By Jennifer Rizzo and Saundra Young
The long-term health effects of exposure to military burn pits used for trash disposal are still uncertain, according to a new study commissioned by the Defense Department.
The Institute of Medicine says "insufficient data" on service members' exposures to open-air pit emissions is one reason the results were inconclusive. High background levels of pollution in the surrounding area, along with a lack of information about the amount and makeup of the waste burned, also made it difficult to analyze the data.
The emissions have been the source of controversy as troops returning from Iraq and Afghanistan have blamed health problems such as cancerous tumors and respiratory issues on exposure to burn pit emissions.
Before an initial outcry about the pits more than three years ago, the largest base in Iraq - Balad Air Base - was burning everything from hazardous and medical waste to plastics, using jet fuel as an accelerant, according to military documents. The smoke poured over the living quarters and the base hospital, exposing thousands of troops to the emissions.
Military officials have denied any consequential effects on most troops, but after Defense Department testing, news reports and congressional hearings, the Department of Veterans Affairs asked the Institute of Medicine to conduct its own study on long-term health effects.
Using data collected mostly from Balad Air Base, the study showed that levels of pollutants there were not higher than levels measured at other "polluted sites worldwide" and were a mixture of burn pit emissions and pollutants from the environment
"Most of the pollutants detected at JBB (Joint Base Balad) were present at concentrations lower than health-based reference values of individual pollutants that are considered to be protective of the general U.S. population," the study said. The exceptions were pollutants that could not "be attributed primarily to the burn pit."
The study also said that long-term health issues may be caused by something other than burn pit emissions, given the variety of other hazards and substances that troops are exposed to in the field.
The Defense Department says it is reviewing the report.
"The DoD will closely review and evaluate the IOM's findings and recommendations for ways we can work with the VA so that we can better answer the questions regarding health risks associated with burn pit smoke or with the high levels of airborne particulate matter," said Cynthia Smith, a Defense Department spokeswoman.
The Pentagon is also looking into establishing an expert panel to further examine the issue, Smith said.
Open-air waste burning has long been used by the military for waste disposal and had been the primary form of waste disposal in Iraq and Afghanistan until 2009, when the use of burn pits was restricted. Their use in Iraq has gradually been phased out, but the practice continues in Afghanistan, where 100 sites with populations of more than 100 personnel are still up and running. Efforts are under way to get incinerators in place at each of these locations, Smith said.
About 10 pounds of waste is generated per service member every day, meaning that on large bases in Iraq and Afghanistan, an average of 30 to 42 tons of waste is produced on a daily basis. Balad Air Base's population sometimes swelled past 25,000 people, and it could have burned between 100 and 200 tons of waste on any given day, according to the report.
Dr. Robert Miller, a pulmonologist at the Vanderbilt-Ingram Cancer Center at Vanderbilt University who recently published a study in the New England Journal of Medicine on troops exposed to burn pits, said the study would have yielded different results if the Institute of Medicine had all the information it needed.
"I think the IOM felt like they did not have the data they needed to really answer the question whether people were clearly harmed by the burn pits or not," he said. "I think they felt frustrated by the data they had. And I think they felt like it was likely the things that they measured were at higher concentrations than what was reported."
The health effects associated with burn pit emissions are long-term and have to be studied over an extended period of time, Miller said.
"I think the other conclusion of the IOM is at this point, we are dealing with disorders that are progressive and there are likely to be problems down the road that we don't know about now."
The doctor says a registry is needed to track troops with respiratory problems after deployment.
"We need to know where you were, what do you think your exposures were, what can't you do now that you could do before deployment. And we need centers of excellencies to evaluate these patients."
Miller began seeing soldiers with the disorder in 2004. Since then, he has examined about 50, mostly from Fort Campbell, Kentucky. Lung biopsies revealed constrictive bronchiolitis, a rare and life-threatening lung disease in which small airways, or bronchioles, are compressed and become narrow because of inflammation and scar tissue.
The common thread was that all had been to Iraq and exposed to smoke from the Mishraq sulfur mine fires or the burn pits on bases like Balad.
"We started seeing people as they came back with shortness of breath," Miller said. "Most came back and could not pass physical training. They could not complete their two-mile run without stopping. Most were elite athletes that could run two miles in 13 minutes. When we evaluated them, almost all had normal chest x-ray and pulmonary function tests. Surgical lung biopsies found constrictive bronchiolitis - a lesion in the lung known to be associated with toxic inhalation."
Miller said that typically, a biopsy would not be done if the chest x-ray and breathing tests were normal because the procedure is invasive. He ordered them because he could find no reason for the patients' shortness of breath.
"They had a real story of being limited, and I did not understand why. I did everything else to evaluate their shortness of breath," Miller said. "A lot are carried as having asthma, and none had asthma when deployed, they don't respond to asthma treatment, and when you do the biopsy, you see something that is not explained by asthma - lesions."
Dr. Joyce Johnson, a Vanderbilt lung pathologist, read the biopsies, looking for microscopic abnormalities. At first glance, they looked relatively normal, but a closer look revealed a narrowing of the bronchioles, the smallest air passages.
