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2 Current and Historical Uses of Burn Pits in the Military Military engagements have always generated garbage. Troops on the move, or in temporary camps, create all the waste that human communities typically do—food remains, latrine waste, and all the other assorted detritus of living. Military populations produce additional types of waste as well, some of them hazardous to human health and the environment, and many of them in large volumes. Electronics, weapons and munitions, biological waste from combat and medical care, plastic devices of various kinds, rubber tires—all must be disposed of, often in situations where the usual waste management systems such as land-filling, recycling, and incineration are not viable options. In situations where there is no established system to safely and efficiently dispose of these waste products, they can quickly become health and safety hazards. Open-air waste burning is one option that has long been used by the military when other options are not avail - able. The types of items being burned, however, have changed over time. Technological advances have meant that in recent military conflicts there are new items being burned—plastic bottles and electronics, for example—and the burning of these items present new types of health hazards. Burn pits are designated areas, sometimes excavated to create depressions and mounds of earth to aid in con - centrating the burning, used to dispose of a wide variety of waste products. This chapter documents some of what is known about burn pits use by the military in the current conflicts in Iraq and Afghanistan. HISTORY OF MILITARY WASTE MANAGEMENT In past conflicts, poorly managed waste has contributed to the spread of infectious disease, a substantial cause of mortality and morbidity in military populations as well as a contributing factor in the contamination of drinking water. Thus proper sanitation has been historically and remains today the most important issue driving military waste management practices (Weese and Abraham 2009). Methods for military waste management have often adapted current civilian waste management practices for use in military contexts. Beginning in the 19th century, the recognition that poor waste disposal could increase disease transmission led cities and towns to isolate, remove, and decontaminate waste. For solid waste, there were a number of common options including dumping (in nearby waterways or on land), land-filling, reduction (reduc - ing the production of waste), compaction (reducing the volume of waste), recycling, and burning (Melosi 2005). Open-air burning greatly reduces the volume of waste, but because it presents a fire danger and produces noxious fumes, by the early 20th century incinerators became widely used in American cities. Open-air burning 15
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16 HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS remained in use in rural areas for much of the 20th century, but in recent years many state environmental protection offices, in collaboration with the U.S. Environmental Protection Agency (EPA), have enacted bans on backyard trash burning owing to air pollution concerns (EPA 2011). Concerns over the health consequences of air pollu - tion have led to a preference for land-filling and recycling over incineration in urban areas, although incinerators continue to be used in some places (Melosi 2005). In military contexts, open-air burning has proven to be of enduring utility in certain situations. Among its advantages are that it is less expensive than other forms of waste disposal to set up and manage and it can be operational in a short time at a newly constructed camp. Incinerators, in comparison, are relatively expensive in terms of both human labor (trash must be sorted to control moisture content and to remove hazardous materials) and upfront investment in equipment. As a result, incinerators are often considered impractical for use in rapidly changing combat situations. Other types of waste management, such as land-filling or recycling may not be feasible in many overseas operations. BURN PITS IN IRAQ AND AFGHANISTAN The burning of waste in pits has been the primary solid waste management solution in Iraq and Afghanistan from the beginning of the conflicts in 2003 and 2001, respectively. The use of burn pits by the U.S. military in these countries was restricted by U.S. law in 2009, and as of December 31, 2010, their use has been gradually phased out in Iraq but continues in Afghanistan (GAO 2010; DoD 2011). The exact number of burn pits in use in Iraq and Afghanistan is difficult to determine because of the constant fluctuations in the number of operational bases. The use of burn pits also varies depending on the size of the base; some bases might have a burn pit oper - ating one day a week, others 24 hours a day, seven days a week, depending on the activities on the base and the size of its population. This committee requested information from the Department of Defense (DoD) on the location of burn pits in Iraq and Afghanistan and their frequency of use and average burn times. The DoD reported that although data were not available for all sites, as of November 2009, in Iraq burn pits were operating at 14 out of the 41 existing small military sites (defined as housing less than 100 U.S. service members), 30 of the 49 medium-size sites (between 100 and 1,000 service members), and 19 of the 25 large sites (more than 1,000 service members) (DoD 2011). The number of burn pits used in Iraq has declined in response to the 2009 regulations, and a 2010 Government Accountability Office (GAO) study of open-air pit burning in Iraq and Afghanistan listed only 22 burn pits in use in Iraq in August 2010 (GAO 2010). The use of burn pits in Afghanistan, however, continues