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Suggested Citation:"1 Introduction." National Research Council. 2020. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. Washington, DC: The National Academies Press. doi: 10.17226/25837.
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Suggested Citation:"1 Introduction." National Research Council. 2020. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. Washington, DC: The National Academies Press. doi: 10.17226/25837.
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Suggested Citation:"1 Introduction." National Research Council. 2020. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. Washington, DC: The National Academies Press. doi: 10.17226/25837.
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Suggested Citation:"1 Introduction." National Research Council. 2020. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. Washington, DC: The National Academies Press. doi: 10.17226/25837.
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Suggested Citation:"1 Introduction." National Research Council. 2020. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. Washington, DC: The National Academies Press. doi: 10.17226/25837.
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Suggested Citation:"1 Introduction." National Research Council. 2020. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. Washington, DC: The National Academies Press. doi: 10.17226/25837.
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Suggested Citation:"1 Introduction." National Research Council. 2020. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. Washington, DC: The National Academies Press. doi: 10.17226/25837.
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Suggested Citation:"1 Introduction." National Research Council. 2020. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. Washington, DC: The National Academies Press. doi: 10.17226/25837.
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Suggested Citation:"1 Introduction." National Research Council. 2020. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. Washington, DC: The National Academies Press. doi: 10.17226/25837.
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Suggested Citation:"1 Introduction." National Research Council. 2020. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. Washington, DC: The National Academies Press. doi: 10.17226/25837.
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Suggested Citation:"1 Introduction." National Research Council. 2020. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. Washington, DC: The National Academies Press. doi: 10.17226/25837.
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Suggested Citation:"1 Introduction." National Research Council. 2020. Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations. Washington, DC: The National Academies Press. doi: 10.17226/25837.
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1 Introduction More than 3.7 million U.S. service members have participated in operations taking place in the Southwest Asia Theater of Military Operations1 and Afghanistan since 1990. These operations comprise the 1990–1991 Gulf War (Operation Desert Shield and Operation Desert Storm), the post-war stabilization period (1992–September 2001), and the post-9/11 conflicts: Operation Enduring Freedom (OEF);2 Operation Iraqi Freedom (OIF); Operation New Dawn (OND); Combined Joint Task Force–Operation Inherent Resolve; and Operation Freedom’s Sentinel. Figure 1-1 presents a map of the location where these operations took place. Deployment to Southwest Asia exposed service members to a number of airborne hazards, including oil-well fire smoke, emissions from open burn pits, dust and sand suspended in the air, and exhaust from diesel vehicles. The effects of these were compounded by factors such as temperature extremes, stress, and noise, which are almost inevitable during service in a combat environment. Soon after the 1990–1991 Gulf War, veterans began to seek medical treatment for a variety of symptoms and illnesses. Initially the Department of Defense (DoD) and the Department of Veterans Affairs (VA) responded to these health issues by establishing voluntary clinical examination programs. By 1994 these had been formalized under the Comprehensive Clinical Evaluation Program and the Persian Gulf Registry and Uniform Case Assessment Protocol (IOM, 1998). The programs began with an initial physical examination, including patient and exposure history and screening laboratory tests, followed by an opportunity for referral to more specialized testing and consultation if needed. Similar efforts continued and expanded during the post-9/11 period. This chapter provides introductory material on U.S. deployments to the theater, the laws that stimulated the National Academies involvement in studies of theater veterans’ health, and the impetus for and conduct of the current study. It sets the stage for an evaluation of the available scientific and medical literature regarding the respiratory health effects of exposure to airborne hazards encountered during service in the Southwest Asia theater, which is presented in later chapters of the report. 1  The Department of Veterans Affairs defines the Southwest Asia Theater of Military Operations as comprising Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Gulf of Aden, Gulf of Oman, Oman, Qatar, the United Arab Emirates, and the waters of the Persian Gulf, the Arabian Sea, and the Red Sea (VA, 2019). For the sake of brevity, this report refers to this region plus Afghanistan as the “Southwest Asia theater” or simply the “theater.” 2  Originally called Operation Infinite Justice. 11

12 RESPIRATORY HEALTH EFFECTS OF AIRBORNE HAZARDS EXPOSURES FIGURE 1-1  The Southwest Asia Theater of Military Operations and Afghanistan. SOURCE: GAO, 2017, Figure 1. U.S. DEPLOYMENTS TO THE SOUTHWEST ASIA THEATER This section provides a brief overview of the deployments of U.S. service members to conflicts in Southwest Asia from 1990 through early 2020. The deployments span seven military operations. 1990–1991 Gulf War U.S. military operations during the 1990–1991 Gulf War took place in two phases: Operation Desert Shield and Operation Desert Storm. Operation Desert Shield, the preparation and positioning phase, began on August 2, 1990, and ended on January 16, 1991. More than 500,000 American troops were deployed to Saudi Arabia during this period (Collins, 2019). Operation Desert Storm, the combat phase, began on January 17, 1991, and ended on April 6, 1991. A total of approximately 697,000 U.S. troops took part, with ground forces operating in Kuwait and southern Iraq (Collins, 2019). Post-9/11 Operations OEF commenced in Afghanistan on October 7, 2001, in response to the September 11, 2001, terrorist attacks in the United States, and it formally ended on December 28, 2014 (CRS, 2019a). OIF began in Iraq on March 20, 2003, initially as a response to perceived threats to U.S. interests, and ended August 31, 2010 (CRS, 2019a). OND overlapped the final stages of OIF and marked the transition of the United States from combat operations to stability-building in Iraq. It began on September 1, 2010, and ended on December 15, 2011, with the withdrawal of the U.S. military mission (CRS, 2019a). These operations were fundamentally different from the 1990–1991 Gulf War in their heavy dependence on the National Guard and reserves and in the pace of deployments, the duration of deployments, the number of redeployments, the short dwell time between deployments, and the type of warfare (IOM, 2010b).

