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News Release

FOR IMMEDIATE RELEASE

Ombudsman Finds that the Health Concerns of Canadian Forces Veterans were Ignored

Ottawa, November 1, 2006 – Department of National Defence and Canadian Forces Ombudsman, Yves Côté, today released a special report, entitled Heroism Exposed: An Investigation into the Treatment of 1 Combat Engineer Regiment Kuwait Veterans (1991), regarding the treatment received by Canadian Forces members exposed to toxic environmental substances more than a decade and a half ago.

The Ombudsman’s report follows a comprehensive, three-year investigation into concerns raised by Major (Ret’d) Fred Kaustinen, former Deputy Commanding Officer of 1 Combat Engineer Regiment, that members of his Regiment were exposed to harmful substances throughout their deployment to Kuwait in 1991, and that their significant health concerns were systematically ignored during, and after, their service to Canada.

“It is clear from our investigation that members of 1 Combat Engineer Regiment discharged their responsibilities with exemplary courage and dedication to duty that demands special recognition,” stated Mr. Côté. But he added, “It troubles me greatly that the legitimate health concerns of these proud veterans were not given the weight and respect that they deserved.”

The investigation included more than 350 one-on-one interviews, 261 of which were with 1 Combat Engineer Regiment veterans of the Kuwait deployment. The investigation also included a review of the 2000 Croatia Board of Inquiry and two earlier operations in Afghanistan (2002 and 2003) to determine if the Department and the Canadian Forces have improved their practices since the 1991 Kuwait deployment.

It is important to note that the investigation was not an examination of potential causes of illnesses related to the First Gulf War, and not a review of the health consequences of the Kuwait experience. Instead, the investigation focused on the systemic treatment of Canadian Forces members that came forward with concerns about their exposure to harmful substances throughout their deployment in Kuwait.

Through this investigation, the Ombudsman found that members of 1 Combat Engineer Regiment on deployment in Kuwait were exposed to toxic environmental materials of various kinds for which they were not adequately prepared and about which they were not adequately informed.

Ombudsman investigators also found that the real and significant health concerns of 1 Combat Engineer veterans were not taken seriously when they returned to Canada from Kuwait.

“The core issue is one of trust,” stated Mr. Côté. “Our military members need to know – and truly believe – that if they go on a mission healthy and return sick, Canada will take care of them and their family. Unfortunately for 1 Combat Engineer Regiment veterans, this was not the case,” added the military Ombudsman.

The investigation also found that documentation of the environmental exposures in Kuwait was inadequate in the medical files of those exposed. This means that a number of veterans have experienced great difficulty demonstrating a connection between their health concerns and the environmental hazards they faced in Kuwait, thus making future disability claims much more challenging and time consuming.

Also of note, Ombudsman investigators found that the Department and the Canadian Forces are unable to provide, with any certainty, a complete list of all of those Canadian Forces members who were deployed in Kuwait in 1991, with the result that the organization is unable to communicate effectively with Kuwait veterans or track and analyze health outcomes on an organization-wide basis.

In releasing his special report, the Ombudsman recognized that improvements have been made in the areas of environmental risk assessment and the protection of Canadian Forces members deployed overseas, particularly since the implementation of many Croatia Board of Inquiry recommendations. Indeed, the Ombudsman concluded that the Canadian Forces has an environmental health program that is now second to none among Canada’s allies.

At the same time, the Ombudsman highlighted significant concerns that were uncovered through an examination of recent missions in Afghanistan. Specifically, investigators found that the Canadian Forces remains overly reactive in communicating environmental and health risks to its personnel, both in the theatre of operations and post-deployment.

“In Afghanistan in 2003, the Department and the Canadian Forces were doing the right things technically but they were not communicating the results of their testing to the people on the ground,” stated Mr. Côté. He added, “This resulted in the common perception that negative results were being withheld from them.”

Ombudsman investigators also found that significant documentation problems identified in the case of the 1991 Kuwait deployment remain unaddressed more than a decade later.

Heroism Exposed contains nine recommendations aimed specifically at improving the way in which the Canadian Forces communicates and documents concerns – real, perceived and potential – related to environmental hazards on international military operations.

Additional information on the Ombudsman’s special report can be found in the attached backgrounder or online at the following address: www.ombudsman.forces.gc.ca.

For additional information, please contact:

Darren Gibb
Director of Communications
Office of the Ombudsman
Tel.: 613-992-6962

Michelle Laliberté
Communications Advisor
Office of the Ombudsman
Tel.: 613-995-8643

A Summary of Findings from
Heroism Exposed: An Investigation into the Treatment of 1 Combat Engineer Regiment Kuwait Veterans (1991)

November 1, 2006

Background

Heroism Exposed is the result of a comprehensive, three-year investigation into concerns raised by Major (Ret’d) Fred Kaustinen, former Deputy Commanding Officer of 1 Combat Engineer Regiment (1 CER), over the treatment that members of his regiment received following their exposure to toxic environmental substances when they were deployed in Kuwait in 1991.

