At a public hearing held on July 13, 1999, the Presidential Special Oversight Board for Department of Defense Investigations of Gulf War Chemical and Biological Incidents (PSOB) directed that the Office of the Special Assistant for Gulf War Illnesses (OSAGWI) report on the status (including preliminary findings and conclusions reached to date) of on-going investigations, including the Water Use investigation. The purpose of this request was to determine whether the available information supported a decision for the continuation of the investigation at hand. They wanted to know whether continued work would eventually lead to identifying a cause and effect relationship between water use and unexplained illnesses in Gulf War veterans.

In response to the PSOB, OSAGWI provided a summary of the preliminary findings of all work in progress at a public hearing on Sept. 16, 1999. Based on its review of this material, the Board concluded that the information obtained to date on water use during Operations Desert Shield and Desert Storm did not support a cause and effect relationship, and that emerging results and anticipated outcomes are not likely to improve our understanding of any of the unexplained illnesses. Consequently, the PSOB directed that further activities be curtailed and the Water Use investigation terminated. To bring the investigation to closure, however, the Board requested that the Office of the Special Assistant complete a close-out report and present the data, documentary evidence, and personal accounts obtained during the investigation. The following sections of this report provide such an accounting.

The rapid influx of Coalition forces into the Persian Gulf region during the early stages of Operation Desert Shield taxed the region's available potable water resources. Host nation and commercial outlets were unable to provide sufficient supplies of potable water to incoming troops. Water purification systems were brought in by the United States to supply U.S. forces with chlorinated drinking water and flexible water use policies were implemented in theater with respect to non-potable water.

In the post-war era, some American Gulf War veterans voiced concerns that the water they had either consumed or come into contact with during their deployment may have contributed to their own reported illnesses, or to a variety of illnesses reported by other Gulf War veterans. In response to these concerns, the Office of the Special Assistant for Gulf War Illnesses launched an investigation into the possible link between water use in the Gulf and health problems reported by veterans. After an extensive review of scientific, medical, and health safety literature, examination of water storage and distribution policies and practices, personal interviews with Gulf War veterans, and inspection of unit accounts, the preponderance of available evidence suggests no definitive link between water use during the Gulf War and subsequent reports of illnesses. Some short-duration illnesses—diarrhea and similar gastrointestinal disorders, for example—were reported contemporaneously by personnel in theater. These individual episodes may have been triggered by contaminated, over-chlorinated, improperly stored water, or contaminated water used for irrigating produce taken from the local market,[2] but barring a more definitive link to post-War illnesses, there is no compelling reason to continue the investigation beyond this point.

The water use investigation considered numerous aspects of water policy, including:

• Water requirements for soldiers in theater;
• US military water standards;
• Individual service responsibilities and specific water-related duties;
• Bottled water policy, sources, and testing;
• Health effects of contaminated water;
• Reverse osmosis water purification unit systems and policy;
• Host nation water sources and distribution;
• Transportation and storage of water in the field;
• Potential for chemical and biological warfare agent contamination of water supplies;
• Petroleum products contamination of water supplies; and
• Water policy, sources, testing, and distribution for forces at sea.

This investigation was based on discussions with subject matter experts, and a number of interviews of veterans with water supply-related duties. The investigation also included an extensive literature review, including military field manuals, scientific and medical journals, intelligence, after-action reports, and newspaper articles. Tab B contains a complete list of sources.

Water use was a significant part of every aspect of the Gulf War deployment. Service personnel serving at sea as well as those forces operating in the desert were equally dependent on adequate supplies of potable (fit for human consumption) and non-potable (unfit for consumption) water. Ship-based water use was examined, but the primary focus of the investigation was on the more acute problem of access to water by land-based forces, and the plans and policies developed to assure a continuous supply of drinking and general use water for these forces.

In addition to the threat of casualties from inadequate water supplies, the other, major, and anticipated threat was the potential for water-borne disease. Water can serve as the vehicle for disease-causing infectious agents, biological and chemical contaminants, and excessive amounts of dissolved solids. In particular, a vast historical record exists of disabling gastrointestinal disease (diarrhea, dysentery, and hepatitis) caused by bacteria and viruses contaminating water supplies during military operations.[3],[4]

Military water policy and doctrine requires that water for human consumption be filtered and disinfected (usually by chlorination or iodinization) before distribution.[5] Procedures in the theater adhered to these policies, although exceptions did occur. Field testing of water quality provided immediate results for levels of chlorine in water. Water producers and preventive medicine personnel routinely monitored water quality in this way. In addition, preventive and veterinary medical personnel took cultures of water for bacterial contamination, which yielded results within 18 to 24 hours. However, cultures were performed much less often than tests for chlorine residuals, which were the mainstay of quality control.[6],[7]

Reverse osmosis processing which incorporated chlorine as the primary disinfectant is the preferred source of water for U.S. troops; the Saudi reverse osmosis processes generally incorporated an ozone-based purification method instead of chlorine, because the taste of chlorine is considered undesirable. Reverse osmosis treatment of raw water removes excessive amounts of dissolved solids, which can cause diarrhea. The seawater and ground water in Saudi Arabia were so salty that the taste of such untreated water would make it difficult—if not dangerous—to consume significant amounts. Chemical contaminants of raw water, potentially present from industrial pollution or deliberate contamination, are largely removed by reverse osmosis process, but the potential exists for small amounts to pass through the treatment process and remain in the finished water due to operator error or equipment problems.[8]

Water quality was monitored for bacteriological contamination and the presence of adequate concentrations of residual chlorine. Such testing was performed at production points, where chlorine was added to the water, and at the distribution points. Medical personnel, mainly preventive medicine technicians, possessed the training, equipment, and supplies to perform such testing. In addition, water production workers often were responsible for testing the water. More sophisticated testing had to be obtained from host nation laboratories, as well as laboratories outside of the theater.[9]

Efforts to provide sufficient, potable water during the entire operation were an overall success. Although there were documented instances of dehydration and heat injury during Operations Desert Shield and Desert Storm, none can be attributed to failure of the logistical support system to provide sufficient water to military units.[10] This record is a credit to commanders who emphasized a reliable water supply and the use of water to prevent dehydration and to the personnel of combat support and service support units who made maximum use of the available water sources, treatment options, and transportation assets.

