STATEMENT OF
DENNIS MICHAEL DUGGAN, DEPUTY DIRECTOR
NATIONAL SECURITY/FOREIGN RELATIONS
COMMISSION
BEFORE THE
SUBCOMMITTEE ON TOTAL FORCE
COMMITTEE ON ARMED SERVICES
UNITED STATES HOUSE OF REPRESENTATIVES
ON
FORCE HEALTH PROTECTION AND SURVEILLANCE IN
THE GLOBAL WAR ON TERRORISM
FEBRUARY 25, 2004
Chairman McHugh and Members of the
Subcommittee:
The
American Legion, as the Nation's largest
organization of wartime veterans, is pleased
to appear before this Subcommittee to
express its concerns with regard to the
Department of Defense Force Health
Protection (FHP) and surveillance efforts
for service members deployed to Operation
Enduring Freedom and Operation Iraqi
Freedom. The American Legion is supportive
not only of veterans, but national security
issues and military quality of life concerns
of the active duty military, Guardsmen,
Reservists, military retirees, and their
families. A lot of our first-hand
observations come from the immediate
families of Guardsmen and Reservists who
have either deployed or have returned from
deployments. Since the Persian Gulf War,
The American Legion's Family Support Network
has worked with literally tens of thousands
of service members and their families.
As
American military forces are once again
engaged in combat overseas, the health and
welfare of deployed troops is of utmost
concern to The American Legion. The need
for effective coordination between the
Department of Veterans Affairs (VA) and the
Department of Defense (DOD) in the force
protection of U.S. forces is paramount. It
has been thirteen years since the first Gulf
War, yet many of the hazards of the 1991
conflict are still present in the current
war.
A
pretreatment for the nerve agent soman,
pyridostigmine bromide (PB), was approved by
the Food and Drug Administration just prior
to the start of Operation Iraqi Freedom.
Although its effectiveness is questionable,
and it has not been ruled out as a possible
cause of multi-symptom illnesses reported by
thousands of Gulf War veterans, this
treatment turned out to be unnecessary;
however, PB available for use at commanders'
discretion. The contentious anthrax vaccine
is also being administered to deployed
personnel and controversial depleted uranium
munitions continue to play a large role in
American combat operations.
Although Chemical and
biological weapons have not been used
against American troops in Afghanistan and
Iraq, the potential for such an attack in
future operations and deployments still
exists. The American Legion is
concerned about the ability of American
military forces to operate and survive in a
nuclear, biological or chemical (NBC)
environment. During the 1991 Gulf War,
the thousands of chemical detection alarms
were later reported as "false alarms."
The ability to properly detect the presence
of NBC agents in the area of operation
remains a grave concern.
Just
prior to Operation Iraqi Freedom, questions
surfaced around DOD's ability to properly
identify, track and locate defective
chemical protective suits. In October
2002, the General Accounting Office (GAO)
reported that in May 2000, DOD ordered
storage depots and units to locate 778,924
defective suits produced by a single
manufacturer. As of July 2002,
military officials were unable to account
for 250,000 defective suits.
Responding to an American Legion inquiry,
officials from the Deployment Health Support
Directorate reported they "believed" the
remaining defective suits had either been
destroyed or used in training activities.
The difficulty in locating the defective
suits was a result of inventory records
lacking contract and lot numbers. GAO
also reported that DOD could not determine
whether its older suits would adequately
protect military personnel because some of
the systems' records do not contain data on
suit expiration. Finally, GAO reported
that the risk of shortages of protective
clothing might increase dramatically from
the time of its report (October 2002)
through at least 2007.
Prior to the 1991 Gulf War
deployment, troops were not systematically
given comprehensive pre-deployment health
examinations, nor were they properly briefed
on the potential hazards, such as fallout
from depleted uranium munitions, that they
might encounter. Record keeping was poor.
Numerous examples of lost or destroyed
medical records of active duty and reserve
personnel were identified. Vaccines were not
administered nor recorded in a consistent
manner and records were often unclear or
incomplete. Moreover, personnel were often
not provided information concerning
vaccinations or prescribed medications.
Some medications were distributed with
little or no documentation, including dosage
instructions, information on possible side
effects or instructions for service members
to immediately report unexpected side
effects to medical personnel.
