably to define the scope of the work. We identified a difference of opinion between DOD and VA regarding the overall focus of the contractor’s research efforts. Officials in OUSD (AT&L)’s chemical and biological defense office stated that they believe the contractor should focus only on identifying participants in DOD tests since the Defense Authorization Act for FY 2003 was the genesis of this task order, and they believe that the primary interest is in individuals who were not aware of their exposures or are unable to report their exposures due to the classified nature of the tests. They also believe that individuals accidentally exposed at a work location might be protected under occupational health regulations and statutes. However, VA officials stated that they would prefer that DOD provide information on all exposures, including those not associated with DOD tests, since VA is responsible for adjudicating all claims by servicemembers, regardless of how they were exposed. The contractor conducting the search has included all types of exposures in its research, which according to DOD and contractor officials is based on VA’s stated preferences. Second, the scope of DOD’s current effort is unclear. Specifically, while the Defense Authorization Act for FY 2003 directed DOD to identify only members of the armed forces, the task order’s 2004 statement of work and the June 2007 concept of operations plan state that the objective of the project is to collect information on all servicemembers and civilian personnel who might have been exposed from 1946 to present. However, DOD’s current effort has not included an active search of civilian personnel. Instead, at the direction of DOD, the contractor is collecting information on civilians who may have been exposed to chemical or biological substances when it comes across those names while searching for servicemembers. DOD officials stated that they focused their efforts on servicemembers because VA has actively requested information about servicemembers from DOD for years and the department has not received any inquiries about the civilians. At the time of our review, the contractor had collected information on approximately 700 civilian personnel who were potentially exposed to chemical or biological substances. Third, the amount and type of information that the contractor needs to collect for this effort has been expanded from the original task order requirement. The task order specifies that the information to be collected should identify potential human exposure events, the names of test programs, chemical and biological substances involved, and the names of volunteers or participants. However, DOD has expanded the information that the contractor should collect, which may be lengthening the time for the contractor to complete its work. For example, in February 2007, officials from one of the repository sites provided the contractor a CD with names and exposure information for 2,300 individuals who were exposed to a series of biological tests at Fort Detrick, Maryland, known as Operation Whitecoat. However, as of October 2007, the contractor had not provided DOD with these names because it was adding information, such as the test objective and summary, and exposure and treatment information. Since most of these 2,300 individuals had been previously aware of their exposures due to Fort Detrick’s independent outreach efforts, a DOD official who has worked with these individuals has stated that it is unclear how much additional information the contractor needs to collect about this group. While OASD (HA) officials have said that the additional information has been helpful for their needs, they and VA officials have also acknowledged that the identity of the chemical or biological substance to which an individual was potentially exposed is the most pertinent information. Without consistent guidance about the objectives, scope of work, and information necessary to meet DOD’s goals and objectives, DOD’s current effort might not produce the desired results. After discussing this issue with DOD officials, in December 2007 officials in OUSD (AT&L)’s chemical and biological defense office stated that they plan to revise the task order’s statement of work, concept of operations plan, and a DOD implementation plan to clarify the scope of work and the focus of the research to servicemembers—the original focus as identified in the Defense Authorization Act for FY 2003. Until recently, DOD’s current effort has lacked adequate oversight of the contractor activities and results. We have previously reported that providing effective oversight is essential and, at times, DOD’s oversight was wanting, as it did not always task personnel with oversight duties or establish clear lines of accountability. While OUSD (AT&L)’s chemical and biological defense office established three different points of contact throughout the life of the task order who participated in meetings when the work started in 2004 and assisted the contractor undertaking the effort in accessing repository sites when requested, these points of contact were not performing active oversight activities nor were they designated as the project manager for this effort. During our review, officials in OUSD (AT&L)’s chemical and biological defense office realized that their predecessors had not selected a project manager and selected one of the office’s civilian employees to oversee the effort. We also found that DOD had not visited any of the repository sites where the contractor had proposed or completed its research to ensure that the work was effectively and efficiently meeting the task order’s objectives. We visited the three repository sites where the contractor was conducting its work during our review. At one location, a knowledgeable DOD official expressed concerns