The overall result of water operations during Operations Desert Shield and Desert Storm was a reliable supply of water, fit for consumption. There were exceptions to the overall success of water use plans. These included missteps in procedures, equipment problems, shortcomings in quality control capability, and failures to adhere to policy; often a result of the practical realities of supporting large numbers of forces in such a hostile environment. These shortcomings are described to identify lessons to be applied in preparing for, and executing, future operations.

Supplies of water fit two broad categories: water approved for drinking—potable water—and water designated for other specific or general, non-consumption purposes—non-potable water. The military forces arriving in the Kuwait theater of operations required considerable quantities of both kinds of water, and the pressure to meet the water needs of a rapidly increasing military population required U.S. planners to consider all water resources in the region. Host country water desalinization plants along the Persian Gulf coast were augmented with U.S.-supplied specialized water purification systems known as reverse osmosis water purification units, which had the capability to process salt water, but not always at the rate needed to meet the demands of the influx of troops. Bottled water from commercial sources, and bottled water supplied by the Saudi water processing plants were made available to U.S. troops, although operations planners would have preferred separate U.S.-standardized potable and non-potable water supplies. Given the water demands of U.S. forces across the region, U.S. supplies of non-potable water were occasionally used for drinking and in food preparation.[11],[12]

The reverse osmosis water purification units employed chlorine to kill and protect against the re-growth of water-borne microorganisms. Chlorine was the preferred agent used by U.S. forces theater-wide to eliminate most waterborne organisms. Non-chlorinated water of the host country reverse osmosis and multi stage flash desalinization plants during the Gulf War produced potable water—including bottled water—often through an ozone purification process as opposed to a chlorination process.[13],[14] One significant advantage of chlorine over ozone-purification is that while both processes produce microorganism-free water, chlorine leaves an easily detectable residual marker that serves as a tracing element for long-term water quality assurance.[15] The goal of U.S. Central Command policy covering U.S.-controlled, land-based water resources was for purified water to have a chlorine residual of no-less than five parts per million in order to be considered safe for potable purposes.[16] However, there are some contemporaneous reports that water supplies using this standard chlorine level contributed to diarrhea and stomach distress among some soldiers because the standard levels of chlorine were too high for them to tolerate.[17]

The Reverse Osmosis Water Purification Units (ROWPUs) fielded by the U.S. were the principal sources for the land-based production of drinking water for American troops in the Gulf. The ROWPU is essentially a pressure-driven straining device that separates impurities from water by forcing it through filters. In combination with a specialized membrane, the filters reject suspended and dissolved impurities and most color and odor-causing compounds. After this first filtration stage, the water must pass through three post-treatment cylinders: a radiological cylinder containing resin beads which absorb radioactive ions; a biological cylinder containing chlorine to kill any waterborne organisms; and a chemical cylinder containing carbon that absorbs a number of different chemicals, including chemical warfare agents.[18]

American water production teams initially had difficulty producing enough potable water with the 150,000-gallon per day ROWPUs to meet the water requirements of U.S. forces arriving in theater. At the beginning of Desert Shield, the purification units were set up at coastal locations, where the Persian Gulf was the primary source of incoming water. The seawater was so salty and mineral laden, the ROWPUs were not able to produce freshwater at the most efficient or effective capacities and initial water production output was well below expected levels.[19],[20] It was estimated that as of the end of September 1990, the water purification teams were able to meet no more than 20 percent of the predicted capacity of 150,000 gallons per day.[21] ROWPUs set up inland, using less salty ground water sources, showed marked improvements in performance.[22]

Doctrine and plans called for many inland forces to come to water supply points to get water, which would have been run through ROWPUs distributed across the area of operations. In practice, not all units received ROWPUs or had access to ROWPU-processed water. In some instances, unassembled purification units or ones with missing parts were delivered to units. In addition, in order to meet the huge demand for water requirements in theater, American and Coalition water purification specialists at times altered equipment to produce faster water flow rates. While this may have produced more water, the modifications to increase flow rates shortened the life of the filters, for as the flow rate increased, filter service life decreased.[23],[24],[25] Problems with filters and inadequate supplies of replacement filters and membranes caused delays in water processing and delivery to some units in the field and a number of units were forced to rely on host nation water delivered by tankers.[26],[27]

Many veterans asked questions about the use of Petroleum, Oils, and Lubricants (POL) transport tankers being used to carry water. According to Field Manual 10-280, this was an acceptable practice for the movement and storage of water, once the tanks in question were super-chlorinated to 200 parts per million of water, allowed to sit, and then flushed out thoroughly.[28] However, contemporaneous reporting and interviews with veterans indicate that the presence of petroleum, oils, and lubricants in water, especially in water designated for hygiene purposes, was wide-spread.[29],[30]

Due to shortcomings in technology and the inability to obtain on-the-spot water testing results, water samples taken in the field had to be sent to military laboratories in Al Jubayl, Saudi Arabia; Cairo, Egypt; Bethesda, Maryland; Naples, Italy; Lima, Peru; Bangkok, Thailand; Washington, DC; and Porton Down, United Kingdom, among others.[31] Preventive medicine personnel often faced the unenviable task of having to decide whether to validate a water source or well site as usable because the water was needed or not validate it because testing results would not be received for 24 to 72 hours.[32]

Each company-size Army unit was to appoint, train, and provide supplies for field sanitation personnel who, in addition to their regular duties, would perform water purification and testing. However, interviews with veterans and contemporaneous reporting from Operations Desert Shield and Desert Storm indicated that field sanitation teams were often ineffective. Many units never fully trained their appointed teams in aspects of field sanitation.[33] The lack of training in water testing and purification procedures was critical because field sanitation teams were often the unit’s initial protection against water contamination due to a shortage of preventive medicine or quartermaster personnel available to inspect a unit’s water supply. One report in reference to the Army’s field sanitation operations concluded, "Field sanitation teams are inadequately trained and equipped; they are ineffective as the first-line PM [Preventive Medicine] support for units."[34]

The sheer scope of the deployment of troops and equipment for Operations Desert Shield and Desert Storm was immense. Overall, military logisticians did an excellent job, especially considering the massive scale and the rapid pace of the preparations and complex logistical activities undertaken. However, the United States took a calculated risk by deciding to deploy combat forces without a satisfactory accompanying logistical support structure.[35] Some units arrived in theater without the authorized or required equipment and had to procure these items from other units, had to use unauthorized local water storage and distribution methods, or had to buy unapproved products from the local economy.[36] Water was a necessity for U.S. solders in the arid environment of the Gulf region, and without a satisfactory logistical support structure, American forces often depended on host nation supplies and equipment. This allowed water sources to become more vulnerable to possible sabotage efforts from Iraqi sympathizers.

