For example, it was unable to follow up on more than 1,200 toll-free calls received on DOD’s hot line with Gulf War veterans. Specifically, we were asked to (1) describe DOD’s progress in establishing an organization to address Gulf War illnesses issues and (2) evaluate the thoroughness of OSAGWI’s investigations into and reporting on veterans’ potential exposure to chemical or biological agents during the Gulf War. In addition, OSAGWI is actively engaged in identifying improvements DOD needs to make to protect servicemembers on contaminated battlefields. Our review confirmed that OSAGWI has made significant progress in establishing communications with veterans and others. OSAGWI also publishes a bimonthly newsletter called GulfNEWS. OSAGWI is presently working with DOD agencies to implement the lessons learned. OSAGWI generally followed its investigation methodology and used appropriate investigative procedures and techniques. Also, OSAGWI did not use DOD or Department of Veterans Affairs medical databases on Gulf War illnesses in conducting any of the six investigations. In three of the six case narratives, we found investigative problems such as failures to (1) follow up with appropriate individuals to confirm key evidence, (2) identify or ensure the validity of key physical evidence, (3) include important information, and (4) interview key witnesses. During our review, OSAGWI found a printout from one of these tests in its files, but it was negative for chemical agent. Despite the investigation’s shortcomings, we believe that OSAGWI’s assessment of “likely” exposure to a chemical warfare agent in this case is reasonable. Our Review of OSAGWI’s Investigation

OSAGWI overlooked a key piece of evidence and did not report other significant information in its case narrative. However, this information was not reported in OSAGWI’s narrative. In our opinion, the lack of effective quality assurance policies and practices within OSAGWI contributed to the weaknesses we noted. Recommendations

To ensure that OSAGWI’s case narratives contain all relevant facts, we recommend that the Secretary of Defense 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 and/or unreported information noted in our report and 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. To enhance the thoroughness of OSAGWI’s investigative and reporting practices, we recommend that the Secretary of Defense 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; include relevant medical information in its case narratives where it is needed to fully explain incidents of possible exposure to chemical agents or other potential causes of Gulf War illnesses; and 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.
Why GAO Did This Study

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.

What GAO Found

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.