to us that the contractor’s presence and research in one of the site’s libraries might not be needed. However, since officials in OUSD (AT&L)’s chemical and biological defense office had not visited the site or met with site officials, they were unaware of these concerns and therefore were unable to decide whether the contractor should be conducting work at that particular site or whether the research funds and time should be spent at a site that they believe might provide more relevant information. In addition, until June 2007, OUSD (AT&L)’s chemical and biological defense office had not regularly evaluated the effectiveness or efficiency of the contractor’s work. For example, at the time of our review, officials in OUSD (AT&L)’s chemical and biological office told us that they did not know the extent to which each of the task order’s four tasks was meeting its objective to identify servicemembers and civilians who were potentially exposed to chemical or biological substances during testing and other activities. Therefore, DOD was not in a position to determine whether the task order needed to be modified to focus DOD’s resources and the contractor’s research efforts to those tasks that will best meet its objectives. Further, while the contractor had implemented its own quality assurance/quality control process that was approved by OUSD (AT&L)’s chemical and biological defense office, the office had not taken any action to independently assess the accuracy and characterization of the information that the contractor was providing to the OASD (HA), which maintains DOD’s databases of potentially exposed individuals. As a result, officials in OUSD (AT&L)’s chemical and biological defense office, who are responsible for overseeing the contractor’s efforts, have limited knowledge about the accuracy and characterization of the information that was being collected. Review and assessment of the contractor-provided data by the project manager are important because we identified potential problems with the accuracy of that information. For example, our work indicated that there are discrepancies between the number of individuals reported by the contractor in its monthly reports to OUSD (AT&L)’s chemical and biological office and the number of individuals that exist in OASD (HA)’s database that could not be adequately explained. In addition, at the time of our review, the characterization in the contractor’s monthly reports provided to OUSD (AT&L)’s chemical and biological defense office that all of these individuals were potentially exposed during chemical or biological tests gave the wrong impression to the project manager. For example, while the contractor has characterized the individuals it has identified as having been involved in DOD’s chemical and biological “tests”, an unknown number of these exposures resulted from immunizations, transportation, occupational, and storage accidents. This number also includes individuals who might have been associated with the tests but who were not exposed to any substances, such as those who participated in physical exercises to test the durability of chemical and biological suits or who could have been part of a test control group. OASD (HA) officials were able to identify at least 1,800 names in the database that were not exposed to any substances, which leaves about 7,100 names in the database that have been potentially exposed to chemical or biological substances, as shown in table 2. DOD and contractor officials stated that they have included these names in the database so that they could appropriately respond to these individuals’ concerns if they contact DOD or VA. Specifically, according to DOD, including these names in the database enables the department to refute any claims by individuals who participated in tests where they were not exposed to any chemical or biological substances. We identified a variety of factors affecting the ability of OUSD (AT&L)’s chemical and biological defense office to provide oversight, including a lack of consistent leadership, inadequate internal controls, a shortage of personnel, and a lack of defined roles and responsibilities. For example, the position that was identified as the office’s point of contact for the task order is a 1-year position. Consequently, the contractor has had to work with three different individuals during the first 3 years of the task order. The official holding this position during our review requested and was granted a 2-year extension in this position, and thus he has been able to implement a number of internal controls to improve the oversight and accountability of this project. In addition, until September 2007, the respective roles and responsibilities of OUSD (AT&L)’s chemical and biological defense office and OASD (HA) had not been clearly identified. In September 2007, in response to our review, OUSD (AT&L)’s chemical and biological defense office and OASD (HA) signed an implementation plan that identified their respective roles and responsibilities. In planning, executing, and evaluating DOD’s current effort, OUSD (AT&L)’s chemical and biological defense office did not fully leverage the work of other entities that had previously identified exposed individuals. Multiple DOD and non-DOD organizations have conducted a variety of independent efforts since the early 1990s, through which they have identified thousands of individuals who were potentially exposed during chemical or biological tests. These entities possess specific information about the tests—to include the location of test records—and the personnel conducting the work developed institutional knowledge. While OUSD (AT&L)’s chemical and biological defense office leveraged Project 112 information from the OASD (HA), it did not leverage information available from other DOD and non-DOD sources. For example, between 1993 and 1997, the joint DOD-VA task force identified approximately 6,400 individuals who were potentially exposed to sulfur mustard, lewisite, and other chemical substances. OUSD (P&R) led the effort by using some of its own personnel to conduct the research and visit several repository sites in addition to issuing a task order for a contractor—the same contractor DOD is currently using to research and identify tests and exposures—to develop a database containing information on the location, chemicals tested, and dates of the chemical weapons research program. 