and in January 2011, 126 out of the 137 small sites, 64 of the 87 medium-size sites, and 7 of the 18 large military installation sites in Afghanistan had operating burn pits (DoD 2011). The committee also requested information from the DoD on the types and volumes of materials burned in pits in Iraq and Afghanistan. The DoD responded that no data were available on the volumes of trash burned, but estimated that, on average, 8–10 pounds of waste were generated each day by each person in theater. Based on the average populations of large bases of Iraq and Afghanistan, this would mean that these large bases would produce approximately 60,000–85,000 pounds of solid waste per day (DoD 2011). The DoD characterized the waste burned at Joint Base Balad (JBB; also called Balad Air Force Base and Logistic Support Area Anaconda) in Iraq as “municipal waste” (Taylor et al. 2008). The committee was provided with a summary of the results of a 2010 study by the Army Institute of Public Health on burn pits in Iraq and Afghanistan as well as several older studies of waste production at American bases in the Balkans (Faulkner 2011). The Army study reported that large bases in Iraq and Afghanistan burned waste with the general composition of 5–6% plastics, 6–7% wood, 3–4% miscellaneous noncombustibles, 1–2% metals, and 81–84% combustible materials (further details on waste composition were not available). The committee notes a considerable variation in the types of materials burned at each base, and the DoD states that the efforts to segregate waste and recycle materials “are often inconsistent and dependent on the waste being received and the personnel available to perform the waste segregation/recycling duties” (Faulkner 2011). In addition, bases differ in terms of burn pit oversight. At some bases the burn pit is managed directly by DoD, while at many others the burn pit is managed by civilian contractors through the Logistics Civil Augmenta -
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17 CURRENT AND HISTORICAL USES OF BURN PITS tion Program, which is the Army program for logistics support using civilian contractors. Some bases in Iraq and Afghanistan are able to use local contractors to remove waste from bases and operate off-site burn pits. For all of these reasons, the committee finds that an assessment of one burn pit on a U.S. military base is unlikely to be applicable to all, or most, burn pits on U.S. military bases in Iraq and Afghanistan. Burn pit activi - ties and thus their emissions will, in most cases, need to be considered on an individual basis. The Burn Pit at Joint Base Balad The burn pit at JBB has been in operation at least since 2003 when the base was established at a former air base of the Iraqi military, originally built in the 1980s (Taylor et al. 2008). The burn pit operation was used to burn the trash generated by the base population as well as refuse left by the Iraqi military when it abandoned the base (personal communication, William Haight, Engineering Division, Joint Staff, DoD, February 3, 2010). The burn pit operated 24 hours per day, 7 days a week (Taylor et al. 2008). The committee requested but did not obtain documentation from the DoD on the volumes and types of materi - als burned specifically at JBB. Although the total quantity of waste burned daily is unknown, the DoD estimates that JBB, with a large population that sometimes surpassed 25,000—including U.S. troops, host nation soldiers, coalition troops, civilians, and contractors— burned as much as several hundred tons a day of waste in the spring of 2007 (Taylor et al. 2008). A subsequent DoD report estimates that the waste stream in spring 2007 was as much as 200 tons per day (USAPHC 2010). By fall 2007, when two incinerators were operational, about half the spring 2007 volume was being burned and by May or June 2009, when three incinerators were operating, only about 10 tons of waste were burned in the pit each day (USAPHC 2010). The burn pit ceased operating in late 2009. DoD studies and fact sheets prepared for service members stationed at JBB indicated that the pit likely burned a heterogeneous mixture of food waste (including food items, styrofoam, and other related materials), human waste, shipping and packaging materials, meals-ready-to-eat packages, chemicals (paints, solvents), metal/aluminum cans, petroleum, and jet fuel, which was used as and accelerant (Taylor et al. 2008; CHPPM undated). Electronics, tires, batteries, and clothing are not listed specifically, but it is plausible they were burned as well. Based on congres - sional testimony by individuals who had been present at JBB, medical waste (including needles, gloves, bandages, body fluids, and expired pharmaceuticals) was also burned at least occasionally in the pit (U.S. Congress 2009a). MILITARY BURN PITS POLICIES AND STUDIES Although open-air waste burning has long been used by troops in combat situations, concerns regarding the possible health effects and environmental impacts created by such burning have only recently been addressed. Combat situations pose so many other grave risks that the negative aspects of military waste burning have histori - cally been largely ignored. Concerns about possible health risks associated with smoke from open-air waste burn - ing can be traced back in part to the 1990–1991 Persian Gulf War. In response to a constellation of unexplained symptoms and illnesses reported by returning Gulf War veterans, the DoD, the Department of Veterans Affairs (VA), and Congress sponsored a series of studies. These studies indicated that exposures to smoke from oil-well fires and from other combustion sources, including waste burning, were stressors for troops serving in the Gulf War (IOM 2005). Peace-keeping operations in the Balkans in the 1990s offered the U.S. military an opportunity to