The Gulf War and its veterans' subsequent unexplained symptoms have increased awareness of "dirty battlefield" hazards and their possible impacts on the health and readiness of deployed forces. In the aftermath of the conflict, retrospective investigations and analyses, including this one, have identified deficiencies and gaps in how DoD and the services recognized and responded to non-traditional or unanticipated risk factors, such as toxic industrial materials (including DU). This awareness in turn has produced a major new emphasis on improving medical readiness and force health protection programs aimed at protecting the health, safety, and wellness of deployed US personnel.

While Gulf War exposures to depleted uranium (DU) have not to date produced any observable adverse health effects attributable to DU's chemical toxicity or low-level radiation, the requirement to prevent or minimize unnecessary exposures still stands. DU munitions' and armor's success in the Gulf War has confirmed DU's place in the US arsenal -- and increased the likelihood enemy forces will employ DU munitions in future conflicts. Accordingly, DoD and the services need to ensure that all deployable personnel know what DU is, how it is used, how they might encounter it on the battlefield, the potential effects of overexposure, and how to prevent or minimize personal exposures to comply with the principle of keeping exposures as low as reasonably achievable. This training requirement extends to non-combat medical personnel who could find themselves treating DU casualties or working inside DU-contaminated combat vehicles.

This investigation has identified several findings and observations indicating deficiencies and gaps in both Gulf War policies and procedures dealing with DU and across the readiness domains (doctrine, organizations, training, materiel, or leadership development). OSGAWI's Lessons Learned Implementation Directorate is working with the services and Joint Staff lessons learned programs to remedy past weaknesses and identify and help implement corrective actions to support current medical readiness and force health protection goals.

The formal military "Lessons Learned" process distinguishes between "system failures" (incidents or events that point to significant flaws in policies, procedures, guidance, and training) and "individual failures" (deviations from established guidelines). While it is important to recognize and correct both types of failures, the "system failures" are of greater significance, since they may require fundamental changes to policies, procedures, and the readiness domains listed above. Accordingly, this Section categorizes the described findings, observations, and problems across these domains and as applicable also recommends and summarizes corrective actions and strategies aimed at implementing (and institutionalizing) necessary "fixes."

Military doctrine provides the conceptual and operative guidance governing US forces' operations. At the unit level, tactics, techniques, and procedures (i.e., the ways and means units use to carry out their assigned missions and tasks) put doctrine into practice. Policies are implemented through prescribed procedures the responsible officials and organizations are to carry out.

The US military forces that deployed to the Persian Gulf were organized, equipped, and trained primarily to counter a Soviet-Warsaw Pact attack in Central Europe. The Pentagon expected enemy forces would resort to heavy, offensive use of chemical, biological, and possibly nuclear weapons. Accordingly, wartime doctrine and policies (and force structures, training, materiel, etc.) emphasized readiness to survive and operate despite widespread, lethal "chem-bio" contamination or fallout from tactical nuclear weapons. US doctrine, policies, and guidance (for medical, safety, and environmental-occupational health and operational programs and activities) were less prepared to deal with what personnel actually encountered in the Gulf: low-level exposures to toxic industrial materials such as DU.

During the Gulf War and for several years afterwards, US Army Technical Bulletin (TB) 9-1300-278, "Guidelines for Safe Response to Handling, Storage, and Transportation Accidents Involving Army Tank Munitions or Armor Which Contain Depleted Uranium" was the primary guidance for responding to DU accidents. Developed for peacetime accidents, the Army did not intend this bulletin to directly apply to combat scenarios; therefore it is one of several sources requiring revision to reflect more realistic, operationally sound guidance while providing appropriate safeguards and protective measures. DoD has recognized and is addressing these doctrinal issues within the larger, still-evolving context of "dirty battlefield" hazards. Key Army officials met in April 1998 to discuss organizational roles and responsibilities for low-level radioactivity in operational settings. More recently, the Office of the Special Assistant hosted a working group drawn largely from the Army's Training and Doctrine Command (TRADOC) and Surgeon General's office to address and correct deficiencies in current doctrine, policies, and guidance.

US forces at peacetime bases and installations could rely on fairly robust, well-developed preventive medicine and industrial hygiene support, including radiation protection officers and health physicists operating under peacetime regulatory guidance and programs. In the deployed, operational setting, however, gaps and deficiencies in the organizational response to incidents and accidents involving DU quickly became apparent.