INTRODUCTION 13 The numbers of individuals and total numbers of deployments to OEF/OIF/OND have not been available since 2017, when these data were removed from public access (Mosbergen, 2018). A 2018 report from RAND Corpora- tion found that from September 11, 2001, to September 2015, across all branches and components, 2.77 million service members had served on more than 5.4 million deployments (Wenger et al., 2018). Table 1-1, which was adapted from that report, indicates that the proportion of those deployed from the regular units ranged from 64% in the Army to 91% in the Navy and Marine Corps. Those in the National Guard and reserves units constituted one-quarter of all those deployed. The average age for those deployed was 29.0 years. Those deployed from the Marine Corps had the lowest average age (25.0 years), and those deployed from the Air Force had the highest average age (31.1 years). Of those deployed, 89.6% were male and 10.4% were female. Two smaller-scale operations have taken place in the theater in more recent years. Combined Joint Task Force–Operation Inherent Resolve began on October 17, 2014, in Iraq and Syria as a result of threats posed by TABLE 1-1  Characteristics of U.S. Service Members Deployed to OEF, OIF, or OND as of September 2015 Characteristics Army Air Force Marine Corps Navy All Services Individuals Deployed by Component and by Service Regular 855,000 397,000 333,000 515,000 2,100,000 Reserve 156,000 47,000 38,000 55,000 295,000 National Guard 344,000 84,000 N/A N/A 428,000 Totala 1,326,000 518,000 367,000 563,000 2,774,000 Number of Deployments by Rank, Gender, and Family Structure Commissioned Officer 325,000 284,000 73,000 172,000 854,000 Warrant Officer 73,000 0 6,000 7,000 86,000 Enlisted 1,938,000 968,000 597,000 1,009,000 4,512,000 Male 2,096,000 1,089,000 652,000 1,034,000 4,871,000 (90.0%) (87.2%) (96.6%) (87.5%) (89.6%) Female 232,000 160,000 23,000 148,000 563,000 (10.0%) (12.8%) (3.4%) (12.5%) (10.4%) Age at time of deployment 29.3 31.1 25.0 28.7 29.0 (average, in years) Married at time of deployment 1,389,000 768,000 305,000 622,000 3,085,000 (59.7%) (61.5%) (45.2%) (52.7%) (56.8%) Had children at time of deployment 1,164,000 606,000 198,000 492,000 2,460,000 (50.0%) (48.5%) (29.4%) (41.6%) (45.3%) Totala 2,335,972 1,252,424 676,351 1,187,932 5,452,679 Average Number of Cumulative Months Deployed, Among Those Who Have Deployed Regular 17.8 12.0 12.0 9.9 Reserveb 12.5 8.8 8.1 8.9 National Guardb 12.8 7.3 N/A N/A NOTES: In contrast with the Army and the Air Force, the Navy and the Marine Corps do not have National Guard components. N/A, not avail- able; OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom; OND, Operation New Dawn. a Total figures are lower than the sum across rows because some service members deployed with multiple components or ranks. b Nearly 25% of cumulative months deployed in the U.S. Army Reserve and the U.S. Army National Guard were accrued in the U.S. Regular Army. SOURCES: Wenger et al., 2018, Table 1, used with permission from RAND Corporation; derived from Defense Manpower Center’s Contin- gency Tracking System Deployment File (September 2001 through September 2015; 2001 and 2015 represent partial calendar years).