examine patterns of waste management and to establish waste management guidelines and policies to reduce health and environmental impacts. During Operation Joint Endeavor in Bosnia in 1995–1996, military preventive-medicine personnel recognized that open burning of waste might be an operational necessity during combat operations, but they emphasized that burning should be used to the minimum extent feasible and that burn pits should be located as far as possible downwind of personnel (U.S. Congress 2009b). Open-air waste burning in Bosnia and Kosovo was replaced by other waste management practices, including incinerators. A comparative study of waste generation and management practices at several U.S. bases in the Balkans found that bases differed in the generation of plastic waste, primarily from drinking water bottles. The waste stream at one base was comparable to a similarly sized civilian community except for an “extraordinarily large volume of
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18 HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS plastic water bottles,” which was a cause of concern in part because of the health risks associated with burning plastics (U.S. Army Corps of Engineers 2003). When military operations began in Afghanistan in 2001 and in Iraq in 2003, there were no regulations govern - ing the use of burn pits in overseas combat operations. An Overseas Environmental Baseline Guidance Document (DoD 2007) did offer guidance on their appropriate use as part of a waste management program, but this docu - ment excluded “contingency operations” and thus was not enforceable in Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) in Iraq, both of which were defined as such. In the absence of formal policy, operation orders were issued, until 2007 when the DoD issued a policy that included contingency operations; revised regulations were released in 2009 (CENTCOM 2009). The 2008 study by the U.S. Army Center for Health Promotion and Preventive Medicine (CHPPM) at JBB was not the first DoD study of the possible health risks associated with waste burning. A series of risk assessment studies of a waste incinerator near the U.S. Naval Air Facility in Atsugi, Japan, were conducted by the Navy Environmental Health Center beginning in 1995 in response to local concerns about breathing toxic chemicals (NRC 2001). In 2001, the CHPPM performed a health risk assessment of the municipal and medical waste incinerators at Camp Bondsteel in Kosovo (CHPPM 2001) identifying coarse particulate matter (PM) exposure as a moderate threat at one location (but with low confidence) and providing recommendations for improved operation of the incinera - tors. A follow-up study in 2005 found that all exposures had low hazard severity and probability (CHPPM 2005). A CHPPM study of possible health risks specifically from waste burning was conducted in 2004 at Camp Lemonier in Djibouti. There was concern over health risks posed to troops from exposure to smoke from an off-base burn pit located approximately two kilometers from the camp. The burn pit was administered by local civilians, who burned items from both the U.S. base and from the local community. The study concluded that there was a “moderate” overall risk, primarily due to levels of acrolein, aluminum, and PM 10. The report recommended that burn barrels be used instead of burn pits and that exposure of military personnel be reduced by putting limits on access to the base and restrictions on outdoor activity during periods of heavy smoke (CHPPM 2004). The impacts of burn pits were also considered in a 2008 RAND report on environmental concerns for overseas combat operations. The report, commissioned by the U.S. Army, considered burn pits as just one among many case studies, and concluded that “environmental considerations are not well incorporated into Army planning or operations.” The report argued that while Army leadership has not always seen environmental concerns as a pri - ority in contingency operations, they should, for two main reasons: “First the environment can affect the health and safety of soldiers. Second, the environment can affect the ability of commanders to accomplish their mission and achieve U.S. national objectives.” To change how environmental issues are dealt with in contingency opera - tions, the report urged changes in policy and in the message from commanders who must promote the belief that environmental issues are critical to military missions. The attitude shared by commanders and troops that environ - mental considerations were not important contributed to the dumping of waste without taking basic precautions with potentially hazardous waste. The report discussed the policy implications of labeling bases “temporary,” even after years of habitation, because it limited available funding for alternative waste management options such as incinerators (RAND 2008). FEDERAL GOVERNMENT’S RESPONSE TO CONCERNS REGARDING BURN PITS Department of Defense Studies In response to personnel complaints of odor, poor visibility, and health effects (eye and respiratory irritation) attributed to burn pit emissions, the CHPPM and the Air Force Institute for Operational Health (AFIOH) conducted ambient air sampling and a screening health risk assessment in the spring of 2007. The assessment was designed to detect potentially harmful inhalation exposures for personnel at JBB from chemicals expected to be released from the burn pit (Taylor et al. 2008). A review of the screening health risk assessment conducted by the Defense Health Board (DHB 2008) was answered by an Addendum to the initial report, and a second Addendum followed further sampling in the fall of 2007 (CHPPM and AFIOH 2009). Follow-up sampling in 2009, after most of the waste was diverted to incinerators led to another, similar assessment (USAPHC 2010).