"They are not getting adequate air flow," Johnson said. "They are young, incredibly fit people who are now limited in what they can do physically. We don't know what's causing this, but what they have in common is they are healthy, in this war and have no reason to have this problem. The burn pits seem to be the common thread as best we can ascertain.”
According to Johnson, the diagnosis is very uncommon. Typically, she might see one or two of these biopsies a year. Vanderbilt is a referral center for the area, so it sees cases from around the region. A standard urban hospital, she said, would see even fewer cases. The long-term prognosis is hard to predict.
"We don't know what the expected outcome is for these folks. This is a new phenomenon. The ones that become scarred are probably not going to be resolved. But since they are no longer exposed, they will not get worse."
Chief Warrant Officer Jimmy Williams has had three tours of duty in Iraq. He's spent time in Balad and Mosul. On all three rotations, he said, he was exposed to burn pits. He says his symptoms began shortly after his first tour in 2005. Initially, he thought he was just out of shape, and before too long, he was heading back to Iraq.
"My second rotation, I lived right next to the burn pits in Balad for 15 months and that burned 24 hours a day, seven days a week, 365 days a year," Williams said. "It was huge, eight acres, and they burned everything they could: buildings that were torn down, hospital waste, I watched vehicles rolled in there, it was amazing what was burned. At night, we were covered with a fine ash - a black soot - and we would wake up choking, but didn't think anything of it. We just did our job. There was like a black cloud that settled over our sleeping area, our housing. And when the weather was bad, it just settled right there where we were and it wouldn't go away for a day or two."
By the time his final tour was over in 2009, he knew he was in trouble.
"I came back from Iraq in 2009, and I was choking real bad, short of breath real bad, and it kept getting worse and worse." A pulmonologist at Fort Campbell performed a series of tests and referred him to Miller after he found a small node on his left lung. The diagnosis was constrictive bronchiolitis and lung inflammation. He says he has no doubt it was caused by the burn pits.
Today, this grandfather says he gets short of breath easily, has a lot of chest pain and very little stamina. He's unable to do such simple tasks as mowing the lawn without constantly stopping to rest after just a couple of pushes. It's hard, he says, to play with his 15 grandchildren the way he used to. He retired after 32 years of service.
"I used to be really active, I used to be able to do a lot of things, yard work," Williams said. "I just had to change my life and do things at a lot slower pace. I gained weight because I can't exercise anymore. It's just really slowed me down to a snail's pace."
Now the 54-year old military contractor is a champion for other veterans. He has testified in Washington before the Senate Committee on Veterans' Affairs in an effort to bring attention to this disease.
"We are wounded on the inside. You can't see it on the outside, but we're wounded on the inside. And there's more soldiers out there that have my disease, but they don't know they have it. I will continue to speak out every chance I get because soldiers need help. They need to be taken care of. They served their country, they don't complain, they do their job unconditionally. They are heroes, and I feel the medical system should take care of them."
In March 2010, Miller got word that the military would no longer allow civilian evaluations of veterans with post-deployment respiratory disorders. The official reason he says he was given was that this was a way for the military to look at the problem; that it would be a more cost-efficient method.
"I am concerned about the fact that a lot of the people we have been evaluating and finding constrictive bronchiolitis are not likely to get biopsied in Army facilities. I think the Army feels like there's not an indication to do it if pulmonary function testing and x-rays are normal."
Some vets have been allowed to go back to Vanderbilt for treatment. Miller sees about 15 of them, and most are no longer in the military but have disability ratings that allow them to be treated there using their coverage from Tricare, the Department of Defense's health care program. Others have private insurance. He says that because there is no real defined treatment for this disease, he is mostly just following their cases.
"We may need to go back under a different charge and determine how we evaluated patients with shortness of breath following service and issue some guidance on disability ratings in this population of soldiers," he said. "The current strategies make it difficult; they are mostly based on pulmonary function testing. I have guys not fit to continue to serve and not eligible for a disability rating because their pulmonary function tests are too good."
Miller, who has also testified before the Senate's Committee on Veterans' Affairs on post-deployment respiratory disorders, says he still hopes to work with the VA on this problem. He's pushing for the military to do a pulmonary function test before soldiers are deployed and says a registry of soldiers with post-deployment respiratory disorders should be set up. "We are still very engaged with the VA in trying to determine how to assess this population once they get into the VA system," he said.
The Disabled American Veterans organization, which until recently kept a database of troops who reported health problems related to the pits, is concerned that the inconclusive study will allow the Defense Department to close the case on the issue.
"My concern is they're going to say we monitored this situation and there wasn't sufficient evidence, and so we don't need to do anymore," the DAV's John Wilson said.
Before the organization's database was closed, about 550 troops reported health problems ranging from asthma to cancer.
"Our concern is they have denied in the past. When it came to Agent Orange, they denied the issue for too long, which meant over many years, veterans couldn't get VA health care without having to pay a co-pay and couldn't get disability compensation," Wilson said. "Will they act, or will they continue to deny?"