It is beyond this investigation's scope to directly assess deployed organizations' operations and performance of DU-related roles and responsibilities. However, we noted the medical, safety, and environmental health assets that deployed to the Gulf were insufficient, in terms of doctrine, training, and materials, to carry out industrial hygiene and health physics missions, such as supporting large-scale DU remediation efforts. The thrust of radiation safety capabilities was primarily geared to the much higher amounts of radiation associated with tactical nuclear battlefield detonations and not toward the low-level radiation associated with DU contamination.

The post-war ammunition explosion at Camp Doha, Kuwait illustrates the need for faster, more responsive health physics and industrial hygiene support for deployed units. In the first week after that fire damaged or destroyed 660 DU rounds and 3 M1A1 Heavy Armor tanks, the regimental commander lacked the on-site technical expertise, advice, and resources needed to formulate a proper response. Although his nuclear, biological, and chemical (NBC) unit, the 54^th Chemical Troop, was familiar with DU and could carry out limited surveys and clean-up efforts, their effectiveness in this role, for which they lacked the requisite specialized training and equipment, was limited. When radiation control (RADCON) teams did arrive at Doha, days or weeks after the initial fire, their mission was not to support the unit or installation per se, but rather to assess and clean up radiological contamination on the three burned-out M1A1 tanks and collect and prepare the tank hulks and "spent" DU penetrators for shipment back to the US.

The DoD and armed service initiatives now under way, especially those under the auspices of the US Army Industrial Hygiene Program Strategy, are aimed at further defining "dirty battlefield" threats and challenges facing US forces and fielding appropriate capabilities to address them. This process continues and likely will result in organizational changes designed to improve responses to suspected environmentally based health threats.

Authoritative post-war investigations and reports have documented significant shortcomings in military DU training and awareness programs.^[186] DoD acknowledges that DU awareness training was inadequate. Personnel who did not routinely handle DU munitions rarely received DU awareness training or guidance. Consequently, they did not practice the established field safety and hygiene measures (e.g., avoiding the practice of entering Iraq's DU-struck tanks and refraining from collecting battlefield debris) that might have prevented or minimized most exposures to DU contamination.

DoD and the services now recognize the need for sound, appropriate DU training. This training must accurately define DU health effects, which frequently were overstated in pre-war guidance advising imprudent, even dangerous operational measures, or inappropriately lumping DU with deadly radiological threats such as nuclear fallout. These pre-war practices contributed to widespread misconceptions about DU's properties, characteristics, and hazards.

To help address the need for appropriate DU training and awareness, we convened a Tri-Service DU Awareness Working Group, which met for the first time on March 16, 1999. The Working Group brought together staff representatives from each service and the Joint Staff's medical, safety, training, and operational communities to agree on a common framework for improving DU training. DoD recognized the Army as the lead agency for defining DU's hazard potential. The working group agreed that future guidance and training must satisfy two essential requirements -- force health protection and operational effectiveness.

Much of the existing guidance and training satisfied neither requirement. For example, the DU Hazard Awareness Training Support Package–Tier I (for the general soldier audience), fielded in 1997, directed personnel to run a RADIAC meter over casualties to detect any DU contamination before providing treatment. The training video in this package implied that DU radiation is sufficiently dangerous to warrant delaying life-saving medical attention, when this is most emphatically not the case. Similarly, the recommendation to don the MOPP-4 ensemble (chemical protective mask, overgarments, rubber "booties," and gloves) when responding to DU incidents or accidents was excessive. In hot climates like Southwest Asia, wearing MOPP-4 gear can rapidly degrade situational awareness and personal performance and increase the risk of dehydration and heat injury. On the battlefield, these conditions paradoxically could increase the risk of death or serious injury, a risk unwarranted by the relatively insignificant hazard DU poses.

Consequently, the working group suggested the services should shift their emphasis to:

• clearly and accurately characterizing DU's risks;
• telling personnel how they might encounter DU contamination; and
• giving personnel the knowledge they need to operate safely and effectively despite the presence of DU contamination.

To accomplish this shift in awareness, the Tri-Service DU Working Group suggested future training should emphasize this information:

1. DU's primary "hazard" is chemical toxicity, not low-level radioactivity;
2. When handling intact DU armor or unfired DU rounds and in almost all non-combat circumstances, personnel need not take protective measures against depleted uranium contamination;
3. Standard field safety and basic field hygiene procedures will ensure personnel safety;
4. Personnel may need to take protective measures in these circumstances:

• in, on, or near (closer than 50 meters) an armored vehicle when DU munitions struck it;
• near (closer than 50 meters) DU munitions fires (although standard guidance is to stay at least 400 meters away from such fires due to the risk of explosions and blast-fragmentation injuries); and
• spending extended periods (hours daily for many days) entering and working inside DU-damaged vehicles as part of everyday duties.