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19 CURRENT AND HISTORICAL USES OF BURN PITS Air samples were initially taken between January and April 2007 when an estimated 200 tons of waste per day were being burned in the pit. Based on those air sampling results, a screening health risk assessment was conducted to estimate potential cancer and noncancer risks to personnel serving at JBB. The CHPPM report indi - cated that the risk of acute health effects from all substances detected except PM 10 was low, with screening-level cumulative hazard indices below 1.0 and acceptably low cancer risk estimates for exposures of up to 15-months duration. For noncancer endpoints, the hazard quotient is the ratio of a chronic daily intake for a specific chemi - cal to the toxicological reference dose for that chemical. For JBB this would be the inhalation reference dose. A sum of the hazard quotients for all chemicals at a site is the hazard index. A hazard index of less than 1.0 is considered “safe” or “acceptable” by EPA (EPA 2000). For cancer endpoints, EPA guidance indicates that a risk ranging from 1 in 10,000 to 1 in 1,000,000 or lower is “safe” or “acceptable” (EPA 2000). The CHPPM made several recommendations for engineering controls and better planning to reduce exposure to burn pit emissions, as well as recommending further study, improved risk communication, and policy review. See Chapters 4 and 5 for more details on the measurements and assessments in the CHPPM study. The second addendum to the screening health risk assessment included an analysis of additional air samples collected from October through November 2007 at JBB, after two incinerators were operational, diverting about half the waste previously going to the burn pits. The fall 2007 sampling data were used for a human health risk assessment that produced results similar to the earlier study. Risks for both cancer and noncancer health outcomes were considered to be “acceptable” for those stationed on the base for up to 15 months; again except for PM 10 all measured air concentrations were within 1-year military exposure guidelines. However, the results of the risk assessment indicated screening-level cumulative hazard indexes greater than unity for some of the exposure loca - tions and time periods, although cancer risk estimates were still acceptably low. Similar risks were estimated using the May–June 2009 sampling data, when almost all the waste was being burned in the on-site incinerators and only about 10 tons of waste per day was being burned in the pit (USAPHC 2010). Congressional Responses After the release of the initial screening health risk assessment in May 2008, which found no cancer or non - cancer health risks attributable to exposure to burn pit emissions at JBB, Congress held a series of public hearings, and several bills on the subject were introduced. Hearings during the fall of 2009 included testimony from both military officials and veterans groups. Much of the testimony focused on the CHPPM screening report, with DoD and VA officials emphasizing the study’s conclusion that exposures at JBB fell within DoD and EPA values for acceptable risk. Military officials outlined efforts to enlarge and improve surveillance and assessment activities by Army and Air Force medical and environmental units, as well as enhanced coordination with the VA on the surveillance and treatment of any possibly related medical issues. Other witnesses presented first-hand accounts of the burn pits. During testimony and in media interviews, veterans and individual medical and environmental professionals attributed a range of medical problems to smoke from burn pits, including asthma, joint pain, cancer, vomiting and nausea, burning lungs, and Parkinson’s disease (U.S. Congress 2009a). Witnesses testified to the pervasive presence of noxious smoke in their tents and emphasized the limitations and shortcomings of the CHPPM report. Medical and environmental personnel reported increased respiratory symptoms among service members in Iraq and in returning veterans seeking medical treatment stateside. In October 2009, the National Defense Authorization Act for FY 2010 was passed. The law included language (Section 317) prohibiting the disposal of waste in open-air burn pits by the DoD and called for the DoD to issue appropriate regulations. In 2009, Congress also requested that the GAO investigate the use of burn pits in Iraq and Afghanistan; the guidance available on burn pits and adherence to that guidance; alternatives to burn pits and the DoD’s implemen - tation of these alternatives; and the efforts made by the DoD to evaluate air quality and exposures in accordance with applicable guidance. The GAO report, released in October 2010, recommended that the DoD issue, imple - ment, and ensure adherence to guidance for burn pit operations and waste management; conduct monitoring of burn pits as directed by guidance; characterize the waste produced and implement waste management strategies