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. OUSD (P&R) officials transferred the names of the individuals who were identified to OASD (HA) officials in April 2005. 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. Furthermore, as a result of independent research efforts by the Institute of Medicine about the health effects of DOD chemical tests using human subjects, the organization developed a database that contained the names and addresses of more than 4,000 servicemembers who were potentially exposed to chemical substances during a series of tests at Edgewood, Maryland. However, OUSD (AT&L)’s chemical and biological defense office was not aware of this database since the office had not coordinated with the organization. Institute of Medicine officials told us that they believe the names and contact information in this database could help DOD with its efforts since the names were collected from the same locations where the contractor for DOD’s current effort is doing its research. Subsequent to our September 2007 meeting with the Institute of Medicine, its officials contacted OASD (HA) to establish the protocols to transfer the names of identified individuals to DOD so that it can determine whether these individuals are already included in any of DOD’s databases. Without communicating and coordinating with DOD and non- DOD organizations that have previously conducted similar efforts, DOD’s current effort will not be able to take advantage of existing information so that it can focus its resources on the areas where information is missing. DOD’s current effort lacks transparency since it has not worked with veterans, and it has not kept Congress and veterans service organizations fully informed about the status of its efforts. Although DOD officials conducted outreach to veterans during its Project 112 research effort and the Defense Authorization Act for FY 2003 required DOD to work with veterans and veterans service organizations to identify projects and tests outside of Project 112 that may have exposed members of the armed forces to chemical and biological substances, DOD has not included veterans and veterans service organizations during its current effort. DOD also has not kept Congress, veterans, and the public informed on the status of its current effort as it did during its Project 112 investigation. Specifically, in 2002, DOD established a public internet site to provide interested persons with information on what happened during those tests that might have affected the health of those who served. The internet site included a status report on DOD’s efforts so that veterans and others could monitor the progress, and it also contained reports, documents, and links to related internet sites. The internet site, which was operated by OASD (HA), has not been updated with information about DOD’s current effort to identify individuals outside of Project 112. Representatives from a veterans service organization that has pursued information regarding DOD’s use of servicemembers as human subjects told us they were not aware of DOD’s current effort and they believe DOD has not been transparent and forthcoming with the information that it has obtained. These officials stated that the continuous lack of collaboration and transparency has negatively affected the level of trust veterans and the veterans service organization have in DOD regarding its commitment to fully identify and disclose information regarding these tests. The representatives stated that it is imperative for DOD to be as transparent as possible so that Congress, veterans, and the public have reason to believe the cloak of secrecy regarding these tests has been lifted and individuals who were potentially exposed could receive appropriate medical care and benefits. DOD officials acknowledged the importance of keeping veterans informed so that they know that these tests are no longer classified, they are entitled to a medical screening for long-term health effects, and they can assist in DOD’s efforts to identify other individuals who might have been exposed. Until DOD is more transparent about its efforts to identify individuals who were potentially exposed during these previously classified tests, Congress, veterans, and the public could have reason to believe that the cloak of secrecy has not been lifted and not realize the reasonableness, effectiveness, success, and challenges of DOD’s current effort. DOD and VA have had limited success in notifying individuals who were potentially exposed to chemical and biological substances during Project 112 tests or testing that occurred outside of Project 112 due to several factors. First, DOD has inconsistently transmitted information about identified servicemembers to VA. Second, VA has not used all available resources to obtain contact information for servicemembers who were identified as having been potentially exposed. Finally, DOD has not taken any actions to notify civilians who have been identified. While DOD and VA have a process in place to share the names of servicemembers who are identified as having been potentially exposed to chemical and biological substances, the transmission of information between the two agencies has been