Using the best available dose assessment and health effects data, the working group also suggested:

1. Brief entries into vehicles hit by DU are safe; and
2. Personnel wounded by DU do not pose a contamination hazard to first responders or treatment personnel, who should never delay first aid and medical treatment because of DU wounds or wound contamination.

The Army's new DU Hazard Awareness Training Support Package–Tier I, fielded in July 1999, incorporates all these points in a new video; the other services will follow suit. In November 1999, the Army fielded Tier II for battle damage and assessment personnel and Tier III for chemical personnel. While these training support packages substantially improve earlier guidance, they are not fully implemented. As such, it is still too early to assess their effectiveness in increasing required DU awareness force-wide.

The Army also has incorporated DU awareness training into the Soldier's Manual of Common Tasks -- the set of core competencies in which every soldier must demonstrate proficiency during individual and unit testing. In concert with mandatory "go/no-go" Common Task Training, the new DU training support packages will provide the primary institutional means of enhancing DU awareness and training among both Army generalists and specialists. Beginning in 2000, the Army also has added DU awareness training to the pre-command course for Army officers, promoting a wider awareness among unit leaders regarding DU's potential hazards and appropriate response to incidents involving DU.

The Marine Corps uses a three-stage DU training continuum:

• The Marine Battle Skills Training Program provides Level I DU training to every entry-level Marine and those Marines taking annual training to sustain battle skills;
• In the second quarter of Fiscal Year 2000, the Marine Corps initiated Level II DU training to military occupational specialties most likely to be exposed to DU;
• In the second quarter of FY 2000, the Marines initiated Level III DU training to leaders to help them gauge and manage operational risk.

The Marines and Navy use a service-specific variant of Army's DU Awareness Training video, supplemented by technical and medical information. The Navy and Marines have sent out fleet-wide safety messages and bulletins advising their personnel of DU's potential hazards.^[187]

In the Air Force, current plans are for all personnel on mobility status (subject to deployment for wartime and contingency operations) to receive DU awareness training. The Air Force has also incorporated DU awareness guidance into its Handbook 32-4014, "Ability to Survive and Operate in a Nuclear, Biological, and Chemical (NBC) Environment," issued to and carried by all deploying Air Force personnel.

The Army also has provided updated DU awareness training to military medical care-givers. The US Army Medical Command broadcast a training video, "Policy for the Treatment of Personnel Wounded by Depleted Uranium Munitions," to a worldwide audience of DoD and VA care-givers in December 1998 and January 1999. The Medical Command is providing the videotape to medical units to incorporate into their training.

To further develop and implement improved DU training, the Office of the Special Assistant spot-checks DU awareness during its outreach visits to Army installations. We bring to the proper officials' attention any noted deficiencies or areas for improvement. We also monitor related efforts, such as GAO's recent assessment of DU training, and then facilitate appropriate DoD action. These spot-checks and GAO's recent check of high-readiness Army units indicate systemic barriers remain to implementing DU awareness training satisfactorily and completely.^[188] Until this training is fully implemented and its success verified through assessment mechanisms, we cannot view long-standing deficiencies in DU awareness and training as fully remedied, although anecdotal evidence continues to indicate a much wider, increasing awareness of DU among personnel and leaders.

Much of the equipment used to respond to DU accidents and incidents in the Gulf was less than optimal in this role. The Fox vehicles used in the initial radiation detection surveys at Camp Doha were inadequate to monitor for depleted uranium; they were designed to detect battlefield chemical agent threats and their crews had had little experience or training in responding to DU contamination.^[189] Similarly, the AN/PDR-27, AN/PDR-77, and AN/VDR-2 RADIAC instruments had limited utility in detecting and measuring the DU's low-level radiation. Although US forces in the Balkans have improved RADIAC equipment, quantities are limited. Future deployments are more likely to encounter low-level radioactive materials (e.g., DU, plutonium 239, tritium, or americium 241) than nuclear weapons' radioactive fallout. DoD currently is addressing the need for improved equipment to detect, measure, and clean up DU contamination.

Specialists with a greater likelihood of encountering DU during their occupational duties (e.g., battle damage assessment and repair teams) require improved light-weight overgarments, respirators, and disposable gloves suitable for all climates.

The Gulf War identified shortcomings in deployment-related health and medical planning and preparedness. While preventive medicine and health care providers were extremely successful in minimizing casualties from disease and non-battle injury, this office's retrospective analyses produced observations and insights indicating systemic deficiencies. Until rectified, these weaknesses could detract from medical and operational readiness in future deployments.