Planners must structure forces so that there is enough water production, storage, and distribution available to meet water requirements. They also must schedule the build-up of theater forces so that water support and preventive medicine units arrive as soon as it is operationally feasible to insure adequate and continuous water support and a preventive medicine presence. A steady flow of water production, storage, and distribution materiel that can be quickly delivered to soldiers who need it will bolster future American efforts on the battlefield.

The U.S. Army Center for Health Promotion and Preventive Medicine’s Water Supply Management Program has been tasked to standardize military water policy. The Army’s field water quality guide[37] is currently being converted in to a final tri-service guidance manual for a uniform military water policy. Included in the draft tri-service standard is an adjustment of the required chlorine residual levels in any U.S. field water supply to two parts per million.[38] As mentioned in the earlier discussion of chlorination the five parts per million goal for chlorine in purified water produced in-theater during the Gulf War may have proved too high in some instances and may have caused some veterans to experience stomach cramping and diarrhea.

Gulf War planners were acutely aware of the need to maintain adequate supplies of water for U.S. troops fighting in a desert environment. Logistically, they faced the significant challenge of providing water during a time of a rapid troop buildup and dispersion in a region of the world with few abundant fresh water resources. There were problems with obtaining, producing, storing, and distributing sufficient supplies of potable water, but thanks in great part to host nation support, as well as the flexibility and improvisational skills of US forces, the bulk of the water needs were met from day-one to the close of the conflict.

While bottled water was available, it came at a cost, both financially and logistically. Bottled water should not be viewed as a primary water source for U.S. forces. It should be used as a temporary measure until other sources of potable water become available. It is only as good as the source from which it is acquired and the quality of treatment it receives before being bottled. Although there were standards in place that discouraged such use, non-potable water was used for drinking and cooking on occasion. Veteran reports of drinking water and shower water tasting or smelling of fuel oil or other petroleum products suggests that water storage was not always up to regulatory standards. However, restrictions against transporting water in tankers used to transport petroleum products or any other tanker or storage container not intended for the transportation or storage of water have been implemented. Regulations suggesting that this was an acceptable practice have been superseded.

Planners for any future deployment of this scope and speed of buildup need to consider more efficient, safe, and practical methods of delivering adequate supplies of both potable and non-potable water to the field absent the support of a host nation. Self-sufficiency in water production for a deployed force is the goal, but that goal must be tempered with the reality that at times self-sufficiency may not always be feasible.

Contaminated ice is often the vector of waterborne transmission of disease. Ice should be prepared with potable water only and provided the same protection as potable water sources. Instructions to deploying troops need to emphasize the potential health hazards of using improperly processed ice.

Since the Gulf War, many improvements have been and continue to be made to American water purification equipment. Some of the improvements are:

1. Water Packaging

A water packaging system that produces one liter bags of water that are small enough to fit into the cargo pocket of the battle dress uniform is being developed as an alternative to the five gallon water can as the primary method for water resupply at the unit level. Also under development is a six-gallon water bag that has been designed to fit in military ration boxes. Bagged water has been used successfully at the Joint Readiness Training Center in Fort Polk, Louisiana, and in Operation Joint Endeavor, where from March 1996 to January 1997, it was the main supply of potable water in the intermediate staging bases in Taszar and Kaposvar, Hungary.[39],[40] In this operation the US military had control over its own water quality and production capabilities, and this water production method also was very cost effective.[41]

2. 1,500 Gallon Per Hour ROWPU

The 1,500-gallon per hour ROWPU is currently being developed to eventually replace the 600-gallon per hour ROWPU. It will be able to produce 1,500 gallons of potable water per hour when used on water with less than 1,000 parts per million of total dissolved solids. The water produced by the 1,500 gallon per hour ROWPU will meet the Tri-Service Field Water Quality Standards for short and long-term consumption and will be able to operate in temperatures ranging from minus 25 degrees to 140 degrees Fahrenheit.[42]

3. Lightweight Water Purifier

An Army program to field a water purifier that will provide 75 gallons per hour of potable water from seawater sources and 125 gallons per hour of potable water from fresh water sources to small units and medical detachments is under development. It will be a modified commercial item that is small, lightweight (less than 150 pounds), and easy to transport and use.[43]

4. Canteen Insert Water Purifier

Scientists are developing equipment that will provide safe drinking water to soldiers, in an emergency, where the only water source is untreated surface water. This device, currently in the research stage, is expected to be compatible with the Army’s standard canteens. It will remove microbiological contaminants, improve the taste of the water, and work with iodine or chlorine tablets. It will be able to treat a two-week (approximately 21 gallons) supply of drinking water for one person.[44]

The overall water testing and treatment program in the Gulf was successful in providing potable water for a large force in the middle of an extremely hot and arid region that was largely devoid of fresh surface water sources. Casualties due to dehydration were avoided. In addition, although the potential for waterborne disease was real, and occasionally occurred, such disease was the exception rather than the rule. However, certain shortfalls did occur.

1. Biological Testing

During Operations Desert Shield and Desert Storm, U.S. forces had no equipment to detect biological contamination in the field in a timely manner. An improved version of a rapid assay for biological agents has been developed at the US Navy Medical Research Institute. New methods also have been designed to detect biological warfare agents in a broad range of substances other than clinical samples, including water.[45]

2. Chemical Testing

A water sampling submission kit has been developed and will provide containers for the collection and submission of water samples that will be transported from the field to supporting laboratories to test for chemical contamination.[46]

3. Testing Results

Adequate records of water testing results must be kept to fully analyze short and medium-term trends in water quality at particular sources and sites while U.S. forces are in the field, so changes in treatment could be taken if necessary. Long-term water testing results also must be kept so researchers and scientists could go back and analyze water data if there were any questions about particular water sources or sites that U.S. forces used. This was not possible for the Gulf War because almost all of the water sampling data was lost or destroyed.

