For more than a century now, American service members who have gone to war have found themselves in dynamic, often chaotic surroundings, far different from the familiar and well-regulated environment of home – and many have suffered health problems as a result. World War I veterans, after exposure to poison gas weapons on the European front, returned home complaining of respiratory problems. Atomic-era veterans who’d either participated in weapons tests, been prisoners of war in Japan, or occupied the cities of Hiroshima and Nagasaki after their bombing encountered ionizing radiation. Vietnam veterans who came into contact with the herbicide Agent Orange have reported a variety of health problems, and a quarter-of-a-million veterans of the Gulf War of 1990-1991 complained of a chronic multisymptom disorder known as Gulf War syndrome, which is still being studied today.

In each of these cases, the departments of Defense (DOD) and Veterans Affairs (VA) have worked to determine causes and improve health outcomes for returning veterans – but their efforts have often progressed more slowly than veterans and their advocates would have wanted. The deliberate pace of ex post facto data-gathering, research, and resulting clinical practices is often criticized, most notably in the cases of Agent Orange and Gulf War syndrome.

The VHA’s Office of Public Health created the Airborne Hazards and Open Burn Pit (AH&OBP) Registry, an effort mandated by law in 2013 and launched in summer 2014 to gather data to feed into the studies suggested by the IOM. The registry is open to anyone, veteran or active-duty military, who served in Iraq or Afghanistan; was stationed in Djibouti after Sept. 1, 2001; or who served in the 1991 Persian Gulf War and may have been exposed to oil fires and dust. Registrants may also request a free medical exam.

The modern version of the VA’s environmental health effort, the Post-9/11 Era Environmental Health Program within the Office of Public Health, represents a joint effort to begin this data-gathering effort as early as possible to better understand differences in service member health before and after deployment. As soon as veterans began separating from wartime service in Afghanistan and Iraq, the DOD’s preventive medicine experts began providing their VA counterparts a list of who’d been deployed, and to where. The VA gathered health care data from these personnel and prepared quarterly reports. Environmental health coordinators were (and continue to be) stationed at VA medical centers to help returning veterans understand and receive care for any health problems that might have arisen from hazards – chemical, physical, or environmental – they might have encountered during their deployment.

More than a decade of data and anecdotal reports from Iraq and Afghanistan are increasingly suggesting that the air itself has been one of the signature hazards of the Southwest Asia theater. A number of returning veterans have reported respiratory illnesses, and outside the VA’s own research system, several experts have suggested these illnesses, along with other symptoms such as chronic fatigue and recurrent headaches, might be linked to hazardous materials in the air – either borne on the dusty desert winds or emanating from one of the hundreds of open-air burn pits used to dispose of waste at forward installations. Beginning in 2003, Navy Capt. Mark Lyles, chair of medical sciences and biotechnology at the Naval War College, studied dust particles sampled from the air in Iraq and Kuwait and found 37 different metals, including aluminum, lead, chromium, manganese, and tin. According to existing research by the Environmental Protection Agency, these metals have been linked to neurological disorders, respiratory ailments, depression, and heart disease. The dust also contained 147 different kinds of bacteria and several fungi that could cause disease.

Another early indicator of a potential link between particulate matter and service members’ respiratory illness was a study reported in the New England Journal of Medicine in July 2011, which revealed diagnoses of constrictive bronchiolitis (CB), a rare and incurable lung disease, among soldiers – most of them from the 101st Airborne Division, Fort Campbell, Kentucky – who had returned from deployment and were no longer able to meet the Army’s physical fitness standards due to shortness of breath. Bob Miller, a pulmonologist at Vanderbilt University Medical Center, examined 80 soldiers, many of whom had long-term exposure to a fire at a sulfur mine near Mosul, Iraq, in 2003. Forty-nine of these soldiers agreed to an invasive lung biopsy after X-rays and other tests failed to reveal a cause. All 49 tissue samples were judged to be abnormal, and 38 resulted in a diagnosis of CB – a scarring and thickening of the walls of the smallest lung passages. Miller and colleagues concluded from these biopsies that CB could be linked to service in Iraq and Afghanistan; the biopsies also revealed dust particles in the patients’ lungs.