Major (Ret’d) Kaustinen claimed that members of his regiment were exposed to hazardous material through their heroic action on July 11, 1991, when an open-air ammunitions depot caught fire in the American compound close to theirs, causing widespread injuries. During that emergency, members of 1 CER entered the compound at extreme personal risk to monitor the fire and assess the danger of further explosions over a period of hours as the situation was brought under control. In so doing, they were exposed to potentially dangerous substances contained in the exploding munitions, particularly depleted uranium – a radioactive by-product of nuclear reaction used in some weapons.

In addition to this specific exposure, the 1 CER deployment in Kuwait involved continual inhalation of thick smoke from Kuwait’s burning oil wells, which had been ignited by retreating Iraqi forces and which blackened the air throughout their six-month deployment, covering every exposed surface with oily residue. Adverse environmental conditions also included extreme summer heat (50^o C), the practice of spraying insecticides within living quarters, and exposure to unknown contaminants in a former Iraqi hospital.

According to Major (Ret’d) Kaustinen, members of 1 CER experienced significant health concerns in the years following their deployment in Kuwait. And their perception was that the Canadian Forces systematically ignored them, and that the military failed to pay sufficient attention to members’ legitimate concerns about possible links between their Kuwait deployment experience and their illnesses, including constant headaches, emphysema, brain tumours and liver failure.

The Ombudsman’s investigation of Major (Ret’d) Kaustinen’s concerns included more than 350 one-on-one interviews, 261 of which were with 1 CER veterans of the Kuwait deployment. Investigators also analyzed policies and procedures that addressed preparing for, dealing with, and following-up on incidents of potentially hazardous environmental exposures. Finally, the investigation included a review of the 2000 Croatia Board of Inquiry and two earlier operations in Afghanistan to determine if the Department and the Canadian Forces had improved their practices since the 1991 Kuwait deployment.

It is important to note that the investigation was not an examination of potential causes of illnesses related to the First Gulf War, and not a review of the health consequences of the Kuwait experience. Instead, the investigation focused on the systemic treatment of Canadian Forces members who came forward with concerns about their exposure to harmful substances throughout their deployment in Kuwait.

Findings

Through this investigation, Ombudsman investigators found that members of 1 Combat Engineer Regiment on deployment in Kuwait were exposed to toxic environmental materials of various kinds for which they were not adequately prepared and about which they were not adequately informed.

At the pre-deployment stage, medical examinations were not consistently performed and mental health was not considered in such examinations.

Ombudsman investigators also determined that assessment and planning related to environmental hazards was not done. The Canadian Forces were aware that burning oil wells posed air quality issues and some provision was made to protect personnel. However, these measures were partial and not universally applied. Adequate supplies of protective equipment and protocols to guide personnel on the ground were also lacking.

In addition, there was a shortage of Preventive Medicine Technicians and some of these personnel were trained to perform water testing but not air quality testing. There was also an absence of guidance and defined procedures for operating in the various environmental conditions. Authoritative information regarding risks and measures to be taken was lacking at all levels of the chain of command.

For example, information regarding exposure to depleted uranium appears to have travelled through informal rather than formal networks. Some 1 CER veterans told investigators that the practice of climbing into destroyed Iraqi tanks stopped when they received informal information, likely from American troops, that those tanks had been hit by depleted uranium weapons, and that it might not be safe to approach them.

As a result of this investigation, the Ombudsman also found that the legitimate health concerns of 1 CER veterans were not taken seriously when they returned to Canada. Post-deployment medical assessments were inconsistently performed. And a number of 1 CER veterans described an inadequate response received from the Department and the Canadian Forces to their significant health concerns.

For example, a Chief Warrant Officer said that his lungs gave out in Kuwait. He indicated that he was sent to the Kuwait hospital, as it was believed that he might have had a heart attack. He felt that he “was treated by his unit and chain of command as a disease and was outcast right from the start because of all the illnesses.”

A Private told Ombudsman investigators that he reported coughing black mucous during his post-deployment medical. Within two or three months, the problems ceased, so there was no further testing. However, the condition recurred in 1996, at which time he was diagnosed with exercise-induced asthma – an assessment that left him dissatisfied since he had an attack when he was not engaged in physical exertion.

Others described headaches, seizures and other health issues. For example, a Sergeant reported that he had a seizure three months following his tour of duty in Kuwait. He was treated at the time. In 1996 he was given a medical release – reportedly without explanation, beyond being told that his services were no longer required.

A number of former members of 1 CER also informed Ombudsman investigators of the difficulties they had experienced in applying for disability benefits from Veterans Affairs Canada, primarily because they were unable to document the fact that they had served in Kuwait and had been exposed to smoke from the oil well fires. Those who had reported respiratory problems either in theatre or post-deployment expected to find documentation of their exposure in their medical files. Not all found such records.

One soldier described going to the unit medic when he discovered that an annotation regarding exposure to oil fire smoke was missing from his file. With the assistance of the medic he was able to reproduce the document from another soldier’s file and make a declaration stating he was in the theatre of operation and had been exposed to the poor air quality. He was thus able to fill the gap in documentation. Another respondent faced the same problem, but was unable to pursue such a remedy because he had already left the Canadian Forces and it was too difficult to locate the appropriate personnel.