14 RESPIRATORY HEALTH EFFECTS OF AIRBORNE HAZARDS EXPOSURES terrorist organizations (DoD, n.d.). Operation Freedom’s Sentinel began on January 1, 2015, following the end of OEF in December 2014 (DoD OIG, 2019). It was launched to train and assist the Afghan National Defense and Security Forces through the NATO-led Resolute Support Mission while simultaneously conducting counterter- rorism operations against terrorist groups in Afghanistan. An April 2019 Congressional Research Service publi- cation indicated that approximately 7,200 U.S. forces were serving in Iraq and Syria and 15,000 in Afghanistan at that time (CRS, 2019b). Both Operation Inherent Resolve and Operation Freedom’s Sentinel were ongoing as of early 2020. AFTERMATH OF SOUTHWEST ASIA THEATER DEPLOYMENT This section addresses some of the legislative consequences of the deployments to the Southwest Asia the- ater of military operations. Beginning in 1991, Congress passed a number of pieces of legislation in reaction to concerns regarding the health of service members and veterans. These laws led to the involvement of the National Academies in reviews of the scientific literature on this topic. Previous studies that examined respiratory health issues among U.S. veterans deployed to Southwest Asia are noted below. Legislative Actions Following the Gulf War, in December 1991 Congress mandated via Public Law (PL) 102-190 that DoD establish the Persian Gulf Registry to assist in addressing health concerns in veterans who had been exposed to burning oil plumes during Operation Desert Storm (IOM, 1995). Later, a provision of PL 102-585—passed in November 1992—expanded the registry to “any other members who served in the Operation Desert Storm the- ater of operations during the Persian Gulf conflict” (§ 704(a)(2)) and renamed it the Persian Gulf War Veterans Health Registry. In 1998 Congress passed two statutes: PL 105-277, the Persian Gulf War Veterans Act, and PL 105-368, the Veterans Programs Enhancement Act. These laws were intended to facilitate the identification of health outcomes that might result from exposure to environmental agents during deployment. As part of this effort, the laws directed the Secretary of Veterans Affairs to enter into a contract with the National Academy of Sciences to review and evaluate the scientific and medical literature regarding associations between illness and exposure to toxic agents, environmental or wartime hazards, or preventive medicines or vaccines associated with Gulf War service. The Secretary was further instructed to consider the conclusions offered by the National Academies when making decisions about compensation. The National Academies were tasked to study a diverse set of biologic, chemical, and physical agents and their possible effects on the health of service members and veterans. The resulting series of reports, entitled Gulf War and Health, consists of 11 volumes (to date) on various exposures and health outcomes. Additionally, several other reports that were not part of the series were published on specific exposures and health outcomes among theater veterans. Exposures to many of the agents encountered in the theater have been extensively studied and characterized, primarily in occupational settings (e.g., exposure to pesticides, solvents, and fuels), but exposures to others have not been as well studied and characterized in human populations (e.g., exposure to nerve agents and oil-well fire smoke). The Veterans Programs Enhancement Act of 1998 (PL 105-368) established the federal Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC). The RAC, which includes researchers who are studying the health of these veterans, clinicians who have treated them, and members of the general public (including ­ eterans), v has published several reports on the scientific literature related to the health of Gulf War veterans. These are avail- able via the RAC website.3 A later set of laws addressed concerns over possible adverse effects of exposure to smoke from trash burning in the theater. Bills were introduced by Congress in 2009 and 2010 to sharply curtail the use of open-air burn pits and to establish a medical surveillance system to identify health effects attributed to exposure to the burning of 3  See https://www.va.gov/RAC-GWVI/index.asp (accessed August 10, 2020).

INTRODUCTION 15 solid waste (IOM, 2011). A provision of PL 111-84 (§ 317), the National Defense Authorization Act for Fiscal Year 2010, prohibited the use of burn pits for medical waste disposal except in cases where there was no alternative.4 The act also required DoD to take several actions, including reporting to Congress regularly whenever burn pits were used, developing a plan for alternatives to burn pits, assessing existing medical surveillance programs of burn pits exposure and making recommendations to improve them, and studying the effects of burning plastics in open pits and evaluating the feasibility of prohibiting the burning of plastics. In 2009 congressional hearings on the proposed bill included testimony from both military officials and veterans groups and focused on the U.S. Army Center for Health Promotion and Preventive Medicine screening study, with DoD and VA officials emphasizing the study’s conclusion that Joint Base Balad (one of the largest U.S. military bases in Iraq) exposures fell within military exposure guidelines and the Environmental Protection Agency values for acceptable risk. In response, VA asked the Institute of Medicine to determine the long-term health effects from exposure to burn pits in Iraq and Afghanistan (IOM, 2011). On January 10, 2013, PL 112-260 was signed, and § 201 of that law directed VA to establish an open burn pit registry within 1 year after its enactment (NASEM, 2017). The law directed the VA secretary to coordinate with DoD to establish and maintain an open burn pit registry for eligible individuals who may have been exposed to toxic airborne chemicals and fumes created by open burn pits. It specified that the registry should include information that would be necessary to ascertain and monitor the health effects of members of the armed forces exposed to toxic airborne chemicals and fumes caused by open burn pits. The law instructed VA to develop a public information campaign to inform eligible individuals about the registry and to periodically notify eligible individuals of significant developments in the study and treatment of conditions associated with exposure to toxic airborne chemicals. It also called for an independent scientific organization to prepare a report addressing issues related to the establishment and conduct of the registry and the use of its data, and VA contracted with the National Academies to conduct the