On November 11, 1998, President Clinton directed the Secretaries of Defense, Health and Human Services, and Veterans Affairs to "…create a Military and Veterans Health Coordinating Board to improve the health protection of our armed forces, veterans, and their families. This Board will oversee the implementation of a new interagency plan requiring better medical record keeping, improved health surveillance, advanced research, and enhanced communications about health risks."^[190]

Force health protection and related military medical issues are undergoing a major shift based on the Gulf War's lessons and assessments of future requirements. While the most immediate focus of the military health system is on treating and caring for casualties, that system now is increasingly emphasizing preventive measures, a redirected focus with far-reaching implications on medical support for deployed US personnel.

Force health protection is designed to prevent short- and long-term health effects from exposure to environmental hazards, including depleted uranium, and to clearly and accurately communicate risks. The force health protection "Capstone" document, produced by the Joint Staff J-4 (Logistics) Medical Readiness Division and implemented throughout the Military Health System (MHS), contains the strategic context of force health protection. This strategy integrates preventive medicine, medical surveillance, and clinical programs to protect the total force, and focuses on preventing casualties before, during, and after military operations. Military health and medical services will:

• emphasize fitness, preparation, and preventive measures;
• improve monitoring and surveillance of threats and forces engaged in military operations;
• enhance servicemembers' and commanders' awareness of potential health threats before they can affect the force; and
• support the healthcare needs of the fighting forces and their families across the continuum of medical services.

In hindsight, it is clear that medical care-givers required instruction and training on DU's military use and its implications in treating casualties . In 1990, most combat life-savers, medics, medical care-givers, and clinicians knew little or nothing about DU and therefore rarely recognized, documented, and evaluated DU casualties. The military health service system had not specifically developed or disseminated protocols to guide the appropriate care-givers in processing and treating casualties with embedded DU fragments or DU-contaminated wounds.

In keeping with the first force health protection concept -- fitness, preparation, and preventive measures -- medics, the first line of trained medical responders, now are trained to annotate a casualty card (used to describe injuries) if they suspect DU contamination. Care-givers are learning DU awareness and have established and implemented medical protocols to specifically address treating DU wounds and patients. These protocols, established after extensive medical and scientific consultations, are necessary to safeguard against unnecessary surgery more risky than leaving the DU in place.

In practical terms, the second point -- monitoring and surveillance of threats and forces engaged in military operations -- means tracking and measuring potential hazards and assessing exposures that occur. The Gulf War guidance on medical monitoring and surveillance called for medical personnel to perform bioassays, urinalyses, and other appropriate evaluations for DU intakes suspected of exceeding exposure guidelines. However, during the entire Operation Desert Shield-Desert Storm campaign, medical personnel collected only seven urine samples from potentially exposed personnel. Moreover, the availability and use of local, in-theater and out-of-theater health physics and industrial hygiene expertise (or other radiation safety support) was very limited. The number and magnitude of DU incidents and accidents simply outstripped the resources and assets required to respond to them.

The third point -- enhancing servicemembers' and commanders' awareness of potential health threats before they can affect the force -- was the most obvious, significant shortcoming we noted during our investigation. Servicemembers and unit commanders were not aware of the relatively small health threats DU poses. The focused training DoD currently provides leaders (officers and NCOs), specialists, general servicemembers, and medical care-givers should improve our forces' readiness to operate safely and effectively despite the presence of DU contamination. The strong emphasis on effective risk communication and personal protective measures will help prevent overexposures to DU contamination and other battlefield toxins (e.g., burned plastics, solvents, munitions residues, and combustion products).

Presidential Review Directive (PRD)-5, "A National Obligation: Planning for the Health Preparedness and Readjustments of the Military, Veterans, and Their Families after Future Deployments," most comprehensively spells out the fourth point -- support fighting forces' and their families' health care needs across the continuum of medical services. PRD-5 identifies major deficiencies in how Federal departments, including DoD and the VA, have monitored the health of deployed personnel, kept records, tracked troop and asset movements to determine who might have been exposed to any given environmental or wartime health hazard, and handled risk communication.