In a 2006 memo, and in 2009 testimony before the U.S. Senate, then-Air Force Lt. Col. Darrin Curtis, a bioenvironmental flight commander at Iraq’s Joint Base Balad, warned that open-air burn pits represented an “acute health hazard for individuals,” citing a number of possible toxic contaminants in the smoke, such as arsenic, benzene, cyanide, toluene, and formaldehyde. The types of waste burned in these pits varied widely until 2009, when the military updated its policies to prohibit the burning of toxic materials such as solvents, batteries, jet fuel, tires, and some medical wastes.

To learn more about the issue of burn pits and service members’ health, the VA commissioned a study by the Institute of Medicine (IOM, now the National Academy of Medicine), which reported in 2011 that while there was evidence that exposure to smoke from burn pits may cause short-term reductions in lung function, there wasn’t enough data to draw any conclusions about long-term respiratory health consequences. On the heels of this report, then-Secretary of Veterans Affairs Eric Shinseki directed the Veterans Health Administration (VHA) to conduct long-term prospective studies on all adverse health effects that might be related to deployment in Iraq and Afghanistan, including those that might be related to exposure to airborne hazards and burn pits.

The VHA’s Office of Public Health created the Airborne Hazards and Open Burn Pit (AH&OBP) Registry, an effort mandated by law in 2013 and launched in summer 2014 to gather data to feed into the studies suggested by the IOM. The registry is open to anyone, veteran or active-duty military, who served in Iraq or Afghanistan; was stationed in Djibouti after Sept. 1, 2001; or who served in the 1991 Persian Gulf War and may have been exposed to oil fires and dust. Registrants may also request a free medical exam.

The VA also views the registry as an online tool for increasing veterans’ access to information. Visitors to the site can connect with resources to help them learn more about their health concerns, schedule an examination, or file a compensation claim. It also provides a channel for the VA to reach back to registrants if new developments arise.

As of April 2018, more than 140,000 service members and veterans had signed up for the registry, and several studies were under way within the VA, the DOD, and the Joint Pathology Center, including comparisons of cardiopulmonary function and other health measures during and after deployment to burn pit and non-burn pit sites; birth outcomes among service members after burn pit exposure; molecular indicators (biomarkers) of burn pit exposure; analysis of more than 20,000 biopsy samples (including about 500 cancer tissues) from deployed service members; and the effects of pulmonary exposure to particulate matter among animal models.

Within the VA, much of this research is coordinated by the War-related Illness and Injury Study Center (WRIISC) in East Orange, New Jersey. “They focus on lung injury and deployment-related lung disease,” said Dr. Patricia Hastings, DO, MPH, FACEP, RN, a retired Army colonel who now serves as deputy chief consultant for the VA’s Post-deployment Health Services. “A lot of the really important research that’s going on has been done there by their pulmonary physiologist.” The WRIISC also serves as a kind of center of excellence, a site for specialty care related to environmental exposures that often receives cases from other VA facilities, where providers may be encountering cases they haven’t seen before.

The research foundation for this specialty care is admittedly in need of growth, and both DOD and VA have been battered, in recent years, by news stories profiling veterans who’ve suffered serious health problems – neurological disorders, strange rashes, rare and aggressive cancers – that they and their family members claim were linked to burn pit exposure. In February 2017, for example, Amie Muller, a 36-year-old wife and mother of three who served in the Air National Guard as a photojournalist during two (2005 and 2007) tours in Iraq, died of pancreatic cancer, which her family attributed to burn pit exposure. In response, Sen. Amy Klobuchar, D-Minn., from Muller’s home state, co-sponsored a bill that would compel the VA to create a center of excellence dedicated solely to accelerating and improving its understanding of the health effects associated with burn pits, and to treat veterans who become sick after exposure. That provision passed the Senate, but the final defense authorization for 2018 contained watered-down language directing the VA to “coordinate efforts related to furthering understanding of burn pits, the effect of burn pits on veterans, and effective treatments relating to such effects, including with respect to research efforts and training of clinical staff on related matters” – which the VA already does, using the WRIISC as its center of excellence.