inconsistent. To date, DOD has provided information to VA as agreed upon through an informal arrangement. Under the arrangement, DOD generally provides VA with the servicemember’s name, as well as any information related to the potential exposure that DOD uncovered during its investigation, such as the chemical or biological substance that was used, the dosage of the chemical or biological substance, and the date of the exposure. As of October 2007, DOD had used this process to transmit to VA approximately 20,700 names of servicemembers who had been potentially exposed to chemical or biological substances. The informal arrangement between DOD and VA did not establish a schedule for the exchange of information, so DOD provides newly acquired exposure information to VA in batches of varying size and at inconsistent intervals. When we began our work we found that DOD had not provided VA with any updates after September 2006 even though, as of June 2007, DOD had added approximately 1,800 additional servicemember names to its chemical and biological exposure database. Subsequent to our inquiries, however, DOD provided VA with an update in September 2007. According to DOD officials, regular updates to VA have been delayed because of a number of factors, including competing priorities such as current military operations, lack of personnel, database management issues, and lack of an impetus to take a proactive approach. Although limited personnel and competing priorities might be valid issues, until DOD provides regular updates of identified servicemembers to VA in a timely manner, VA will be unable to notify identified veterans about their potential exposure to chemical or biological substances. VA has not used certain available resources to obtain contact information for and to notify veterans who were identified as having been potentially exposed to chemical or biological substances. To notify veterans who were potentially exposed to chemical or biological substances during DOD tests, VA matches the list of potentially exposed veterans it obtains from DOD against its own database of veterans to find either contact information or a Social Security number. If no Social Security number is located, VA matches the available veterans’ information to information contained in the National Personnel Records Center. Once a Social Security number is obtained, VA usually uses a private credit bureau and on occasion has used the Internal Revenue Service database to obtain contact information for the veteran. In responding to a draft of this report, VA notes that it uses the credit bureau for a variety of reasons, including its up-to-date data transmissions from the Social Security Administration, expedience in responding, and general accuracy of information. As shown in table 3, as of December 2007, VA had obtained contact information for and sent notification letters to 48 percent of the names that DOD provided to them and that they may be able to contact. VA officials noted that while the total number of notification letters sent is 48 percent of the number of names that DOD has provided to them and that they may be able to contact, it represents all of the individuals for whom they were able to obtain contact information. A number of factors beyond VA’s control have impeded its ability to notify veterans of their potential exposure to chemical or biological substances. For example, some records have been lost or destroyed, and existing documentation contains limited information and often does not identify names of participants, while others were not turned in by the scientists who were conducting the research. When the records can be found, they do not necessarily identify the participants, but may instead refer to control numbers that were issued to the participants, which cannot be cross-referenced to other documents for identification. For those records that do include identification of participants, the information may contain only the participants’ initials, nicknames, or only first or last names. Also, since a number of these records do not include the participant’s military service number or social security number, it is difficult to determine the exact identity of these individuals. Further, the contact information that VA is able to obtain may not be accurate. For example, more than 860 notification letters have been returned as undeliverable to VA. However, VA is not using other available resources to obtain contact information to notify veterans. For example, while VA told us that it was using a company that is able to provide current contact information as a source, it had not coordinated with the Social Security Administration to obtain contact information for veterans receiving social security benefits or to identify deceased veterans using the agency’s death index and had not regularly used the Internal Revenue Service’s information. VA officials acknowledged that they had not directly used the death index and that a memorandum of understanding with the Social Security Administration might facilitate a new way to accomplish this. However, they noted the credit bureau receives weekly updates from the Social Security Administration’s death index. VA officials also acknowledged that it planned to make more frequent use of IRS databases. Until VA implements a more effective process to obtain contact information for veterans, some veterans will remain unaware of their potential exposure or the availability of health exams and the potential for benefits directly related to an exposure. DOD has not taken any actions to notify civilians who have been identified as having been potentially exposed during Project 112 tests and other chemical and biological tests, due in part to a lack of specific guidance defining the requirements to notify civilians. The Defense Authorization