Veterans for Common Sense

December 2011 (US Medicine) – Whether exposure to war zone burn-pits causes long-term health issues has created heated debate among military officials, veterans, Congress members and currently deployed troops.

Unfortunately, a long-awaited report does little to provide definitive answers or cool down the controversy.

A recent Institute of Medicine (IoM) report done at the request of the VA concluded that it could not say whether troops’ exposures to emissions from open-air burn-pits cause ongoing health effects. The report leaves open the possibility that the burn-pits or other sources of air pollution could be causing respiratory problems in deployed troops, which some researchers maintain is occurring.

Among the reasons for the IoM’s inconclusive results were “insufficient data” on troops’ exposures to open-air burn-pits as well as high background levels of ambient pollution from other sources and lack of information on the quantities and composition of wastes burned in the pits, all of which “complicate interpretation of the data,” according to the authors.

“In light of its assessment of health effects that may result from exposure to air pollutants detected at [Joint Base Balad in Iraq] and its review of the literature on long-term health effects in surrogate populations, the committee is unable to say whether long-term health effects are likely to result from exposure to emissions from the burn pit,” the report summary stated.

While the IoM committee could not come to a conclusion about the health effects of the burn-pits, it did state that, “a broader consideration of air pollution than exposure only to burn pit emissions,” might be associated with long-term health effects in Iraq and Afghanistan, “particularly in highly exposed and/or susceptible populations, mainly because of high ambient concentrations of [particulate matter].”

The report recommended that further study be conducted to evaluate the health status of troops from their time of deployment to Joint Base Balad into the future to determine health problems that might not show until many years later.

“We didn’t find a smoking gun,” IoM committee report member Mark Frampton, MD, of the University of Rochester Medical Center, told U.S. Medicine. “The monitoring data that was done by the military at the Balad Pit didn’t show huge differences from what we know is in air pollution in polluted cities around the world. There was a high level of particulate matter, certainly higher than air quality standards around the world, but much of that didn’t seem to be coming from the burn pit. It was from other sources around the base and from windblown dust. What we can’t be sure about is whether something was missed.”

Frampton said that, while the committee did not find evidence “implicating the burn-pits,” he explained this “doesn’t mean that they are not having long-term health effects.”

“The only way to really answer that question is to study the people that have been exposed, and that hasn’t been done so far,” he said.

Burn-pits a Health Hazard?

The health impact of burn-pits has been a hot-button issue. Troops and veterans have expressed concern that their respiratory and other ailments are linked to exposure to those areas, where materials such as chemicals, paint, medical and human waste, aluminum cans, munitions and other unexploded ordnance, petroleum and lubricant products, plastics and Styrofoam, rubber, wood or discarded food are incinerated. Some researchers also have raised concern, particularly when it comes to respiratory issues. In a study published in September, VA researcher Anthony Szema, MD, noted that what he and other researchers have dubbed “new-onset Iraq/Afghanistan war lung injury” (ILI) is common, and rates of symptoms leading to a diagnosis requiring spirometry are high. His research suggests that dust, aeroallergens and uncontrolled burning of trash in Balad burn-pits without the use of incinerators prior to November 2009 may be among the causes of ILI.

In June, Matthew King, MD, a pulmonologist who has been examining respiratory issues among troops and veterans, spoke on behalf of the American Thoracic Society at a congressional hearing. He said pulmonologists are “deeply concerned” about the respiratory issues that some military personnel are suffering, such as constrictive bronchiolitis (CB). He also cited the burn-pits, noting that troops in Iraq and Afghanistan are faced with a barrage of respiratory insults, “ranging from dust storms to inhaled smoke from burn-pits to aerosolized metal and chemicals from exploding IEDs, blast overpressure or shock waves to the lung, outdoor aeroallergens such as date pollen and indoor aeroallergens such as mold aspergillus.”