The water use investigation conducted extensive research into all aspects of water policy, supply, storage, treatment, distribution, and use in the Kuwait theater of operations. There is an absence of any hard data (water sampling and monitoring data) available to make responsible health-related conclusions about possible contaminants. The passage of time since the Gulf War makes it almost impossible to obtain this physical evidence, and in a number of cases physical evidence was never collected at all. Contact with water occurred several times a day for months. The specific factors that could differentiate one soldier’s experience from another, even between two members of the same unit, let alone across the entire theater of operations, are many.

There is no definitive evidence to link contaminated water to the undiagnosed symptoms or illnesses reported by Gulf War veterans today. It also is doubtful whether additional research would lead to any new findings or a different interpretation of the existing findings. Because the preponderance of evidence collected and evaluated to-date does not link water use in the Gulf to any of the unexplained symptoms reported by Gulf War veterans, the Presidential Special Oversight Board decided to conclude the investigation with this close-out report.

ARCENT U.S. Army Central Command (3rd Army)

mg/l milligrams per liter

NFL Navy Forward Laboratory

PH potential hydrogen

POL petroleum, oils and lubricants

PPM parts per million

PSOB Presidential Oversight Board

ROWPU reverse osmosis water purification unit

SECDEF Secretary of Defense

SITREP situation report

SMFT semi-trailer mounted fabric tank

USAF U.S. Air Force

USCENTAF U.S. Central Command Air Force

USCENTCOM U.S. Central Command

Acute health effect

An immediate (within hours or days) effect that may result from exposure to certain water contaminants.

Chlorination

Treatment of water by the addition of chlorine either as a gas or liquid, or in the form of hypochlorite powder, usually for the purpose of disinfection.

Chlorine demand

The difference between the amount of chlorine added to water and the amount of residual chlorine remaining at the end of a specified contact period.

Chlorine residual

The total amount of chlorine remaining in water at the end of a specified contact period following chlorination.

Chronic health effect

The possible result of exposure over many years to a drinking water contaminant at levels above recommended standards.

Coliform

A group of related bacteria whose presence in water may indicate contamination by disease-causing microorganisms.

Contaminant

Any physical, chemical, biological, or radiological substance or matter in water that may be harmful to human health or which degrades the palatability of water.

Disinfection

The process of killing harmful and objectionable microorganisms by various agents such as chemicals, heat, ultraviolet light, ultrasonic waves, or radiation.

Escherichia Coli (E. Coli)

One of the species of bacteria in the coliform group. Its presence is considered indicative of fecal contamination.

Field water supply system

The assemblage of collection, purification, storage, transportation, and distribution equipment and personnel to provide potable water to field units.

Finished water

Water that has been treated and is ready for use.

Fixed installation

An installation that through extended use, has gained structures and facilities not initially found or intended for use at a temporary standard facility (paved roads, fixed electrical distribution systems, fixed water treatment facilities, and underground distribution lines).

Ground water

Water occurring in an aquifer below the surface of the ground. The term is not applied to water that is percolating or held in the top layers of the soil, but to that below the water table.

Non-potable water

Water that has not been examined, properly treated, and approved by appropriate authorities as being safe for consumption; in Operations Desert Storm and Desert Shield, all water was considered non-potable until examined, properly treated, and approved.

Palatable water

Water that is free from most color, cloudiness, unpleasant tastes, and odor

Potable water

Water that is free from disease-producing organisms, poisonous substances, chemical, biological, and radioactive contaminants which would make it unfit for human consumption and many other uses

Raw water

Untreated water; usually the water first entering a water purification unit

Reverse osmosis

Reverse osmosis is a process that separates impurities from water by forcing it through filters under great pressure into a spirally wound tube called a reverse osmosis element. The membrane allows water to pass through the filter while rejecting suspended and dissolved impurities and most color and odor-causing compounds. If the filters do not absorb the contaminants, then they have to pass through three post-treatment cylinders

Surface water

The water from sources open to the atmosphere, such as rivers, lakes, and reservoirs.

Total dissolved solids

The dissolved matter found in water comprised of mineral salts and small amounts of other inorganic and organic substances. The total dissolved solids standard was established to prevent chemically induced diarrhea, which could interfere with soldiers’ performance.

Treated water

Water that has undergone a cleansing process such as sedimentation, filtration, or disinfection, and that is ready for consumption. During the Gulf War, it was not considered potable until preventive medicine personnel had inspected it and the command surgeon had approved it.

Water quality

The chemical, physical, and biological characteristics of water with respect to its suitability for a particular purpose; the same water may be of good quality for one purpose or use, and poor for another, depending on its characteristics and the requirements for the particular use.

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"Foodborne Illnesses – August 1990 – July 1991" USCENTCOM, undated.

"Foodborne Pathogenic Microorganisms and Natural Toxins Handbook," US Food & Drug Administration Center for Food Safety and Applied Nutrition, Washington, DC, January 1992.

"Fresh Water System Precautions for Ships Operating in Oil Saturated Waters," NAVCENTCOM, February 1991.

"G3 Plans Rear Daily Journals," XVIII Airborne Corps, Aug.13 – 17, 1990.

"Giardiasis Fact Sheet," Centers for Disease Control and Prevention, Atlanta, GA, web site – http://www.cdc.gov/ncidod/dpd/giardias.htm (as of December 21, 1999).

Grau, Lester W., William A. Jorgensen, "Beaten by the Bugs: The Soviet-Afghan War Experience," Military Review Magazine, November/December 1997.

Greeson, Philip, Infectious Waterborne Diseases, US Geological Survey, Alexandria, VA, 1981.

Guidelines for Chemical Warfare Agents in Military Field Drinking Water, National Academy Press, Washington, DC, 1995.

Hanson, Kevin, "The Navy’s Preventive Medicine Experience in Desert Shield," The Journal of the US Army Medical Department, March/April 1992.