work. Previous Studies That Examined Respiratory Outcomes Among Military Personnel Deployed to Southwest Asia The National Academies has convened a number of expert consensus committees to examine health issues in U.S. veterans of conflicts in Southwest Asia. The reports that most directly address environmental exposures are listed in Appendix B. Studies that examined respiratory health outcomes are cited below. In one of the earliest efforts to address respiratory health issues—Health Consequences of Service During the Persian Gulf War: Initial Findings and Recommendations for Immediate Action (IOM, 1995)—a committee was tasked to evaluate VA actions to collect and maintain health information for assessing the health consequences of Gulf War deployment and to recommend further studies. That committee specifically noted the need to more adequately characterize the hazards of oil-well fires; it also recommended carrying out epidemiologic studies with better designs and statistical power to make associations between specific exposures encountered in theater and health outcomes and included chronic respiratory effects among the “putative outcomes” that the committee would continue to evaluate. A follow-up report (IOM, 1996) recommended that military medical preparedness for deployments include “detailed attempts to monitor natural and man-made environmental exposures and to pre- pare for rapid response, early investigation, and accurate data collection, when possible, on physical and natural environmental exposures that are known or possible in the specific theater of operations.” It also recommended that the mortality experience of Persian Gulf War veterans be monitored for up to 30 years. Gulf War and Health, Volume 3: Fuels, Combustion Products, and Propellants (IOM, 2005) contained a comprehensive review of the literature addressing the association between exposure to fuels, combustion products, and propellants present in the 1990–1991 Gulf War and health outcomes. Combustion products were defined as 4  The National Defense Authorization Act used the definition of hazardous wastes from the 2002 Solid Waste Disposal Act, Section 1004(5): “a solid waste, or combination of solid wastes, which because of its quantity, concentration, or physical, chemical, or infectious characteristics may—(A) cause, or significantly contribute to an increase in mortality or an increase in serious irreversible, or incapacitating reversible, ill- ness; or (B) pose a substantial present or potential hazard to human health or the environment when improperly treated, stored, transported, or disposed of, or otherwise managed” (https://public.ornl.gov/sesa/environment/policy/rcra.html [accessed May 10, 2020]).

16 RESPIRATORY HEALTH EFFECTS OF AIRBORNE HAZARDS EXPOSURES “smoke from fires, exhaust from burning fuels, and products of other combustion sources,” and it was noted that these are also constituents of air pollution in general. Using information from studies of military populations, occupational cohorts, and others, the committee reached conclusions on the association between these exposures and several respiratory health outcomes, details of which are presented in Chapter 4. The committee responsible for Gulf War and Health, Volume 4: Health Effects of Serving in the Gulf War (IOM, 2006) evaluated the overall health status of 1990–1991 Gulf War veterans by reviewing epidemiologic literature to compare the incidence and prevalence of health outcomes in veterans deployed to the region with veterans not deployed there. The committee found it “striking” that while self-reported respiratory symptoms were strongly associated with deployed veterans, objective measures of pulmonary function failed to show increased respiratory illnesses in this population compared with nondeployed veterans. When examining specific exposures and using objective measures, the committee found an indication of an association between asthma exacerbation and oil-well fire smoke; however, the committee did not find nerve agents present in the theater as the result of the destruction of a munitions storage facility at Khamisiyah, Iraq, in March 1991 to be associated with changes in pulmonary function. The committee also provided recommendations for pre- and post-deployment screening of health status, assessment of exposures, and surveillance for adverse health outcomes. Gulf War and Health, Volume 8: Update of Health Effects of Serving in the Gulf War (IOM, 2010a)—an update to Volume 4—reviewed the studies in the earlier report together with literature published since that volume’s literature search. The committee assessed and compared health outcomes in veterans deployed to the 1990–1991 Gulf War with veterans who were not deployed or who were deployed elsewhere. Its main focus was diseases that Volume 4 reported as having occurred with greater prevalence in Gulf War–deployed veterans, which did not include respiratory conditions, but it was also asked to identify emerging health outcomes. The committee concluded that there was inadequate or insufficient evidence to determine whether an association existed between Gulf War deployment and respiratory disease and that there was limited or suggestive evidence of no association between deployment to the Gulf War and decreased lung function in the first 10 years after the war. The Review of the Department of Defense Enhanced Particulate Matter Surveillance Program Report (NRC, 2010) evaluated a report (Engelbrecht et al., 2008) that summarized the results of DoD’s Enhanced Particulate Matter Surveillance Program, which was an effort to characterize and quantify particulate matter in the ambient environment at 15 sites5 in the Middle East over 12 months in 2006–2007. The committee’s evaluation included a consideration of the potential acute and chronic health implications based on information presented in the ­ ngelbrecht et al. E (2008) report. The committee was also asked to consider epidemiologic and health-surveillance data collected by the U.S. Army Center for Health Promotion and Preventive Medicine (since renamed the U.S. Army Public Health Center) to assess potential health implications for deployed personnel, and to make recommendations for reducing or characterizing health risks. The committee found that while the design and conduct of the Enhanced Particulate Matter Surveillance Program limited its usefulness in health studies, the data showed that “a large-scale assessment of the air-pollution exposures of military personnel and associated health risks is feasible and needed,” and it made recommendations regarding, among other things, data re-analysis, improving surveillance study design, and analysis of DoD database medical data. The committee concluded that it was plausible that exposure to ambient pollution in the Middle East theater was associated with adverse health outcomes. It recommended that “[a] more complete inventory of all major sources of ambient pollutants and potential emissions in the theater should be constructed before assessment of health effects to ensure that all relevant pollutants are monitored.” Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan (IOM, 2011) summarized the health effects associated with exposures to 51 pollutants that were detected in air samples taken at Joint Base Balad in Iraq in 2007–2009 or thought to be in emissions, as well as health-effects information on populations considered to be surrogates of military personnel exposed to combustion products from burn pits (firefighters, municipal incinerator workers, and veterans of the 1990–1991 Gulf War exposed to oil-well fire smoke) because there were few studies on post-9/11 veterans exposed to burn pit emissions. The committee concluded that burn pits were not a major source of the pollutants of greatest concern but also noted that there were many air pollut- 5  The 15 sites were in the following countries: Djibouti (one), Afghanistan (two, in Bagram and Khowst), Qatar (one), United Arab Emirates (one), Iraq (six, in Balad, Baghdad, Tallil, Tikrit, Taji, and Al Asad), and Kuwait (four, in northern, central, coastal, and southern Kuwait).

INTRODUCTION 17 ants present in the theater that had not been measured by the surveillance campaigns. Based on the epidemiologic literature, the committee concluded that there was inadequate or insufficient evidence of an association between exposure to combustion products and cancer or respiratory disease in the populations studied; however, it found limited or suggestive evidence of an association between exposure to combustion products and reduced pulmonary function. The committee concluded that additional study of health effects specifically in OEF and OIF veterans was necessary. Based on the information that was available, the committee was unable to say whether long-term health effects were likely to result from exposure to emissions from the burn pit at Joint Base Balad. It also stated that none of the individual chemical constituents of the combustion products emitted at Joint Base Balad appeared to have been present at concentrations likely to be responsible for the adverse health outcomes studied in the report. However, the committee’s review also suggested that service in Iraq or Afghanistan—taking into account exposure to air pollution not limited to that generated by burn pit emissions—might be associated with long-term health effects, particularly in highly exposed populations (such as burn pit workers) or susceptible populations (such as those with asthma), mainly because of the high ambient concentrations of particulate matter from both natural and anthropogenic (including military) sources. It concluded that respiratory effects and cancer could result in circumstances where exposure to air pollution was sufficiently high. Gulf War and Health, Volume 10: Update of Health Effects of Serving in the Gulf War, 2016 (NASEM, 2016) was an update to Volume 4 (IOM, 2006) and Volume 8 (IOM, 2010a) on the health effects in the 1990–1991 Gulf War veterans that included literature published since those reports were assembled. The committee was charged to pay particular attention to certain disorders, including lung cancer. The thorough literature search conducted by the committee (including studies of experimental toxicology, neuroimaging, and genetics) found little evidence to warrant changes to the conclusions of Volume 8. The Volume 10 committee concluded that there was inadequate or insufficient evidence to determine whether an association existed between Gulf War deployment and any cancer or respiratory conditions and concluded that there was limited or suggestive evidence of no association between deployment and decreased lung function. The committee noted that with the exception of cancer, enough time had passed to determine whether veterans had an increased incidence of respiratory conditions compared with non- deployed counterparts, and it concluded that further studies to examine the incidence or prevalence of respiratory conditions due to deployment in the Gulf War should not be undertaken. The committee also posited that as recall bias likely increases with time, further collection of self-reported exposure information from Gulf War veterans was unnecessary but that in the future collecting exposure information before, during, and after deployment as well as information on troop locations and toxicant concentrations would enable a more accurate assessment of actual exposures. The committee noted that efforts to model or reconstruct the exposures of Gulf War deployment were unlikely to yield useful results, and it recommended that without definitive and verifiable individual veteran exposure information, further studies to determine cause-and-effect relationships between Gulf War exposures and health conditions in Gulf War veterans should not be undertaken. It recommended that VA and DoD develop a joint strategy on incorporating emerging diagnostic technologies and personalized approaches to medical care into sufficiently powered future research to inform studies of Gulf War illness and related health conditions. The committee that authored Assessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry (NASEM, 2017) was asked to analyze the data collected by a VA environmental health reg- istry—the Airborne Hazards and Open Burn Pit Registry—created for military personnel who might have been exposed to airborne hazards generated by open burn pits, fumes, and other toxic chemicals during deployment to Southwest Asia from August 1990 onward. The committee was also asked to recommend ways to improve the registry and to suggest how the data could best be used. The information that the committee reviewed had been collected over the registry’s first 13 months and included data from about 46,400 participants who had completed the questionnaire6 during that time. These participants represented about 1% of 1990–1991 Gulf War veterans and 1.7% of post-9/11 veterans. The committee found that the registry questionnaire exhibited problems arising from the basic weaknesses of voluntary, self-report registries and that these were exacerbated by flaws in the registry’s structure and operation and the type and manner of questioning. To evaluate the data, the committee focused on health outcomes related to the symptoms, conditions, and diseases associated with the respiratory and the cardio- 6  In that time period, roughly 40% who began a registry questionnaire did not complete it.