Act for FY 2003 required DOD to identify its tests or projects that may have exposed members of the armed forces to chemical or biological substances, but did not specifically address civilian personnel who may have been affected by these tests. However, in our 2004 report we recommended that DOD address the appropriateness of and responsibility for reporting new information, such as the identification of additional potentially exposed servicemembers, civilian employees, contractors, and foreign nationals who participated in the tests. In its response to our report, DOD concurred with our recommendation and stated that it would determine the appropriate reporting channels for civilian employees, contractors, and foreign national participants who were identified as being potentially exposed. However, DOD has not taken any action with the approximately 1,900 civilian names that it maintains, as shown in table 4. Instead, DOD has focused its efforts on the identification and notification of servicemembers who were potentially exposed. DOD officials stated that they have focused on identifying and notifying servicemembers since the primary impetus for their efforts to identify and notify individuals who may have been exposed has been requests for information from veterans and VA. OASD (HA) has not acted in part because it is unclear whether it is required to notify civilians or transmit civilian exposure information to another agency for notification. During our review, DOD and Department of Labor officials stated that they were unaware of a requirement for them to notify civilians of their potential exposure. However, our April 2005 report about civilian and contractor exposures to chemical substances in Vietnam identified compensation programs that might be available for civilians who were exposed during these chemical and biological tests if they come forward and present evidence that they were potentially exposed. Specifically, federal employees can file claims for workers compensation with their employing agency, which refers the claims to the Department of Labor under the Federal Employees Compensation Act. Employees who work under contract to the U.S. government can file workers compensation claims through their employers with the employers’ insurance carrier. Without an effort to develop and provide guidance for notifying civilians, those civilians who have been identified may not be aware of their potential exposure. Since World War II, potentially tens of thousands of military personnel and civilians have been exposed to chemical or biological substances during previously classified DOD tests. As this population becomes older, it will become more imperative for DOD and VA to identify and notify these individuals in a timely manner because they might be eligible for health care or other benefits. While DOD has concluded that continuing an active search for individuals potentially exposed during Project 112 has reached a point of diminishing returns, it has not conducted an informed cost- benefit analysis, which could guide DOD in identifying the extent to which it might need to take additional actions. Without conducting a sound and documented cost-benefit analysis that includes a full accounting of information known and the challenges associated with continuing to search for Project 112 participants, DOD will not be in a position to make an informed and transparent decision about whether any of the remaining investigative leads could result in meaningful opportunities to identify additional potentially exposed individuals. Furthermore, until DOD conducts such an analysis, Congress, veterans, and the public may continue to question the completeness and accuracy of DOD’s efforts. Moreover, while DOD has undertaken efforts to identify and notify individuals who were potentially exposed during tests outside of Project 112, the department has not worked with veterans and veterans service organizations during its current effort as required by the Defense Authorization Act for FY 2003, and it has not coordinated its efforts with other DOD and non-DOD organizations. Until DOD and VA undertake more effective and efficient efforts to identify and notify potentially exposed individuals—including consistent guidance about the scope of work, such as clearly defined goals and objectives and agreement on the type and amount of information that is necessary to collect; effective internal controls and oversight practices; coordination with other entities to leverage existing information; regular updates to VA; and utilization of all available resources—Congress, veterans, and the public may continue to question DOD and VA’s commitment to this effort. Furthermore, in the absence of transparency about these previously classified tests and DOD’s efforts to identify individuals who were potentially exposed, Congress, veterans, and the public could have reason to believe that the cloak of secrecy has not been lifted and may not understand the success and challenges of DOD’s current effort. While DOD and VA have developed a process for notifying servicemembers who were potentially exposed, it is unclear whether DOD or any other agency, such as the Department of Labor, is required to notify potentially exposed civilians who are identified. Therefore, without specific guidance that defines the requirements, roles and responsibilities, and mechanisms to notify civilians who have been potentially exposed to chemical or biological substances, these individuals might continue to be unaware of their circumstances. We are suggesting the Congress consider the following two matters: 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 should 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. Our draft report addressed this recommendation to the Secretary of Defense; however, because DOD disagreed, we elevated this to a matter for congressional consideration. 