Hellmann, David B., "Grand Rounds at the Johns Hopkins Hospital: Spondyloarthropathy with Hidradentis Suppurativa," JAMA – The Journal of the American Medical Association, May 6, 1992.

Hyams, K.C., A.L. Bourgeois, B.R. Merrell, et al, "The Navy Forward Laboratory During Operations Desert Shield/Desert Storm," Association of Military Surgeons of the United States Journal, 1993.

Hyams, K.C., A.L. Bourgeois, B.R. Merrell, et al, "Diarrheal Disease During Operation Desert Shield," The New England Journal of Medicine, Boston, Mass, Nov.14, 1991.

"Impact and Implications of Chemical Weapons Use in the Iran-Iraq War," Central Intelligence Agency, undated.

"Information Paper on Oil Slicks on Major Units," Office of the Chief of Naval Operations, Washington, DC, Jan. 26, 1991.

"Iraq: Potential For Chemical Weapon Use," Defense Intelligence Agency, Jan. 25, 1991.

"Iron and Manganese," University of Florida Institute of Food and Agricultural Sciences web site – http://www.ifas.ufl.edu/~fairsweb/text/ae/AE009DB.HTML (as of January 26, 2000).

Jamal, W.Y., V.O. Rotimi, "Prevalence and Susceptibility of Shigella Species to 11 Antibiotics in a Kuwait Teaching Hospital," Journal of Chemotherapy, August 10, 1998.

Jehl, Douglas, "Desert Dilemma: How to Shut Off that Designer Water, Get Back to Canteens," The Los Angeles Times, Sept. 25, 1990.

"JULLS Long Report – VII Corps Lessons Learned," Nov. 2, 1990.

Knowles, Robert, "The Importance of Hydrology During the Gulf War," US Army Topographic Engineering Center, Fort Belvoir, VA, 1996.

Koslowe, Patricia, Kurt Kroenke Michael Roy, "Symptoms in 18,495 Persian Gulf War Veterans," Journal of Environmental Medicine, June 1998.

Kravitz, Daniel, "Combined Water Purification Unit Training," Army Logistician, May/June 1996.

Lead Sheet #187, Interview of Maintenance Personnel from 193rd Special Operations Group, Sept. 25, 1995.

Lead Sheet #1235, Interview of Officer from 7th Motor Transportation Unit, 2nd Marine Division, Jan.13, 1997.

Lead Sheet #7741, Interview of General Construction Equipment Operator, 46th Engineer Battalion, Dec. 18, 1997.

Lead Sheet #8044, Interview of Member of 773rd ALS, June 19, 1995.

Lead Sheet #8046, Interview of Air Force Medical Technician with US CENTCOM, June 22, 1995.

Lead Sheet #8152, Interview of Sailor aboard USS Worden (CG 18), Oct. 7, 1996.

Lead Sheet #8197, Interview of Sailor aboard USS Mobile Bay (CG-53), Nov. 6, 1996.

Lead Sheet #8433, Interview of Machinist Mate aboard USS Sylvania, Aug. 29, 1995.

Lead Sheet #8623, Interview of Officer from 7th Motor Transportation Unit, 2nd Marine Division, Nov. 9, 1995.

Lead Sheet #8778, Interview of Marine Corps Hygiene Equipment Operator, Water Purification, June 2, 1995.

Lead Sheet #8831, Interview of Chief of Housing at Dhahran, April 16, 1997.

Lead Sheet #8866, Interview of Officer from 27th Engineer Battalion, Oct. 23, 1995.

Lead Sheet #8888, Interview of Nurse aboard the USS Tripoli, Nov. 2, 1995.

Lead Sheet #9105, Interview of Firefighter from 22nd SubCom, Oct. 25, 1995.

Lead Sheet #9272, Interview of Member of 1^st 82^nd Field Artillery, 1st Cavalry, July 20, 1995.

Lead Sheet #9313, Interview of Member of 363^rd Tactical Fighter Wing, Oct. 17, 1995.

Lead Sheet #9334, Interview of Machinist Mate aboard the USS LaSalle, Oct. 25, 1997.

Lead Sheet #9382, Interview of Member of Delta Company, 1st 502nd Infantry, Jan. 16, 1996.

Lead Sheet #9453, Interview of Chief Electrician aboard USS Shreveport, July 20, 1995.

Lead Sheet #9506, Interview of Machinist Mate aboard USS Charleston, Feb. 12, 1996.

Lead Sheet #10020, Interview of Navy Medical Corpsman, April 1, 1997.

Lead Sheet #10043, Interview of Member of 4^th/32^nd Armor, 1^st Infantry Division, Dec. 30, 1996.

Lead Sheet #10225, Interview of Member of A Company, 12th Engineer Battalion, Jan. 3, 1997.

Lead Sheet #10274, Interview of Member of 2nd Squadron, 3rd ACR RGT, Dec. 18, 1997.

Lead Sheet #10346, Interview of TOW Gunner/HUMVEE Driver assigned to 5th Regiment, Marine Corps, Feb. 24, 1997.

Lead Sheet #10643, Interview of Member of the 222^nd Transportation Company, Dec. 18, 1996.

Lead Sheet #11161, Interview of Coast Guard Small Boat Coxswain, June 2, 1997.

Lead Sheet #12228, Interview of Officer from 350^th Evacuation Hospital, July 2, 1997.

Lead Sheet #12422, Interview of Cook with 20^th Engineer Brigade, 82^nd Airborne Division, July 23, 1997.

Lead Sheet #12450, Interview of Member of 7^th Air Defense, July 25, 1997.

Lead Sheet #12716, Interview of Machinists Mate aboard the USS NEW ORLEANS, Aug. 12, 1997.

Lead Sheet #12801, Interview of Engineer from the 12^th Engineer Battalion, Aug. 20, 1997.

Lead Sheet #13000, Interview of Member of the 142nd Field Artillery Battalion, Sept. 16, 1997.

Lead Sheet #13648, Interview of Military Technician with the 475th Quartermaster (Petroleum) Group, Dec. 4, 1997.

Lead Sheet #15015, Interview of Member of 326 Medical Battalion, 101st AD, March 3, 1998.