18 RESPIRATORY HEALTH EFFECTS OF AIRBORNE HAZARDS EXPOSURES vascular systems since these were the most plausible and well-documented potential health effects of the exposures of concern, but the committee found that the limitations of the registry questionnaire and the data collected by it were too great to allow any firm conclusions. Moreover, the committee concluded that the exposure data were of insufficient quality or reliability to make them useful in anything other than the most general assessments of exposure potential. Within this context, [g]enerally speaking, the committee found that the observed prevalences of respiratory and cardiovascular outcomes appear consistent with what would be expected in a population that is predominantly male, aged 25–60, and for whom about one-third report a current or former history of smoking. The committee recommended that questions about specific health outcomes be expanded and sharpened to improve the tool; regarding respiratory outcomes, it suggested adding reduced lung function, eosinophilic pneumonia, other lung infections (such as tuberculosis, fungal pneumonia, community-acquired pneumonia), lung scarring or fibrosis (a more inclusive diagnosis than idiopathic pulmonary fibrosis), bronchiolitis other than constrictive bronchiolitis (respiratory or obliterative), sarcoidosis/hypersensitivity pneumonitis, rhinosinusitis, and vocal cord dysfunction. The committee found that the registry’s primary usefulness was as a vehicle by which “the self-reported signs, symptoms, and diseases identified by registrants constitute a record that can alert providers to concerns and problems that may be forgotten about or missed during clinical encounters.” The committee recommended that VA clarify the intent and purpose of the registry before moving forward, while noting that even a well-designed and executed registry would have little value as a scientific tool for health effects research compared with a well- designed epidemiologic study. In the time since this report was completed, the number of registry participants has surpassed 200,000 (VA, 2020). A National Academies report updating the 2017 assessment is scheduled for completion in 2022. CHARGE TO THE COMMITTEE The committee’s Statement of Task is shown in Box 1-1. In brief, it directs the National Academies to convene an expert committee to evaluate the available scientific and medical literature and to identify gaps, research that could feasibly be conducted to address outstanding questions and generate answers, newly emerging technologies that could aid in these efforts, and organizations that VA might partner with to accomplish this work. COMMITTEE’S APPROACH TO ITS CHARGE The committee formed to address this task included experts in epidemiology, pulmonology, pathology, expo- sure assessment, military and veteran’s health, and toxicology. It comprised 11 members who held five in-person meetings between March 2019 and February 2020. Two of these in-person meetings included public open sessions, with one of them including a presentation from VA staff who elucidated the charge to the committee and the other consisting of an information-gathering workshop to help clarify and inform the committee’s work.7 Between and after the in-person meetings, groups of committee members held virtual meetings to review specific studies, discuss the evidence base on a particular health outcome or topic, and facilitate the writing of its report. Several activities were undertaken to develop the scientific foundation for the report’s findings, conclusions, and recommendations. These included detailed searches (discussed in detail in Chapter 3) of the published litera- ture, beginning in 1991; requesting information directly from VA and from experts in the field; examining other pertinent published literature, government documents, and reports; attending professional meetings; and consult- ing relevant National Academies reports. Background information on topics such as the use of military burn pits and the health effects of exposure to combustion products in general and burn pit emissions in particular has been 7  Chapter 3 includes a section that details the information presented at this workshop.