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 should 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. To ensure a sound and documented process for DOD’s decision regarding the identification of individuals associated with Project 112, we recommend that the Secretary of Defense 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. 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, we recommend that the Secretary of Defense direct the Office of Under Secretary of Defense for Acquisition, Technology, and Logistics to take the following four actions: 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; 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; coordinate and communicate with other entities that previously identified exposed individuals to leverage existing information, including institutional knowledge and documents; and make its efforts transparent with regular updates to Congress, the public, and veterans service organizations. To ensure that DOD has taken appropriate action in its efforts to notify servicemembers who were potentially exposed, we recommend that the Secretary of Defense 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. To ensure that all veterans who have been identified as having been potentially exposed to chemical or biological substances have been notified, we recommend that the Secretary of Veterans Affairs 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. We requested comments from DOD, VA, and the Department of Labor on a draft copy of this report. DOD generally agreed with five recommendations, but disagreed with the first recommendation to conduct and document a cost-benefit analysis associated with continuing the search for additional Project 112 participants, and to provide Congress with the results of this analysis. VA agreed with one recommendation and partially agreed with another recommendation that pertained to its activities. The Department of Labor did not provide us any comments. Because DOD disagreed with the recommendation to conduct and document a cost-benefit analysis associated with continuing the search for additional Project 112 participants and has 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. DOD and VA also provided technical comments, which we incorporated as appropriate. DOD’s and VA’s comments are reprinted in appendices II and III, respectively. DOD agreed to and has in some cases begun taking action to respond to five of the recommendations. Specifically, DOD stated that it has already coordinated on updating program goals and objectives for the identification of individuals who were potentially exposed during chemical and biological tests outside of Project 112 and is revising the statement of work, implementation plan, and concept of operations to ensure consistent guidance and deliverables. DOD also stated that it has taken steps to increase oversight of the project and has established an implementation plan with OASD (HA) delineating oversight responsibilities. In addition, DOD stated that it will take steps to determine if other organizations are conducting similar work to identify potentially exposed individuals and will coordinate and leverage all available information. The department also stated that it will expand its current efforts to update the public and make efforts more transparent. Finally, DOD and VA are in the process of discussing short-term and long-term improvements necessary for improving the transfer of information to VA in a timely and effective manner. We believe these are positive steps that, when completed, will address the intent of our recommendations. DOD did not agree with the first 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 has disagreed with our recommendation and has not adequately addressed our May 2004 recommendation to determine the feasibility of addressing unresolved issues associated with Project 112, we have added a Matter for Congress to consider directing the Secretary of Defense to conduct such an analysis. In response to our recommendations, VA agreed to work with DOD to modify the guidance about the scope of work for its current effort to clearly define consistent, reasonable, and acceptable goals and objectives; and the types and amount of information that will need to be collected to meet these goals and objectives. VA also agreed to contact the Internal Revenue Service to determine if a more timely response can be obtained from them to assist VA in notifying individuals potentially exposed to chemical or biological substances. We believe these steps are consistent with the intent of our recommendations. However, VA disagreed with a part of our recommendation that it needs to pursue information from the Social Security Administration since the credit bureau that VA uses to obtain contact information already receives the same information from the Social Security Administration. Accordingly, we adjusted our recommendation to the Secretary of Veterans Affairs so that it did not refer to the Social Security Administration as another source of information. We are sending copies of this report to other interested congressional committees, the Secretary of Defense, the Secretary of Veterans Affairs, and the Secretary of Labor. We will also make copies available to others upon request. In addition, the report will be available at no charge on the GAO Web site at http://www.gao.gov. If you have any questions about this report, please contact me at (202) 512-5431 or dagostinod@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made contributions to this report are listed in appendix IV. To assess the Department of Defense’s (DOD) efforts since 2003 to identify servicemembers and civilians who may have been exposed