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20 HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS to reduce hazards from burning waste; and consider alternatives to burn pits (taking into account costs, feasibility, and health effects) (GAO 2010). Department of Veterans Affairs Responses In 2009, the VA requested that the Institute of Medicine (IOM) convene a committee to determine the potential long-term health effects of exposure to burn pits in Iraq and Afghanistan, and to specifically examine the burn pit at JBB in Iraq. That request resulted in this study. The VA also issued a training letter in April 2010 to provide guidance to regional offices on how to handle claims for disabilities related to specific environmental hazards, including burn pits. Based on the 2008 CHPPM report (Taylor et al. 2008), the VA recognized that exposure to polycyclic aromatic hydrocarbons, volatile organic compounds, dioxins and furans, and PM may result from the use of burn pits, but that potential health effects had not yet been determined. Owing to the widespread use of burn pits and the inability of the DoD to identify all duty locations for all personnel, a veteran’s “lay statement” is sufficient to establish exposure to burn pits if they served in Iraq, Afghanistan, or Djibouti. The VA noted that rating authorities should be prepared to review claims and recognize the potential for burn pit exposures because veterans suffering from respiratory, cardiopulmonary, neurological, autoimmune, or dermal disorders may not associate these illnesses with exposure to burn pits. The training letter also identified PM from diverse local sources as a specific environmental hazard in Iraq, Afghani - stan, and Djibouti, and thus regional VA offices were instructed to be prepared to review claims for respiratory and cardiopulmonary health effects (both have been associated with exposure to PM) that may be associated with exposure to PM (VA 2010). CONCLUSIONS Although the practice of open-air waste burning has a long history in the U.S. military, a combination of fac - tors, including the large volume of waste burned, the increase in the waste stream of items such as plastics with the potential to produce toxic materials when burned, and increased public awareness of health risks associated with exposure to air pollution, has led to greater concern among service members and their families about possible long-term health effects resulting from exposure to burn pit emissions at military bases in Iraq and Afghanistan. Given the nature of military conflicts and the constant movement of troops and supplies, it is difficult to char- acterize waste disposal practices at many bases, or apply knowledge of one base to other bases. Although some monitoring of air pollution has been conducted at JBB and preliminary screening risk assessments developed, the air quality and sources of pollution at JBB and other bases are still in question, leading to further concerns about the possible health risks that may ensue from exposure to these pollutants. Although several government agencies are involved in examining burn pits, issues related to their use and safety are unresolved. To help address some of these issues, the VA requested that the IOM conduct this study. REFERENCES CENTCOM (U.S. Central Command). 2009. Environmental quality CENTCOM contingency environmental guidance. Docu- ment number R 200-2. MacDill Air Force Base, FL: Headquarters, U.S. Central Command. CHPPM (U.S. Army Center for Health Promotion and Preventative Medicine). 2001. Environmental surveillance health risk assessment no. 47-EM-2638-01D. Environmental surveillance of Camp Bondsteel incinerators 18–28 January 2001 . With redaction of author information. Camp Bondsteel, Kosovo: U.S. Army Center for Health Promotion and Preven - tive Medicine. CHPPM. 2004. Ambient air assessment for Camp Lemonier, Djibouti, 4–10 Jun 2004. Aberdeen Proving Ground, MD: U.S. Army Center for Health Promotion and Preventive Medicine. CHPPM. 2005. Transmittal of results for deployment occupational and environmental health (OEH) risk characterization . With redaction of author information. Aberdeen Proving Ground, MD: U.S. Army Center for Health Promotion and Preventive Medicine.