DoD Instruction 6055.1, "DoD Safety and Occupational Health (SOH) Program," defines risk management as "[t]he Department of Defense's principal structured risk reduction process to assist leaders in identifying and controlling safety and health hazards and making informed decisions." The Instruction says risk management is a cyclical process involving:

• Identifying hazards.
• Assessing hazards to personnel, equipment, and mission.
• Developing controls.
• Making risk decisions to eliminate all unnecessary risks. Determining which risks are acceptable and unacceptable by balancing benefits against the potential for accidental losses or harm (severity, likelihood of occurrence). The standard for risk management is leadership at the appropriate level of authority making an informed decision to either control hazards or accept risks. If local resources are not available to control residual risks, leaders will consciously decide to either accept the risk or refer the risk decision to the next higher leadership level.
• Implementing controls.
• Supervising and evaluating the appropriateness and effectiveness of established controls and making adjusting where necessary.^[191]

The heart of risk management is making informed, appropriate risk decisions. As noted, Gulf War planners and decision-makers often lacked the information and guidance they needed to make informed risk management decisions or the means to mitigate DU contamination hazards. Effective risk management requires:

• Real-time monitoring and forecasting to assess the hazard's probability or extent;
• Alerting medical care-givers;
• Implementing a medical, safety, and environmental alert system; and
• Developing recommendations for tactical commanders to institute protective measures among their personnel.

As stated, the available risk management resources did not fully meet this requirement. DU sampling and monitoring efforts were rarely conducted, much less promptly or comprehensively. Some have suggested that DoD broke the law and US Army regulations during the Gulf War by not medically evaluating personnel likely to have been exposed to DU to learn if they were at risk. In fact, this is not so. The Army's preventive medicine regulation (AR 40-5) does not require medical evaluation in all cases in which personnel are exposed to radioactive substances. It is important to understand any regulation, including AR 40-5, in its entirety.  AR 40-5 states: "Bioassay procedures will be performed when radioactive materials are used in such a manner that they could be inhaled, ingested, or absorbed into the body." More importantly, it goes on to say, "The necessity, frequency, and methodology for performing bioassay procedures will depend on the radionuclides(s), their chemical and physical form, and the amount of material potentially available for entry into the human body." The "…type of the analysis and the frequency of the bioassay procedure will be determined by the IMA [Installation Medical Authority] in consultation with the RPO [Radiation Protection Officer]."^[192] These statements mean that radiation protection specialists should consider the potential for exposure to radioactive materials when they design facilities or develop procedures. It also means plans for monitoring worker health should include bioassay testing. Ultimately, the decision to test falls to professional medical judgement.

Procedures for addressing DU-related health concerns were tailored toward research and development scenarios or accidental fires involving DU munitions, not widespread combat use. Therefore, no guidelines instructed field medical and health physics personnel on the procedures to follow in combat scenarios. Testing was performed promptly only once. After the April 13, 1991 tank fire, seven soldiers who downloaded munitions from the burned-out Abrams were tested for urine uranium after they were found contaminated with DU. That testing occurred based on recommendations of the responding radiation control worker. All the results were below the analytical limit of detection, well below amounts of possible concern. In hindsight, a well-planned urine testing program would have provided monitoring results to address veterans' concerns.

At the operational unit level, no system ensured tactical commanders and their staffs received continuously updated information about potential environmental hazards like DU or countermeasures against it. Even when unit NBC, safety, or medical personnel were somewhat aware of DU's risks, exposure avoidance was not always feasible, and the drawbacks of wearing the personal protective equipment (MOPP gear) on hand, which was excessive protection for the actual risk, generally prevented its use as protection against DU.

A key component of risk management is risk communication, designed to educate and inform troops and leaders about risk factors and how to prevent or minimize needless exposures. It appears guidance was not widely or centrally disseminated, and risk communication channels and content largely depended on the initiative and knowledge of individual NBC, preventive medicine, or health physics personnel.

The services, unified commands, and joint task forces ideally would have collected medical and environmental surveillance data and information and reported it to the appropriate action offices and addressees. This information was needed to update health risk assessments; improve the medical, safety, and environmental response to identified risks; and aid retrospective investigations and analyses or medical research.

Unfortunately, the lack of data and information on personnel, unit locations, and unit movements in theater was compounded by the lack of medical and health surveillance data or exposure reporting and record-keeping. The data that were collected and reported often were documented or archived irregularly and since have been lost. These deficiencies have resulted in incomplete, often inaccurate data and information collection and reporting, which have detracted from retrospective efforts to characterize the risks of Gulf War service.

Collection and reporting requirements for DU-related events and activities were often non-existent, poorly defined, or disregarded. For example, no one recorded, documented, or archived the survey data from the Camp Doha radiological assessment and control effort, which would have been extremely helpful in estimating doses and might have helped alleviate some Gulf War veterans' exposure fears. Better information management, including record-keeping, is vital to establishing what exposures may have occurred, who was exposed, and the likely dose or intake received. Similarly, in the few cases where urine samples were collected to evaluate personal exposures to DU, the test results were not reported to either the person concerned or a central repository for follow-up actions. DoD and interagency bodies have recognized the crucial importance of information management to both operational readiness and force health protection and are developing strategies and systems to address these crucial information requirements.

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