to chemical or biological substances used during tests conducted under Project 112, we reviewed and analyzed documents pertaining to Project 112, including DOD’s 2003 Report to Congress: Disclosure of Information on Project 112 to the Department of Veterans Affairs. We interviewed officials at the Office of the Secretary of Defense, Washington, D.C., including the Under Secretary of Defense for Acquisition, Technology, and Logistics, and the Under Secretary for Personnel and Readiness. We also interviewed officials at the Office of the Assistant Secretary of Defense for Health Affairs who were responsible for conducting DOD’s investigation of Project 112 tests and have been designated as the single point of contact for providing information related to tests and potential exposures during Project 112. We interviewed officials at the Institute of Medicine and reviewed their 2007 report on the long-term health effects of participation in the shipboard hazard and defense tests of Project 112. In addition, we reviewed and analyzed our prior reports as well as reports of other organizations to provide a historical and contextual framework for evaluating DOD’s efforts. To evaluate DOD’s current effort to identify servicemember and civilian exposures that occurred during activities outside of Project 112 tests, we reviewed and analyzed reports, briefings, and documents and interviewed officials at the Office of the Secretary of Defense, Washington, D.C., including the Under Secretary of Defense for Acquisition, Technology, and Logistics and the Under Secretary of Defense for Personnel and Readiness. We also interviewed officials at the Office of the Assistant Secretary of Defense for Health Affairs, who have been designated as the single point of contact for providing information related to tests and potential exposures outside of Project 112. In addition, we interviewed officials at the U.S. Army Medical Research Institute of Infectious Diseases and the U.S. Army Medical Research and Materiel Command, Fort Dietrich, Maryland; the Department of Veterans Affairs, Washington, D.C.; the Institute of Medicine, Washington, D.C.; the Vietnam Veterans of America, Silver Spring, Maryland; and DOD’s contractor currently conducting research to identify potential exposures that occurred outside of Project 112. We also evaluated DOD’s methodology for identifying servicemembers and civilians who may have been exposed to chemical or biological substances by observing the process the contractor uses to conduct research at repositories containing documents related to chemical and biological exposures from tests and other activities, such as the transportation and storage of chemical and biological substances. We interviewed officials and observed storage facilities at the three chemical or biological substance exposure record repositories where the contractor was currently conducting its work: Edgewood Chemical and Biological Center Technical Library, Aberdeen Proving Grounds, Maryland; U.S. Army Research, Development, and Engineering Command Historical Office, Aberdeen Proving Grounds, Maryland; and U.S. Army Medical Research Institute of Infectious Diseases Technical Library, Fort Detrick, Maryland. In addition, we interviewed officials and observed the records storage area at the U.S. Army Medical Research Institute of Infectious Diseases Medical Records Office, Fort Detrick, Maryland, where information about Operation Whitecoat is maintained. We also reviewed DOD’s outreach efforts and the extent to which DOD coordinated with other agencies that might have useful information, including the Department of Veterans Affairs (VA), the Department of Labor, the Institute of Medicine, and the Vietnam Veterans of America. To evaluate VA’s process to notify servicemembers whom DOD has determined may have been exposed to a chemical or biological substance, we interviewed VA officials with the Veteran’s Benefit Administration, Veteran’s Health Administration, and Office of Planning and Policy, and gathered data concerning their success in making notifications. In particular, we documented the number of servicemembers whose names had been provided to VA by DOD, the extent to which notification letters were sent, the extent to which veterans were deceased, and the number of cases where sufficient documentation was not available to obtain contact information to make notifications. We assessed the reliability of DOD’s and VA’s data by interviewing agency officials knowledgeable about the data and by reviewing existing information about the data and the systems used to maintain and produce them. Although we found that there were potential problems with the quality and reliability of the information, we determined that the data were sufficient for the purposes of this report. We conducted this performance audit from June 2007 to February 2008 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. In addition to the contact named above, Robert L. Repasky (Assistant Director), Tommy Baril, Renee S. Brown, Brian D. Pegram, Steven Putansu, Terry L. Richardson, and Karen Thornton made key contributions to this report. Agent Orange: Limited Information Is Available on the Number of Civilians Exposed in Vietnam and Their Workers’ Compensation Claims. GAO-05-371. Washington, D.C.: April 22, 2005. Chemical And Biological Defense: DOD Needs to Continue to Collect and Provide Information on Tests and Potentially Exposed Personnel. GAO- 04-410. Washington, D.C.: May 14, 2004. Human Experimentation: An Overview on Cold War Era Programs. GAO/T-NSIAD-94-266. Washington, D.C.: September 28, 1994. Veterans Disability: Information From Military May Help VA Assess Claims Related to Secret Tests. GAO/NSIAD-93-89. Washington, D.C.: February 18, 1993.
summary: 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.