Lead Sheet #15058, Interview of Member of 983rd Medical Detachment, March 3, 1998.

Lead Sheet #15182, Interview of Assistant Chief of Fleet Hospital 15, Feb. 25, 1998.

Lead Sheet #15374, Interview of Member of 96th Civil Affairs Battalion, March 9, 1998.

Lead Sheet #15995, Interview of Duty Petty Officer aboard the USS NASSAU, April 10, 1998.

Lead Sheet #16703, Interview of Member of 89th Military Police Brigade, May 19, 1998.

Lead Sheet #16864, Interview of Member of 542nd Maintenance Co., May 28, 1998.

Lead Sheet #17323, Interview of Maintenance Battalion Member, June 17, 1998.

Lead Sheet #17548, Interview of Member of 3^rd Platoon, 44^th Chemical Company, 2^nd Armor, Dec. 2, 1998.

Lead Sheet #17810, Interview of Member of 452nd Quartermaster Company, July 7, 1998.

Lead Sheet #18291, Interview of Pilot with B Company 9th /101st AVN, July 24, 1998.

Lead Sheet #18557, Interview of Member of B Company, 3/502, 101st Airborne Division Air Assault, Aug. 12, 1998.

Lead Sheet #19118, Interview of Member of 136th Quartermaster Battalion, 16th Corps Support Group, Sept. 16, 1998.

Lead Sheet #20172, Interview of Member of 776^th Maintenance Company, 176^th Maintenance Battalion, Nov. 11, 1998.

Lead Sheet #20371, Interview of Communications Navigation Technician aboard the USNS Curtis, Nov. 23, 1998.

Lead Sheet #20537, Interview of Member of the 320^th, Dec. 2, 1998.

Lead Sheet #21380, Interview of Helicopter Mechanic of 159th, Feb. 2, 1999.

Lead Sheet #21574, Interview of Member of the 319^th Transportation Unit, Feb. 5, 1999.

Lead Sheet #23586, Interview of Chief of DoD Tactical Water Equipment Program, May 24, 1999.

Lead Sheet #23587, Interview of Assistant Chief, Medical Services Corps, May 24, 1999.

Lead Sheet #23643, Interview of TRADOC Project Officer for Field Water Supply in ODS/DS, May 24, 1999.

Lead Sheet #25266, Interview of 114th Evacuation Hospital Team Member, Nov. 4, 1999.

"Lessons Learned and Observations," United States Army Infantry School, December 1991.

"Lightweight Water Purifier," TARDEC Water and Wastewater web site http://www.tacom.army.mil/tardec/division/peth2o/peth2o.htm (As of Jan. 26, 2000).

Lindsay, James A., "Chronic Sequelae of Foodborne Disease," Emerging Infectious Diseases, October – December 1997.

"Manual of Naval Preventive Medicine," Department of the Navy, Bureau of Medicine and Surgery, Washington, DC, 1995.

"Major Subordinate Command Historical Reports – 7th Corps Support Group," Tab D, "Units Enclosure – Commander’s Report," ARCENT, VII Corps, May 29, 1991.

"Medical Capabilities Study of the Kingdom of Saudi Arabia," A Defense S&T Intelligence Study, May 15, 1992.

"Medical Characteristics of Chemical Warfare Agents," The Henry L. Stimson Center Chemical and Biological Nonproliferation web site – http://www.stimson.org/cwc/cwissues.htm (as of January 26, 2000).

Montcalm, Richard A., "Commentary – Water Purification on the Go," Army Logistician, September/October 1998.

"A National Security Strategy for a New Century," The White House web site - http://www.whitehouse.gov/WH/EOP/NSC/Strategy/ (as of Jan. 26, 2000).

"Nitrate Fact Sheet," United States Environmental Protection Agency web site - http://www.epa.gov/ngispgm3/iris/subst/0076.htm (as of Jan. 26, 2000).

"Nitrates/Nitrites Fact Sheet," United States Environmental Protection Agency, Office of Drinking Water and Ground Water, Jan. 23, 1998.

Nuki, George, "Ankylosing Spondylitis – HLA B27 and Beyond," The Lancet, March 14, 1998.

"Nutritional Guidance for Military Field Operations in Temperate and Extreme Environments," US Army Research Institute of Environmental Medicine and the Walter Reed Army Institute of Research, Natick, Massachusetts, Washington, DC, February 1993.

"ODS/Kuwait History – August 7, 1990 – December 31, 1991," United States Army Environmental Hygiene Agency, February 1992.

"Operation Desert Shield 483rd Medical Detachment, August 6, 1990 – Jan. 16, 1991," ARCENT, undated.

"Operations Desert Shield and Desert Storm Oral Interview – Commander of 101st Support Group," Department of the Army, XVIII Airborne Corps and US Army Center of Military History, Washington, DC, June 5, 1991.

"Operation Desert Shield Deployment Lessons Learned," Office of the Deputy Chief of Staff, Logistics, December 1990.

"Operation Desert Shield Deployment Lessons Learned," US Marine Corps, December 1990.

Osborn, Michelle, "Bottlers Battle to Supply Troops," USA TODAY, Aug. 27 1990.

Paparone, Christopher R., "How Does the Gulf War Measure Up?" Army Logistician, September-October 1998.

Pawelski, Natalie, "Bottled Water Taps Into Health Angst," CNN Interactive web site –

http:// www.cnn.com/HEALTH/9711/28/bottled.water/index.html (as of Jan. 26, 2000).

"Practical Guidance and Suggestions for Deployment and Survival In Desert Operations," CENTAF, Oct. 12, 1990.

"Preventive Medicine Implications from Crude Oil," United States Army Environmental Hygiene Agency, Feb. 1, 1991.

Proceedings of the 135th Armed Forces Pest Management Board Meeting, "Preventive Medicine on Operation Desert Shield - The First 40 Days," Nov. 14, 1990.

"Preventive Medicine Situation Summary Report, December 1 – 31, 1990" United States Army Environmental Hygiene Agency, January 1991.

"Questions and Answers About Reiter’s Syndrome," National Institute of Arthritis and

Musculoskeletal and Skin Diseases web site – http://www.nih.gov/niams/healthinfo/reiters.htm (as of Jan. 26, 2000)

"Reiter’s Syndrome," The Arthritis Society web site - http://www.arthritis.ca/pages/reiters (as of Jan. 26, 2000).