Also related to the issue of documentation, the Ombudsman expressed disappointment at the fact that the Canadian Forces remain unable to provide, with certainty, a complete list of all those deployed in Kuwait in 1991, with the result that the organization itself is unable to track and analyze health outcomes on an organization-wide basis.

In releasing his special report, the Ombudsman verified that the Department and the Canadian Forces have made major improvements in the areas of environmental risk assessment and the protection of Canadian Forces members deployed overseas, particularly since the implementation of many Croatia Board of Inquiry recommendations. Indeed, on a technical level, the Ombudsman concluded that the Canadian Forces has an environmental health program that is now second to none among Canada’s allies.

At the same time, the Ombudsman highlighted significant concerns that were uncovered by investigators through an examination of recent missions in Afghanistan. Specifically, investigators found that the Canadian Forces remains overly reactive in communicating environmental and health risks to its personnel, both in the theatre of operations and post-deployment.

Ombudsman investigators found that communicating environmental risk successfully in theatre was a problem in Kuwait and Croatia, and that it remained a problem in recent Afghan operations. The Department and the Canadian Forces were doing the right things technically but they were not communicating the results of its testing. A number of interviews revealed a fundamental disconnect in perceptions that contributes to this communications problem.

Investigators determined that environmental professionals are reluctant to provide any information that is not conclusive or the result of careful testing and analysis that necessarily takes time. Their reports are technical in nature, couched in the measured language of science. Thus, although they conducted environmental assessments during the deployments in Afghanistan, results were not made available to Canadian Forces members.

The Canadian Forces member on the ground is less interested in technical certainty. He or she demands immediate information that is very concrete and practical: “Am I safe? What precautions should I take? And if I get sick, will I be taken care of?” These questions are rooted in trust. In Afghanistan, troops appear to have assumed that when they observed testing being done and received no subsequent information, negative results were being withheld from them.

Ombudsman investigators found that the United States has acquired a great deal of recent experience in the field of communicating health-related issues to their military members. To quote one of the people who was interviewed, Colonel Robert DeFraites from the Office of the U.S. Army Surgeon General: “If you can’t convince them you are going to take care of them – there’s no hope!”

Regarding documentation, Ombudsman investigators found that some of the problems identified in the case of 1 CER veterans of the Kuwait deployment remain unaddressed more than a decade later. Most notably and disappointingly, investigators determined that the Department and the Canadian Forces were unable to identify, with confidence, who was deployed, and for what period of time, during recent missions in Afghanistan. Members of the Reserve Force or other “augmentees” attached to deployed units present additional challenges.

Ombudsman investigators also discovered that mandatory pre- and post-deployment questionnaires do not include questions about environmental exposure, and that the medical files of individual Canadian Forces members are missing key pieces of information related to potential exposure needed to support subsequent requests for disability benefits.

Recommendations

As a result of this special investigation, the Ombudsman made nine recommendations to the Minister of National Defence and to the Chief of the Defence Staff, as follows:

The exemplary service of 1 CER personnel in Kuwait deserves formal recognition above and beyond unit recognition, which is not an individual award. In particular, the Department of National Defence and Canadian Forces (DND/CF) should formally review the heroic actions taken by 1 CER members during the Camp Doha incident, and, through the Canadian Forces Honours and Commendations Advisory Committee should consider individual awards or commendations at a level commensurate with the degree of heroism displayed during the incident.
The medical files of all 1 CER members who served in Kuwait (including members who have left DND/CF) should be reviewed to ensure that they contain explicit reference both to service in that theatre and exposure to smoke from burning oil wells.
DND/CF should create a well-publicized hot line (or similar mechanism) for a minimum of three months to receive, follow-up on and resolve any outstanding concerns of 1 CER members with respect to their environmental exposure in Kuwait in 1991.
DND/CF should ensure that it has the ongoing ability to produce complete and accurate lists of all personnel deployed on each mission, including reservists and “augmentees” assigned to the mission.
A form that remains on the medical file of each deployed individual should contain reference to every deployment in which that individual has served. (The Croatia Board of Inquiry made the same recommendation, which was not accepted at that time.)
The medical file of each deployed individual should contain reference to any environmental exposure he or she has sustained in the course of each deployment – whenever such exposure has been identified by DND/CF through an assessment.
Individuals should be encouraged to file Declaration of Injury or Illness Forms (CF98) to record environmental exposures that cause them concern, and a copy of such forms should be retained on their medical files.
DND/CF should review its current standard questionnaire, CF 2078, with a view to better address occupational health issues, including members’ concerns about potential health exposure.
Finally, and most importantly, DND/CF should take concrete steps to build a culture of trust with respect to environmental exposure and the health of its personnel by implementing the above recommendations and through ongoing and proactive communication with regular force and reserve members regarding measures taken (a) to manage the risks associated with environmental exposure, and (b) to support individuals and their families by acknowledging their concerns about health issues and by providing them with accurate and timely information about what is known and not known about the cause of their condition.

A review of the organization’s progress on the implementation of the Ombudsman’s recommendations will take place six months following the public release of this special report.

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