INTRODUCTION 19 BOX 1-1 Statement of Task An ad hoc committee under the auspices of the National Academies of Sciences, Engineering, and Medicine will comprehensively review, evaluate, and summarize the available scientific and medical literature regarding the respiratory health effects of exposure to airborne hazards encountered during service in the Southwest Asia Theater of Military Operations and Afghanistan. The report will pay particular attention to: • hazards associated with burn pit exposures; • excess mortality, cancer, bronchial asthma, chronic bronchitis, sinusitis, constrictive bronchiolitis, and other respiratory health outcomes that are of great concern to veterans; and • emerging evidence on respiratory health outcomes in service members from research such as the Millennium Cohort Study, Study of Active Duty Military for Pulmonary Disease Related to Envi­ ronmental Deployment Exposures (STAMPEDE), National Health Study for a New Generation of U.S. Veterans, Comparative Health Assessment Interview (CHAI) Study, Pulmonary Health and Deployment to Iraq and Afghanistan Objective Study, Effects of Deployment Exposures on Car­ diopulmonary and Autonomic Function Study, and research being conducted by the Department of Veterans Affairs (VA) War Related Illness and Injury Study Center (WRIISC) Airborne Hazards Center of Excellence (AHCE) in New Jersey. It will evaluate the extent to which existing knowledge base informs the understanding of the poten­ tial adverse effects of in-theater military service on respiratory health, identify gaps, research that could feasibly be conducted to address outstanding questions and generate answers, newly emerging technolo­ gies that could aid in these efforts, and organizations that VA might partner with to accomplish this work. The committee shall produce a final report detailing the conduct of these activities and offering any findings, conclusions, and recommendations it deems appropriate. covered by previous National Academies reports, as summarized in the previous section (specifically, IOM, 2011; NASEM, 2016, 2017). With an eye to respiratory health outcomes, the committee considered all epidemiologic studies that had been reviewed in Gulf War and Health series Volumes 4, 8, and 10 (IOM, 2006, 2010a; NASEM, 2016) as well as the two reports that focused on exposures to burn pits (IOM, 2011; NASEM, 2017). Most of the in-person information-gathering occurred during the first and third in-person committee meet- ings. At its first meeting, the committee heard from VA representatives R. Loren Erickson, M.D., Dr.P.H.—then the chief consultant with the Post Deployment Health Patient Care Services in the Veterans Health Administra- tion—and Eric Shuping, M.D., M.P.H., FAAFP—director of the Post-9/11 Era Environmental Health Program. Drs. Erickson and Shuping elaborated on VA’s charge to the committee and on the expectations for the final report. Additionally, National Academies staff briefed the committee on earlier studies of the respiratory health effects of in-theater exposures. ORGANIZATION OF THE REPORT This report is organized into five chapters (including this one) and four appendixes. Chapter 2 provides a detailed description of airborne hazards in Southwest Asia, including regional environmental exposures, exposures associated with the operation of in-theater military sites, occupational exposures encountered by military personnel while deployed, and the exposure tracking performed by DoD. The chapter also identifies other factors that may increase an individual’s risk to these hazards. Chapter 3 explains how the committee carried out its evaluation of the evidence base. It describes the approach and process used by the committee to identify and evaluate the scientific and medical literature on the association

20 RESPIRATORY HEALTH EFFECTS OF AIRBORNE HAZARDS EXPOSURES between exposure to airborne hazards and respiratory health outcomes and the classification system that the com- mittee used to draw conclusions about the strength of the evidence for each respiratory health outcome it considered. The chapter also provides background descriptions of the major epidemiologic cohorts and research initiatives that the committee was tasked to pay particular attention to or that are referenced three or more times in Chapter 4. Chapter 4 provides a detailed evaluation of the scientific literature addressing respiratory health outcomes in service members and veterans who served in the Southwest Asia theater. This begins with an overview of the c ­ ondition—its symptoms, diagnostic criteria and pathology, and prevalence. This is followed by a summary of findings on that condition from epidemiologic studies organized by conflict and cohort and the committee’s conclu- sion regarding the strength of the evidence associating deployment to the theater with the outcome. Where the data permit, separate conclusions are drawn for those deployed to the 1990–1991 Gulf War and the post-9/11 conflicts. Chapter 5 describes the challenges and opportunities for advancing the understanding of respiratory health issues in theater veterans. It addresses the hazards associated with burn pit exposures and uses the results of its comprehensive literature review to fulfill the Statement of Task’s directive to “identify knowledge gaps, research that could feasibly be conducted to inform the field and generate answers, newly emerging technologies that could aid in these efforts, and organizations that VA might partner with to accomplish this work.” The report’s appendixes present supplemental information on the conduct of the study. Appendix A contains the agendas of the committee’s open meeting and workshop. Appendix B lists National Academies reports related to Southwest Asia theater veterans’ health. Appendix C is a table of all the new literature on respiratory health outcomes that was reviewed by the committee. Appendix D provides the committee and staff biographies. REFERENCES Collins, S. 2019. Desert Storm: A look back. https://www.defense.gov/Explore/Features/story/Article/1728715/desert-storm- a-look-back (accessed April 12, 2020). CRS (Congressional Research Service). 