III. SIGNIFICANT FINDINGS
The result of reviewing many Gulf-War-era documents and interviewing veterans corroborated a common Gulf War themetotal absence of disease patterns or even a single disease occurrence associated with biological warfare agents. On the other hand, because of the flawed chain of custody and absence of tracking data for the collected samples, we cannot determine whether all the samples returned to the United States for analysis were harmless or even whether all the samples scheduled for return were shipped. Further, the 9th Chemical Detachment did not continuously conduct biological air sampling and were only in 12 select areas, not throughout the KTO. Therefore, however remote, the possibility exists biological warfare agents were present during periods when the detachment did not monitor or in areas not covered by the detectors.
This investigation produced these significant findings:
Searching the Comprehensive Clinical Evaluation Program database revealed no reports of any biological warfare agent injuries or treatment.
Based on the information available, it is impossible to state categorically that Iraq did not use biological warfare agents during the Gulf War, although it is unlikely. Additionally, it is doubtful continued investigation could shed additional light on this issue or produce findings that are more conclusive.
B. Lessons Learned
1. Chain of Custody
Chain of custody documentation and information on suspected biological warfare samples are incomplete. With some exceptions, it is impossible to correlate samples collected with records of theater area medical laboratories or USAMRIIDs biological warfare assay results. It also is impossible to correlate USCENTCOM desk log entries and TEU transfer records with veterans interviews or reports of suspected biological warfare use. Although the collecting unit and sample custodians were supposed to follow a detailed chain of custody procedure, this was not a consistent practice and correlation information between organizations was not always present.
Establishing a chain of custody from theater of operations sample takers to the sample evaluators and to the ultimate archives requires a comprehensive understanding of the end-to-end sample flow, including all intermediate custodians and their ability to execute their portion of the chain without compromising any samples integrity.
2. Biological Warfare Agent Sample Packaging
Packaging and transportation are two factors determining a biological warfare samples ultimate utility. USAMRIID and the Navy Forward Laboratory both commented they sometimes received improperly packaged or marked samples. For example, biological warfare blood and tissue (but not soil) samples should be frozen or refrigerated. This was not a consistent practice.
Packaging and marking procedures practiced by units responsible for hazardous materiel transportation must adhere to applicable service directives and pertinent Department of Transportation regulations. The packaging materials and containers must meet the directives and regulations specifications to ensure sample safety and integrity during transport.
3. Biological Warfare Air Sampling False Positive Test Results
The XM2 military and PM10 commercial air samplers and SMART kits the 9th Chemical Detachment used for sampling in Operations Desert Shield and Desert Storm produced several false positive reactions. In conjunction with CRDECs XM2 liaison officers, Navy Forward Laboratory doctors identified the false positive problem as a quality control issue. The PM10 samples falsely indicated positive because fragments of filter fiber contaminated the SMART kits sample fluid and the XM2s did so because silt particles fouled the samples. Faulty lots of SMART kit testers used to test blood and fluids caused the false positives the Navy Forward Laboratory experienced.
Presumptive indications of biological warfare agents presence on the battlefield require field diagnostic systems to identify suspected samples highly accurately. Whatever the method used, the system must be thoroughly tested and evaluated before fielding.
4. Biological Warfare Agent Detection Capability
The 9th Chemical detachment was deployed with 12 BW agent detection systems (a mixture of under-development military systems and commercially available systems) and became operational February 1 8. The 12 systems did not provide complete coverage of US forces in the Kuwait theater of operations.
BW agent detection systems supporting force protection should be deployed early in the theater establishment and in sufficient numbers to provide detection capabilities during force buildup and subsequent combat operations.
This investigation attempted to determine whether Iraq used biological warfare agents during the Gulf War and if such use contributed to the causes of undiagnosed illnesses seen in Gulf War veterans. Although reports have indicated incidents of Iraqs possible use of biological warfare agents, as far as this investigation proceeded, we found no evidence confirming such use.
In response to the Presidential Special Oversight Boards request, we provided a summary of this investigation at a public hearing on September 16, 1999. Based on that summary, the Board concluded that the information obtained to date, the emerging results, and the anticipated outcomes from continued investigation are not likely to improve our understanding of any unexplained illnesses. Consequently, the Presidential Special Oversight Board recommended terminating this investigation. With this report, we terminate this investigation because it is unlikely further evidence will emerge to determine if Iraq used biological warfare agents.
This investigation is closed. However, if you have information that would change this report, please contact my office by calling 1-800-497-6261.
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