"Reiter’s Syndrome," University of Washington Orthopedic Physicians web site – http:// www.orthop.washington.edu/Bone%20and%20Joint%20Sources/izzzzzzz1_2.html (as of January 26, 2000)

Riley, Terrence, "Medical Services to the Marine Corps in Desert Shied and Desert Storm," The Journal of the US Army Medical Department, March/April 1992.

"Saudi Arabia," CIA World Fact Book – 1998, CIA web site – http:// www.odci.gov/cia/publications/factbook/index.html (as of Aug. 1, 1999).

"Schistosomiasis Fact Sheet," Centers for Disease Control and Prevention, Atlanta, GA, web site - http://www.cdc.gov/ncidod/dpd/schisto.htm (as of Dec. 21, 1999).

Seper, Jerry, "Allied Forces Will Have Water Despite Oil Spill," The Washington Times, Jan. 30, 1991.

"Sources and Foulability of Drinking Water in Kuwait," Defense Intelligence Agency, Sept. 30, 1990.

Special Assistant for Gulf War Illnesses, "Medical Surveillance During Operations Desert Shield/Desert Storm" (Information Paper) Nov. 13, 1997.

Squires, Sally, "Harsh Conditions Pose Hazard to GIs in Persian Gulf," The Washington Post, Oct. 9, 1990.

Stanley, Doris; "Arthritis from Foodborne Bacteria?" Agricultural Research, October 1996.

"Status of Oil Fires," Central Intelligence Agency, January 1991.

"Sustaining Soldier Health and Performance in Southwest Asia: Guidance for Small Unit Leaders," Natick, MA, US Army Research Institute of Environmental Medicine and the Walter Reed Army Institute of Research, Washington, DC, October 1994.

"TAC SGPB Bioenvironmental Engineering Experiences and Issues," Department of the Air Force, Headquarters, Tactical Air Command, July 10, 1991.

Taylor, Dan, Report on Iraqi Oil Tankers and Desalination Plants, Jan. 31, 1991.

"TB Med 577 - Occupational and Environmental Health: Sanitary Control and Surveillance of Field Water Supplies," Edgewood, MD, US Army Center for Health Promotion & Preventive Medicine, March 7, 1986.

"Tighter Regulation of Bottled Water Sought After Tests of 103 Brands," The Washington Post, March 31, 1999.

US Air Force Instruction 91-10, "Civil Engineering – Water Systems," Jan. 2, 1990.

US Air Force memorandum, Subject: "Drinking Water Surveillance," October 1990.

US Air Force memorandum, Subject: "Preventive Medicine Guidance for Operation Desert Shield," August 1990.

US Army Center for Medical Lessons Learned, "Lesson #714 – Need Info/Policy on Use of Flavorings in Water," Fort Sam Houston, San Antonio, Texas, May 5, 1993.

US Army Center for Medical Lessons Learned, "Lesson # 716 – Environmental Sampling Equipment Not Adequate," Fort Sam Houston, San Antonio, Texas, May 5, 1993.

US Army Field Manual 10-1, "Quartermaster Principles," Washington, DC, August 11, 1994.

US Army Field Manual 10-52, "Water Supply in Theaters of Operations," Washington, DC, July 11, 1990.

US Army Field Manual 10-52-1, "Water Supply Point Equipment and Operations," Washington, DC, June 18, 1991.

US Army Field Manual Number 10-280, "Quartermaster Field Service Company Direct Support," Washington, DC, Oct. 22, 1986.

US Marine Corps point paper, "SECDEF Postwar Briefing on Desert Storm Equipment Performance – Water Purification, Storage, and Distribution," July 23, 1991.

"USAF Report on Drinking Water Surveillance Program," 314 TAW, October 1990.

USCENTAF message, Subject: "False Positives Using M272 Kits," February 1991.

USCENTAF message, Subject: "Foodborne Illness Outbreak," Feb. 19, 1991.

USCENTAF message, Subject: "4 CES SITREP," Feb. 5, 1991.

USCENTAF message, Subject: "FWD SITREP," September 1990.

USCENTAF message, Subject: "ROWPUs," October 1990.

USCENTAF message, Subject: "Saudi Arabia: Desalination Capabilities."

USCENTAF/DE message, Subject: "Effects of High Temperature on Personnel and Ration Storage," Oct. 12, 1990.

USCENTCOM message, Subject: "Oil Slick," Jan. 27, 1991.

Walton-Knight, Matthew, "Supplying Water to the British Army During the Gulf War," The Royal Engineers Journal, Chatham, England, August 1994.

"The Water Quality Analysis Set-Purification," TARDEC Petroleum and Water Quality Team web site - http://www.tacom.army.mil/tardec/division/peth2o/peth2o.htm (as of 1/26/00).

The Whirlwind War: The United States Army in Operations Desert Shield and Desert Storm, Schubert, Frank N., and Theresa L. Kraus, ed., Center of Military History, United States Army, Washington, DC, 1995.