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21 CURRENT AND HISTORICAL USES OF BURN PITS CHPPM. Undated. Just the facts: Balad burn pit. Aberdeen Proving Ground, MD: U.S. Army Center for Health Promotion and Preventive Medicine. CHPPM and AFIOH (U.S. Air Force Institute for Operational Health). 2009. Addendum 2. Screening health risk assessment burn pit exposures, Balad Air Base, Iraq, May 2008. USACHPPM Report No. 47-MA-08PV-08/AFIOH Report No. IOH-RS-BR-TR-2008-0001. Aberdeen Proving Ground, MD: U.S. Army Center for Health Promotion and Preventive Medicine. August. DHB (Defense Health Board). 2008. Defense Health Board findings pertaining to health risk assessment, burn pit exposures, Balad Air Base, Iraq. June 26. Falls Church, VA: Defense Health Board. DoD (U.S. Department of Defense). 2007. Overseas environmental baseline guidance document. DoD 4715.05-G. Washington, DC: Office of the Under Secretary of Defense for Acquisitions, Technology, and Logistics. DoD. 2011. Exposure to toxins produced by burn pits: congressional data request and studies. In Memorandum for the assistant secretary of defense for health affairs. Washington, DC: U.S. Department of Defense. EPA (U.S. Environmental Protection Agency). 2000. Science Policy Council handbook: risk characterization. EPA-100-B-00-002. Washington, DC: Office of Research and Developoment. EPA. 2011. Backyard burning. http://www.epa.gov/epawaste/nonhaz/municipal/backyard/index.htm (accessed March 2, 2011). GAO (U.S. Government Accountability Office). 2010. Afghanistan and Iraq: DOD should improve adherence to its guidance on open burning and solid waste management. GAO-11-63. Washington, DC: U.S. Government Accountability Office. IOM (Institute of Medicine). 2005. Gulf War and health: Volume 3. Fuels, combustion products, and propellants. Washington, DC: The National Academies Press. Melosi, M. V. 2005. Garbage in the cities: Refuse, reform, and the environment. Pittsburgh, PA: University of Pittsburgh Press. NRC (National Research Council). 2001. Review of the U.S. Navy’s human health risk assessment of the Naval Air facility at Atsugi, Japan. Washington, DC: National Academy Press. RAND. 2008. Green warriors: Army environmental considerations for contingency operations from planning through post- conflict. Arlington, VA: RAND Corporation. Taylor, G., V. Rush, A. Deck, and J. A. Vietas. 2008. Screening health risk assessment burn pit exposures Balad Air Base, Iraq, and addendum report. IOH-RS-BR-TR-2008-0001/USACHPPM 47-MA-08PV-08. Brooks City-Base, TX: Air Force Institute for Operational Health and U.S. Army Center for Health Promotion and Preventative Medicine. U.S. Army Corps of Engineers. 2003. Analysis of the waste management practices at Bosnia and Kosovo base camps . ERDC/ CRREL TR-03-6. Hanover, NH: U.S. Army Corps of Engineers. U.S. Congress, Senate, Democratic Policy Committee. 2009a. Are burn pits in Iraq and Afghanistan making our soldiers sick?111th Cong., 1st Sess. November 6. U.S. Congress, Senate, Committee on Veterans’ Affairs. 2009b. VA/DOD response to certain military exposures. 111th Cong., 1st Sess. October 8. USAPHC (U.S. Army Public Health Command). 2010. Screening health risk assessments, Joint Base Balad, Iraq, 11 May–19 June 2009. With redaction of author information. Aberdeen Proving Ground, MD: U.S. Army Public Health Command. July. VA (Department of Veterans Affairs). 2010. VA environmental hazards memo. 211A training letter 10-03. Washington, DC: U.S. Department of Veterans Affairs. Weese, C. B., and J. H. Abraham. 2009. Potential health implications associated with particulate matter exposure in deployed settings in southwest Asia. Inhalation Toxicology 21(4):291-296.
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