Physical examinations (pre-
and post-deployment) were not comprehensive
and information regarding troop
movements/locations and possible
environmental hazard exposures was severely
lacking. The lack of such baseline data and
other information is commonly recognized as
a major limitation in the evaluation and
understanding of potential causes of the
unexplained multi-symptom illnesses,
referred to collectively as Gulf War
veterans' illnesses, still plaguing
thousands of Gulf War veterans thirteen
years after the war. Although the
government has conducted more than 230
research projects, at a cost of more than
$240 million, lack of crucial deployment
data has resulted in many unanswered
questions. Unfortunately, many questions
will probably never be answered.
The goal of DOD's FHP
policies and programs is to promote and
sustain the health of service members during
their entire length of service. On the
surface, the FHP concept and related
policies appear to have addressed the major
problems of the past. Unfortunately,
reality may be a different story. In
previous congressional testimony, officials
from GAO reported that although DOD placed
the responsibility for implementing its FHP
policies with a single authority, the Deputy
Assistant Secretary of Defense for Force
Health Protection and Readiness, each
service branch is ultimately responsible for
implementing DOD initiatives and policies to
achieve FHP goals. GAO noted that this
caused concerns about how the services would
uniformly collect and share core data on
deployments and how DOD will integrate
information on the health status of service
members. According to GAO, DOD officials
also verified that its medical surveillance
policies and efforts depend on the priority
and resources dedicated to their
implementation.
The American Legion would
like to specifically identify an element of
FHP that deals with DOD's ability to
accurately record a service member's health
prior to deployment and document or evaluate
any changes in his or her health that
occurred during deployment. This is exactly
the information VA needs to adequately care
for and compensate service members for
service-related disabilities once they leave
active duty. Section 765 of PL 105-85
directed DOD to take specific actions to
improve medical tracking for personnel
deployed overseas in contingency or combat
operations, outlining a policy for pre- and
post-deployment health evaluations and blood
samples. The conduct of a thorough
"examination" (pre- and post-deployment),
including the drawing of blood samples, was
specifically identified in the law.
DOD initially created a brief
health questionnaire for deploying and
returning service members to fill out,
contrary to the medical examinations as
required by PL 105-85. The pre-deployment
questionnaire, DD Form 2795, contained eight
questions and the post-deployment
questionnaire, DD Form 2796, contained six
questions. The American Legion, in
congressional testimony presented last year
in the early days of Operation Iraqi
Freedom, asserted that a self-reported
health assessment questionnaire is not of
the same value as an examination conducted
by a physician or other medical officer.
Self-reported health assessment is not
necessarily an accurate, or reliable gauge
of an individual's health status prior to or
following deployment.
In response to immense
concern over the brevity and usefulness of
the health questionnaire, the Under
Secretary of Defense for Personnel and
Readiness issued an "enhanced"
post-deployment questionnaire (DD Form 2796)
on April 22, 2003. The pre-deployment
questionnaire was not changed. Upon review,
The American Legion did not see any
significant changes. Although the new
version is more detailed than the previous
one, it still does not fulfill the
requirement of "thorough" medical
examinations nor does it even require a
medical officer to administer the
questionnaire or counsel participating
personnel. The Under Secretary's guidance
to combatant commanders specifically states
that, in addition to a physician, physician
assistant, or nurse practitioner, an
enlisted independent duty corpsman or
independent duty medical technician are also
authorized to administer the questionnaire.
This means that an actual physician or other
medical officer may not even be part of the
post-deployment health assessment process in
at least some, if not most, instances. This
is unacceptable.
Although DOD, as part of the
"enhanced" post-deployment health
assessment, now requires a blood sample be
obtained from returning personnel no later
than 30 days after arrival at their home
station or demobilization site, DOD still
relies on blood samples taken for human
immunodeficiency virus (HIV) tests to
fulfill the pre-deployment blood drawing
requirement of PL 105-85. According to DOD
procedure, deploying military personnel must
be tested and found negative for HIV no more
than 12 months before deployment on
contingency operations. Although a specimen
of serum used for this testing is stored at
the DOD Serum Repository, the pre-deployment
sample could be up to a year old, or older,
and would, therefore, not be an accurate
gauge of health immediately prior to
deployment. This is unacceptable and should
be re-evaluated.
According to DOD policy,
commanders are responsible for ensuring
compliance with and implementation of FHP
programs and policies. In the fall of 2003,
GAO reported on the Army and Air Force's
compliance with DOD's FHP and surveillance
requirements for personnel deploying in
support of Operation Joint Guardian in
Kosovo and Operation Enduring Freedom in
Central Asia. GAO reviewed selected Army
and Air Force bases, medical records of
1,071 service members (from a universe of
8,742) participating in these operations.