Klobuchar and her bill’s co-sponsor, Thom Tillis, R-N.C., aren’t alone, however, in believing the federal bureaucracy needs to move faster to respond to what may be a war-related health crisis. In September 2016, the Government Accountability Office issued a report to Congress that implored the agencies to redouble their efforts at assessing the health effects of burn pit exposure. “Although DOD and the Department of Veterans Affairs have commissioned studies to enhance their understanding of burn pit emissions,” the report stated, “the current lack of data on emissions specific to burn pits and related individual exposures limits efforts to characterize potential long-term health impacts on service members and other base personnel.”

After a 2015 report indicated that nearly 40 percent of those who began filling out the AH&OBP Registry questionnaire didn’t complete it, the VA turned again to the National Academy of Medicine to look over and offer advice on the first phase of its data-gathering efforts. The academy’s evaluation, released in February 2017, contained several recommendations for improving the administration and use of the registry: recommending, for example, that the VA evaluate whether and how registrants who did not complete the questionnaire differ from those who did; analyze why some registrants didn’t complete it; and use this information to develop strategies that encourage registrants to finish and submit their responses. At the same time, the academy pointed out that self-reported data isn’t the best resource of information on interrelationships between exposures and health outcomes. “It’s important to understand,” the authors wrote in an overview of the report’s highlights, “that even a well-designed and executed registry would have little value as a scientific tool for health effects research compared to a well-designed epidemiologic study.”

Hastings said the VA has taken the academy’s recommendations to heart and streamlined the questionnaire – its online format has been shortened from 17 pages to two – but has been cautious about making drastic changes now that there are already tens of thousands of registrants. To do so would risk producing two distinct research cohorts, rather than one large one. “Changing the questions midstream makes it less valid,” she said. “Keeping the questions very similar overall is more helpful to the studies we’re doing.”

Epidemiological research that can conclusively prove or disprove a cause-effect relationship between airborne hazards and illness is particularly challenging because of the diffuse and varied experiences of service members. So many different items were burned, at different times, in different burn pits, that the creation of a framework for studying their effects seems difficult, if not impossible. It’s also likely that the particulate matter causing respiratory disease among service members might come not solely from burn pit smoke, but from ground surface dust, as Lyle’s study suggested. A few years ago Dr. Anthony M. Szema, a physician at the VA Medical Center in Northport, New York, performed lung biopsies of veterans who’d been deployed to Camp Victory, near Baghdad, Iraq, and were complaining of shortness of breath. Every one of Szema’s biopsies revealed microscopic metal particles, including titanium, that had formed crystals in the patients’ lungs. Dozens of patients at the clinic have also been diagnosed with constrictive bronchiolitis. Szema and colleagues coined a new term for this particular war-related respiratory illness: Iraq/Afghanistan War-Lung Injury.

Right now, all that’s known about the dust inhaled at Camp Victory is that it’s far more metal laden than what service members would normally encounter; nobody knows why. Szema has speculated a few possibilities: It could have been borne on the air from other burn pits at nearby installations. It may have been produced by the 1991 Gulf War, when U.S. bombs and Iraqi missiles hammered the desert soil and fused dust and metal. Or it may be naturally occurring.

As difficult and complicated as these questions are, the families of sick service members are demanding answers, and clearly the VA, the DOD, and their research partners have much work to do in determining the relationships between wartime exposures and long-term illness. In the meantime, Hastings, who sees the AH&OBP Registry as much more than a research database, said the VA wants service members to maximize the likelihood of good health outcomes by taking advantage of the free medical exam offered through the registry program.

“We don’t have great participation in the exam right now,” she said, despite the fact that it’s available to all veterans who have served in Southwest Asia since 1991, whether they’re enrolled in VA care or not. “The exam is, of course, free – no co-pay,” said Hastings, “and it can be done by their own practitioner if they’re not enrolled in VA health care. They can have it done by the environmental health coordinator at the VA medical center. And they’ll get the results of the exam afterwards.” The exam is a small, relatively easy step, which Hastings hopes will establish a lifelong relationship between veterans and dedicated professionals who – while they don’t yet have all the answers – are veterans’ best hope for receiving the care they need.

This article was first published in the Veterans Affairs & Military Medicine 2018 Spring edition publication.