2019a. U.S. periods of war and dates of recent conflicts. Updated August 27, 2019. CRS Report RS21405. https://crsreports.congress.gov/product/pdf/RS/RS21405 (accessed May 10, 2020). CRS. 2019b. U.S. war costs, casualties, and personnel levels since 9/11. CRS Report IF11182. https://crsreports.congress.gov/ product/pdf/IF/IF11182 (accessed May 10, 2020). DoD (Department of Defense). n.d. About CJTF-OIR. https://www.inherentresolve.mil/About-CJTF-OIR (accessed May 10, 2020). DoD OIG (Office of Inspector General). 2019. Lead inspector general for Operation Freedom’s Sentinel I quarterly report to the United States Congress I April 1, 2019–June 30, 2019. https://www.dodig.mil/In-the-Spotlight/Article/1938932/ lead-inspector-general-for-operation-freedoms-sentinel-i-quarterly-report-to-th (accessed May 10, 2020). Engelbrecht, J. P., E. V. McDonald, J. A. Gillies, and A. W. Gertler. 2008. Department of Defense Enhanced Particulate Matter Surveillance Program (EPMSP): Final report. Desert Research Institute, Reno, NV. February [online]. https://pdfs. semanticscholar.org/18af/a824db71d54eb0242659b5b224c71e32aaba.pdf (accessed May 10, 2020). GAO (Government Accountability Office). 2017. Gulf War illness—improvements needed for VA to better understand, pro- cess, and communicate decisions on claims. GAO-17-511. June. https://www.gao.gov/assets/690/685582.pdf (accessed May 10, 2020). IOM (Institute of Medicine). 1995. Health consequences of service during the Persian Gulf War: Initial findings and recom- mendations for immediate action. Washington, DC: National Academy Press. IOM. 1996. Health consequences of service during the Persian Gulf War: Recommendations for research and information systems. Washington, DC: National Academy Press. IOM. 1998. Adequacy of the VA Persian Gulf Registry and uniform case assessment protocol. Washington, DC: National Academy Press. IOM. 2005. Gulf War and health: Volume 3: Fuels, combustion products, and propellants. Washington, DC: The National Academies Press. IOM. 2006. Gulf War and health: Volume 4: Health effects of serving in the Gulf War. Washington, DC: The National ­Academies Press. IOM. 2010a. Gulf War and health: Volume 8: Update of health effects of serving in the Gulf War. Washington, DC: The National Academies Press.

INTRODUCTION 21 IOM. 2010b. Returning home from Iraq and Afghanistan: Preliminary assessment of readjustment needs of veterans, service members, and their families. Washington, DC: The National Academies Press. IOM. 2011. Long-term health consequences of exposure to burn pits in Iraq and Afghanistan. Washington, DC: The National Academies Press. Mosbergen, D. 2018. After promises of “transparency,” Pentagon under scrutiny for troop number blackout. July 4. HuffPost. https://www.huffpost.com/entry/pentagon-troop-number-blackout-iraq-syria-afghanistan_n_5b3c6a27e4b07b827cbc12e4 (accessed July 1, 2020). NASEM (National Academies of Sciences, Engineering, and Medicine). 2016. Gulf War and health: Volume 10: Update of health effects of serving in the Gulf War, 2016. Washington, DC: The National Academies Press. NASEM. 2017. Assessment of the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry. Washington, DC: The National Academies Press. NRC (National Research Council). 2010. Review of the Department of Defense Enhanced Particulate Matter Surveillance Program report. Washington, DC: The National Academies Press. VA (Department of Veterans Affairs). 2019. Gulf War service. https://www.publichealth.va.gov/exposures/gulfwar/military- service.asp (accessed May 10, 2020). VA. 2020. Airborne hazards and open burn pit registry. https://veteran.mobilehealth.va.gov/AHBurnPitRegistry (accessed May 10, 2020). Wenger, J. W., C. O’Connell, and L. Cottrell. 2018. Examination of recent deployment experience across the services and components. RAND Corporation. https://www.rand.org/content/dam/rand/pubs/research_reports/RR1900/RR1928/ RAND_RR1928.pdf (accessed May 10, 2020).

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More than 3.7 million U.S. service members have participated in operations taking place in the Southwest Asia Theater of Military Operations since 1990. These operations include the 1990-1991 Persian Gulf War, a post-war stabilization period spanning 1992 through September 2001, and the campaigns undertaken in the wake of the September 11, 2001, attacks. Deployment to Iraq, Kuwait, Saudi Arabia, Bahrain, Gulf of Aden, Gulf of Oman, Oman, Qatar, the United Arab Emirates, and Afghanistan exposed service members to a number of airborne hazards, including oil-well fire smoke, emissions from open burn pits, dust and sand suspended in the air, and exhaust from diesel vehicles. The effects of these were compounded by stressors like excessive heat and noise that are inevitable attributes of service in a combat environment.

Respiratory Health Effects of Airborne Hazards Exposures in the Southwest Asia Theater of Military Operations reviews the scientific evidence regarding respiratory health outcomes in veterans of the Southwest Asia conflicts and identifies research that could feasibly be conducted to address outstanding questions and generate answers, newly emerging technologies that could aid in these efforts, and organizations that the Veterans Administration might partner with to accomplish this work.

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