DoD, however, has maintained that its studies have not found that the burn-pits pose a health risk to troops. DoD officials told U.S. Medicine in a written statement that the IoM’s findings “reflect similar findings of the DoD in the continued attempts to find an association between burn-pit emissions and health consequences.”

Moving forward, the military will “closely review and evaluate the IoM’s findings and recommendations” for ways it can work with the VA “to better answer the questions regarding health risks associated with burn-pit emissions or with the high levels of airborne particulate matter,” DoD officials wrote.

Paul Ciminera, MD, codirector, of VA’s Environmental Health Program, said in response to the report that the VA will form a workgroup to provide recommendations. “Among those recommendations will be the overall structure of the research approach,” he told U.S. Medicine. “We will be working closely with DoD to make sure we understand the IoM recommendations and come up with an approach in the most efficient and effective means possible.”

Terry Walters, MD, deputy chief consultant for VA’s Post-Deployment Health, said she felt that an important part of the IoM report is that it “may not be burn-pits,” but the increased particulate matter or pollution in the air in both Afghanistan and Iraq that may be of interest.

“Burn-pits get all the press because you can see it, you can smell it, there is obvious smoke coming from a point source. But, one of the major important things about this study was that it’s probably pollution — think Pittsburgh in 1950 — rather than just burn-pits,” she told U.S. Medicine.

IoM Findings

For the IoM study, the committee analyzed data on air-monitoring at Joint Base Balad (JBB); health-effects information on chemicals detected in more than 5{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} of the air-monitoring samples at JBB; and health-effects information on populations considered to be surrogates of military personnel exposed to combustion products from burn-pits.

The committee analysis of the raw data from DoD’s air-monitoring efforts at JBB concluded that levels of most pollutants of concern were not higher than levels at other polluted sites worldwide. The air-monitoring data suggest that the pollutants of greatest concern at JBB include a “mixture of chemicals from regional background and local sources — other than the burn pit — that contribute to high PM,” according to the report.

The committee concluded that research on other populations exposed to complex mixtures of pollutants, “has not indicated increased risk for long-term health consequences such as cancer, heart disease and most respiratory illnesses among these groups.”

However, the committee also cited shortcomings in the data it analyzed. For example, there was a lack of specific information on the wastes burned and on other sources of background pollution.

It also was hard for the committee to determine whether the experience of surrogate populations they studied could apply to troops stationed at JBB. The IoM team also indicated that the monitoring data provided by DoD was lacking and that its measurements did not include ozone, carbon monoxide, nitrogen dioxide or sulfur dioxide.

Pointing to the gaps in the data and the IoM’s conclusion, Robert Miller, MD, a pulmonologist at Vanderbilt-Ingram Cancer Center, Nashville, TN, said he was not “reassured that the burn-pits are safe.”

Miller and King authored an article published in July’s New England Journal of Medicine that showed soldiers returning from the wars in Iraq and Afghanistan are suffering from severe respiratory issues. That study found that, of a cohort of 80 troops, 38 were found to have CB. In this group of soldiers, 28 had served in northern Iraq in 2003 and reported having been exposed to smoke from a sulfur-mine fire near Mosul, and many had reported exposure to dust storms and open burn-pits.

One of Miller’s concerns is that returning troops from Afghanistan and Iraq are experiencing serious respiratory issues that may not be caught if physicians rely on X-rays and pulmonary-function testing alone.

“We know that there are at least 10{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} to 15{cd9ac3671b356cd86fdb96f1eda7eb3bb1367f54cff58cc36abbd73c33c82e1d} of soldiers who complain of respiratory issues,” he told U.S. Medicine. “We think there are a number of guys like ours [at Vanderbilt] that might be dismissed as normal because their conventional workups are normal. In our case, it took a lung biopsy to prove these guys were affected,” he said.

Miller said he also would like to see soldiers undergo a baseline pulmonary-function testing before they deploy.

“We would like their physical testing to be a part of their medical record, so we could know exactly what they could do and when they could do it,” he said. “We want to know a little more about the exercise capacity and the pulmonary function capacity of the population being deployed.”