GAO found noncompliance with FHP and
surveillance policies for many active duty
service members. This included required
pre- and post-deployment health assessments,
required immunizations and failure to
maintain health-related documentation in a
centralized location. Of the records
reviewed, 38 to 98 percent were missing one
or both of the pre- and post-deployment
health assessments. The review also found
that as many as 36 percent were missing two
or more required immunizations. This is
unacceptable and a disservice to these
service members.
Additionally noted, many
service members' medical/health records did
not include health assessments found in
DOD's centralized database nor did DOD
maintain a complete centralized database of
service members' health assessments and
immunizations. GAO concluded the
noncompliance problems it uncovered were the
result of the absence of an effective
quality assurance program at the Office of
the Assistant Secretary of Defense for
Health Affairs or at the Army or Air Force
and reported that the centralized deployment
database was missing information needed to
track military personnel's movement in the
theater of operations. As of July 2003,
DOD's data center had begun receiving
location-specific deployment information
from the services and was in the process of
reviewing its accuracy and completeness at
the time GAO released its report. The
American Legion is optimistic these
corrections will be made, but believe timely
verification is absolutely necessary.
As a result of its
investigation, GAO recommended DOD establish
an effective quality assurance program to
ensure the military branches comply with the
FHP and surveillance policies for all
service members. DOD agreed with GAO's
recommendation and informed The American
Legion that it will create a Quality
Assurance directorate under its Deployment
Health Support Directorate. Its focus will
be on ensuring compliance with FHP policies
on pre- and post-deployment health
assessments, immunization records and blood
drawing for HIV and post-deployment
assessments. Annual reports will be
submitted to the Assistant Secretary of
Defense for Health Affairs. The American
Legion appreciates DOD's increased efforts
to ensure its FHP policies and programs are
fully and consistently implemented by each
service; however, considering DOD's
checkered history with respect to deployment
health-related matters, The American Legion
remains skeptical of its commitment.
Continued noncompliance with required FHP
policies will result in personnel deploying
with health problems and or encountering
delays and other problems in obtaining
health care and VA benefits when service
members return, not unlike problems
experienced by the veterans of the first
Gulf War. In order to avoid the problems of
the past, DOD must make FHP a real priority
and dedicate the resources necessary to
ensure each service branch is in full
compliance with all policies and
directives.
Although military personnel
participating in Operations Iraq Freedom and
Enduring Freedom have not been exposed to
chemical munitions fallout like their
counterparts in Operation Desert Storm, some
of the experiences have been similar. Once
again, U.S. military forces have used
Depleted Uranium (DU) munitions. While
exposure to DU fallout during Operation
Desert Storm has not been definitively
linked to Gulf War veterans' illnesses, it
has not been definitively ruled out as a
possible cause. The American Legion
supports DOD's DU awareness training
program. Avoiding DU fallout on the
battlefield may be impossible, but informing
troops about potential health hazards and
instructing them to avoid unnecessary risks,
such as entering an enemy vehicle destroyed
by DU munitions, can help minimize potential
health risk. It is vital that DOD conduct
proper oversight to ensure that its DU
education programs are being properly
implemented by all of the military
services.
The controversial anthrax
vaccine continues to be an important part of
the military's FHP program. The American
Legion agrees with DOD's position to
adequately protect military personnel
against the threat of biological weapons
attack, such as anthrax or smallpox.
However, serious concerns with past problems
associated with BioPort, the sole
manufacturer of the vaccine, and the way
adverse reactions are tracked and followed
up by DOD, continue to worry The American
Legion. Problems with BioPort's
manufacturing facility caused a shortage of
FDA approved vaccine, resulting in a
slowdown of DOD's Anthrax Vaccine
Immunization Program (AVIP). It has been
two years since BioPort reestablished FDA
approval. There continues to be a vaccine
shortage resulting in only those service
members on the ground in Southwest Asia for
15 days or more being vaccinated. The
American Legion has long advocated a second
manufacturer of the vaccine, as well as a
newer vaccine, proven for efficacy and
safety, and an inoculation period shorter
that the current six shots.
The anthrax vaccine
controversy has existed since the first Gulf
War. Based on DOD's experience in tracking
anthrax vaccinations, The American Legion is
concerned. DOD claims, only 150,000 troops
actually received the anthrax vaccine.
Because of extremely poor record keeping, it
can only verify vaccinations for less than
10,000. A similar controversy is emerging
regarding the use of the anti-malaria drug
Lariam. Several recent stories in the media
about military personnel experiencing severe
side effects, including depression and other
psychological symptoms, after being
prescribed Lariam. The military is
obligated to follow strict protocol when
administering Lariam, including counseling
and documenting the drug in the service
member's health record, service members have
complained that such procedures have not
been followed.