1. An acronym and abbreviation list and a glossary of terms used in this close-out report are in Tab A.
2. Hyams, K.C., A.L. Bourgeois, B.R. Merrell, et al, "Diarrheal Disease During Operation Desert Shield," The New England Journal of Medicine, Boston, Mass, Nov. 14, 1991.
3. Christopher, George W., Theodore J. Cieslak, Julie A. Pavin, Edward M. Eitzen Jr., "Biological Warfare: A Historical Perspective," The Journal of the American Medical Association, Aug. 6, 1997, p. 412.
4. Grau, Lester W., William A. Jorgensen, "Beaten by the Bugs: The Soviet-Afghan War Experience," Military Review Magazine, November/December 1997.
5. Headquarters, Department of the Army, "Field Manual Number 10-52-1 - Water Supply Point Equipment and Operations," Washington, DC, June 18, 1991, Chapter One, p. 19.
6. USCENTAF, Message, Subject: "Drinking Water Surveillance Report," p. 1.
7. Lead Sheet #15374, Interview of Member of the 96th Civil Affairs Battalion, March 9, 1998.
8. Kravitz, Daniel, "Combined Water Purification Unit Training," Army Logistician, May/June 1996.>
9. Hyams, K.C., A.L. Bourgeois, B.R. Merrell, et al, "The Navy Forward Laboratory During Operations Desert Shield/Desert Storm," Association of Military Surgeons of the United States, 1993, p. 729.
10. Lead Sheet #23643, Interview of TRADOC Project Officer for Field Water Supply in ODS/DS, May 26, 1999.
11. Hanson, Kevin, "The Navy's Preventive Medicine Experience in Desert Shield," The Journal of the US Army Medical Department, March/April 1992, p. 48.
12. Lead Sheet #8831, Interview of Chief of Housing at Dhahran, April 16, 1997.
13. Al-Tisan, I.A.R., J.P. Chandy, A. Abanmy, and A.M. Hassan, "Optimization of Seawater Reverse Osmosis Pretreatment - Part III - A Microbiological Approach," Abu Dhabi Proceedings, International Desalination Association, 1995.>
14. Proceedings of the 135th Armed Forces Pest Management Board Meeting , "Preventive Medicine on Operation Desert Shield - The First 40 Days," Nov. 14, 1990, p. F-5."
15. US Army Field Manual Number 10-52-1, "Water Supply Point Equipment and Operations," Washington, DC, June 18, 1991, Chapter one, p. 19.
16. "Annex L (Field Sanitation) to 506th MED CO FSOP," ARCENT, undated. "Operation Desert Shield 483rd Medical Detachment, August 6, 1990 - January 16, 1991," ARCENT, undated.
17. Walton-Knight, Matthew, "Supplying Water to the British Army During the Gulf War," The Royal Engineers Journal, Chatham, England, August 1994, p. 155.
18. US Army, Field Manual 10-52-1, "Water Supply Point Equipment and Operations," Washington, DC, June 18, 1991, Chapter one.
19. Lead Sheet #23586, Interview of Chief of DoD Tactical Water Equipment Program, May 26, 1999.
20. Lead Sheet #23643, Interview of TRADOC Project Officer for Field Water Supply in ODS/DS, May 26, 1999.
21. Jehl, Douglas, "Desert Dilemma: How to Shut Off that Designer Water, Get Back to Canteens," The Los Angeles Times, Sept. 25, 1990, Part A, p. 8, column 1.
22. Lead Sheet #23586, Interview of Chief of DoD Tactical Water Equipment Program, May 26, 1999.
23. US Army, Field Manual 10-52-1, "Water Supply Point Equipment and Operations," Washington, DC, June 18, 1991, Chapter one, p. 12.
24. Lead Sheet #8778, Interview of Marine Corps E-3, MOS1171/Hygiene Equipment Operator, Water Purification, June 2, 1995.
25. Walton-Knight, Matthew, "Supplying Water to the British Army During the Gulf War," The Royal Engineers Journal, Chatham, England, August 1994, p. 158.
26. "24th Mechanized Infantry Division Operation Desert Storm After-Action Report," May 31, 1991.
27. Lead Sheet #8778, Interview of Marine Corps E-3, MOS1171/Hygiene Equipment Operator, Water Purification, June 2, 1995.
28. US Army Field Manual 10-280, "Quartermaster Field Service Company Direct Support," Washington, DC, Oct. 22, 1986, p. 49-50.
29. Lead Sheet #21574, Interview of Member of the 319th Transportation Unit, February 5, 1999.
30. Lead Sheet #10043, Interview of Member of 4th/32d Armor, 1st Infantry Division, December 30, 1996.
31. Special Assistant for Gulf War Illnesses, "Medical surveillance during Operations Desert Shield/Desert Storm," Information Paper, November 13, 1997, web site - /nfl/ (As of Jan. 26, 2000)
32. Special Assistant for Gulf War Illnesses, "Medical surveillance during Operations Desert Shield/Desert Storm," Information Paper, November 13, 1997, web site - /nfl/ (As of Jan. 26, 2000).
33. Lead Sheet #25266, Interview of 114th Evacuation Hospital Team Member, Nov. 4, 1999, p. 2.
34. "AAR Comments ODS and DS 14th Preventive Medicine Unit," ARCENT, April 9, 1991, p. 4.
35. Paparone, Christopher R., "How Does the Gulf War Measure Up?" Army Logistician, September-October 1998, p. 1.
36. "Major Subordinate Command Historical Reports - 7th Corps Support Group," Tab D, "Units Enclosure - Commander's Report," ARCENT, VII Corps, May 29, 1991.
37. Departments of the Army, Navy, and Air Force, "Sanitary Control and Surveillance of Field Water Supplies," Washington, DC, May 1999.
38. Departments of the Army, Navy, and Air Force, "Sanitary Control and Surveillance of Field Water Supplies," Washington, DC, May 1999, p. 25.
39. Bosworth, Robert O., "Unit-Level Water Resupply - It's in the Bag," Army Logistician, May-June 1999, p. 21-23./li>
40. Choi, Jinoo V., "Bag Water for Operation Joint Endeavor," Army Logistician, September-October, 1997.
41. Choi, Jinoo V., "Bag Water for Operation Joint Endeavor," Army Logistician, September-October, 1997.
42. "1,500 GPH ROWPU Team," TARDEC Water and Wastewater web site - http://www.tacom.army.mil/tardec/division/peth2o/peth2o.htm (as of Jan. 26, 2000).
43. "Lightweight Water Purifier," TARDEC Water and Wastewater web site - http://www.tacom.army.mil/tardec/division/peth2o/peth2o.htm (as of Jan. 26, 2000).
44. "Canteen Insert Water Purifier," TARDEC Water and Wastewater web site -http://www.tacom.army.mil/tardec/division/peth2o/peth2o.htm (as of Jan. 26, 2000).
45. Special Assistant for Gulf War Illnesses, "Medical surveillance during Operations Desert Shield/Desert Storm," Information Paper, November 13, 1997, web site - /nfl/ (As of Jan. 26, 2000).
46. US Army Center for Medical Lessons Learned, "Lesson # 716 - Environmental Sampling Equipment Not Adequate," Fort Sam Houston, San Antonio, Texas, May 5, 1993.