Lariam is only one of several
anti-malarial drugs currently being used by
the military; it is vital that its
distribution is thoroughly documented to
properly address and track side effects that
may occur. If a service member suffers a
chronic disability as a result of taking
Lariam, but there is no documentation in the
health record, proving service-connection
becomes more difficult. This is especially
true if the disability does not manifest, or
was not identified, while the member was on
active duty.
Due to the duration and
extent of sustained combat in Operations
Iraqi Freedom and Enduring Freedom, the
psychological impact on deployed personnel
is of utmost concern to The American Legion.
The military has counseling available for
those having difficulty coping with the
aftermath of combat and other traumatic
events. DOD needs to actively encourage
troops to take advantage of such services.
Counseling programs are useless unless
service members feel that they can use them
without adverse consequences to themselves
and their careers. It is crucial for
commanders to publicly inform their troops
that treatment and counseling for stress and
psychological problems are okay and no
adverse action will be taken against any
individual seeking that care. Post
Traumatic Stress Disorder (PTSD)
often-manifest months or years after an
individual has been removed from a traumatic
event. There should be periodic follow up
psychiatric evaluations for the active duty
military and reservists upon return. The
military should encourage treatment and
counseling for those returning home. This
is especially important for Reserve and
National Guard personnel who are often
quickly demobilized after returning from a
deployment and do not have the same support
system that is available to their active
duty counterparts.
Military service is
inherently dangerous and certain risks are
to be expected. The American Legion believes
the Federal government is obligated to
provide health care and compensation to
those who sustain chronic disabilities as a
result of such service. Title 38, United
States Code places the burden of proof in
establishing a service-connected disability
on the veteran and establishing service
connection directly impacts the veteran's
ability to access VA health care. VA's
ability to adequately care for and
compensate our nation's veterans depends
directly on DOD's efforts to maintain proper
health records/health surveillance,
documentation of troop locations,
environmental hazard exposure data, and the
timely sharing of this information with VA.
The American Legion remains
appalled at the numbers of Guardsmen and
Reservists who were called to active duty
and not deployable due to existing medical
and dental conditions. Unquestionably, many
Guardsmen and Reservists are included in
that group of 40 million or more Americans
who have no, or limited, medical coverage.
Certainly, fault lies not only with Reserve
Component commanders, but also active duty
commanders for knowingly calling medically
unready and non-deployable Reservists to
active duty status.
For these reasons, The
American Legion is strongly supportive of
the Guard and Reserve Readiness and
Retention Act of 2004, which would make all
Guard and Reserve members and their families
eligible for health coverage through TRICARE
regardless of their mobilization status.
Beneficiaries would pay a modest annual
premium. This change would, we believe,
improve individual and unit readiness and
eliminate the need for Reservists and their
families to change health care providers
when mobilized. There should be a seamless
transition from reserve status to active
status and a seamless transition from DOD to
VA. Also, during periods of mobilization,
Reservists who opt to maintain private
health care coverage, rather than TRICARE,
would receive assistance in paying their
health insurance premiums. This health care
legislation would help with medical
readiness for mobilization and
pre-deployment, but it could also provide
their post-deployment and post-deactivation
health and dental care.
The American Legion strongly
urges that Congress mandate separation
physical exams for all service members,
particularly those that have served in
combat zones or have had sustained
deployments. The American Legion believes
this is essential because of
oftentimes-inadequate medical record keeping
and to ease accessing VA healthcare and
applying for disability compensation and
other veterans programs. DOD reports that
only about 20 percent of discharging service
members opt to have separation physical
exams. Clearly, The American Legion
believes separation physicals should not be
optional. The American Legion understands
many of the reasons to opt out of a
separation physical, but there is ample
evidence to prove the importance these
physicals or lack thereof plays in the VA
claims process. Knowing the final health
status of separating service members is also
in the best interest of public health.
During this war on terrorism and frequent
deployments, with all their strains and
stresses, this figure, we believe, should be
substantially increased.
The American Legion strongly
recommends that field hearings be conducted
throughout the country to hear first hand
accounts from those who served, including
active, guard, reserve and family members to
determine how FHP is working. Further,
these hearings should not be held near large
military installations.
Mr. Chairman, The American
Legion thanks you again for the opportunity
to discuss these important health care
issues for the total force.
