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1 Introduction During deployment, military personnel are exposed to a variety of environmental hazards, such as dust, intense heat and sunlight, kerosene heaters, pesticides, and depleted uranium. Exposure to some such hazards has been associated with long-term adverse health outcomes. Many U.S. military personnel returning from the current conflicts in Iraq and Afghanistan are reporting health problems that they contend are related to their exposure to emissions from the burning of waste in open-air “burn pits” on military bases. Throughout the military operations in Iraq and Afghanistan, burn pits have been used to dispose of all types of waste. Military field operations generate large quantities of waste that must be disposed of. It is estimated that about 8–10 pounds of solid waste is generated per person per day at the bases in Iraq and Afghanistan, although this number can vary depending on the base and its population (Faulkner 2011). Historically, the U.S. military has established open-air waste burning sites when hauling trash to appropriate disposal sites or the sanitary discharge of latrine wastes are not available options. A wide range of refuse can be burned, from food and human waste to packaging and equipment, as well as materials abandoned by the enemy. Current Department of Defense (DoD) regulations permit the use of burn pits only until better disposal options such as incinerators are available and operational (AFIOH undated). Nevertheless, burn pit use continues to be widespread at U.S. military bases in Afghanistan, although they are being phased out in Iraq. Special controversy surrounds the open burn pit used to dispose of solid waste at Joint Base Balad (JBB), near Baghdad, one of the largest military bases in Iraq and a central logistics hub for U.S. forces there. On the cover of this report is a photograph of the burn pit at JBB, taken for the Stars and Stripes newspaper. The DoD has been conducting environmental monitoring and health studies at JBB since 2004 and a health screening study, released in May 2008, stated that burn pits posed an “acceptable” health risk (Taylor et al. 2008). Nevertheless, an Army Times article published in October 2008 generated widespread public concern about the pits by reporting that the JBB burn pit “may have exposed tens of thousands of troops, contractors, and Iraqis to cancer-causing dioxins, poisons such as arsenic and carbon monoxide, and hazardous medical waste” and emphasizing claims that such exposures resulted in reported illnesses among troops. This article and subsequent ones helped to trigger congressional hearings and legislative proposals requiring further study of the potential health effects that might arise from exposure to burn pits on U.S. military bases in Iraq and Afghanistan. JBB, also known as Logistic Support Area Anaconda, is a 10 square-mile forward operating base located approximately 40 miles north of Baghdad. The military population of the base fluctuated over the years when the burn pit was in operation from an average of 241 service members within a 5-mile radius of JBB in 2003 to 11

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12 HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS an average of 10,430 service members in 2009; the average population of U.S. service members peaked at over 15,000 in 2007 (Steve Halko, Defense Manpower Data Center, personal communication, August 25, 2010). An unknown number of coalition forces and civilian contactors were also on the base. Because of its large population, the scale of the Balad burn pit was also large, with estimates of the amount of waste burned ranging from about 2 tons per day early in its operation in 2003 to 200 tons of waste being burned daily in 2007 (Taylor et al. 2008; USAPC 2010). The burn pit ceased operating in late 2009. No inventory of the items burned in the pit was made available to the committee, but the refuse was reported to include a wide variety of materials that could produce potentially hazardous emissions. Among these substances were plastics, metal cans, rubber, chemicals (paints, solvents), petroleum, munitions, and wood waste. In addition, JP-8 jet fuel was used as an accelerant for the fire (Taylor et al. 2008). Anecdotal accounts mention specifically the burning of plastic water bottles, food waste, human waste, and munitions, but ordnance does not appear to have been burned deliberately in the JBB burn pit. Uncontrolled open-air burning does not completely burn the wastes, and military documents, eyewitness accounts, and publicly available photographs and videos confirm that at JBB and at other bases smoke plumes rose from burn pit areas, and at times smoke blew over the base and into living areas (Taylor et al. 2008). Open air pit burning at JBB generated complaints as early as 2003 (CHPPM undated). In 2007, in response to the concerns of active-duty military personnel about potential hazardous inhalation exposures at JBB and other installations with burn pits, the U.S. Army Center for Health Promotion and Preven - tative Medicine (CHPPM, now called the U.S. Army Public Health Command) and the U.S. Air Force Institute for Operational Health (AFIOH) began a formal screening health risk assessment at JBB (Taylor et al. 2008). The study collected air samples from January through April of 2007 at several locations around the base, and the samples were analyzed for many of the chemicals expected to be emitted during trash burning. The objective was to assess the potential for adverse health effects to personnel stationed at the base who might be exposed to such chemicals. The CHPPM report (released in May 2008) found risks for cancer or noncancer health effects of con - cern that could be attributed to exposure to the air pollutants detected at JBB to be “acceptable” (that is, a cancer risk between 1 in 10,000 and 1 in 1,000,000 or lower, and a hazard index less than one). However, it should be noted that many air pollutants were not measured at JBB including U.S. National Ambient Air Quality Standard priority pollutants such as nitrogen and sulfur oxides, ozone, and carbon monoxide. Follow-up sampling in the same locations occurred in the fall of 2007 after two incinerators were installed, and subsequently in 2009 just before complete closure of the burn pit. Screening health risk assessments based on those sampling campaigns also found the risks from exposure to the air pollutants to be “acceptable” for cancer risks, with some potential for short-term, reversible non-cancer effects, and a “moderate” operational risk from particulate matter (CHPPM and AFIOH 2009; Taylor et al. 2009; USAPHC 2010). Members of Congress also became interested in military burn pit use and safety. Bills were introduced in 2009 and 2010 to sharply curtail the use of open-air burn pits and establish a medical surveillance system to identify veteran health effects attributed to exposure to the burning of solid waste. HR 2647, the National Defense Authorization Act for Fiscal Year 2010, prohibits the use of burn pits for hazardous prohibits the use of burn pits for hazardous and medical waste except in cases where there is no alternative, 1 and the act requires the DoD to take several actions including: reporting to Congress regularly whenever burn pits are 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 CHPPM screening study, with DoD and Department of Veterans Affairs (VA) officials emphasizing the study’s conclusion that JBB exposures fell within military exposure guidelines and U.S. Environmental Protection Agency values for acceptable risk. 1 Hazardous wastes in the National Defense Authorization Act uses the definition in the 2002 Solid Waste Disposal Act, Section 1004(5) to mean “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, illness; 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” (; accessed August 23, 2011).

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13 INTRODUCTION Veterans and individual medical and environmental professionals who served in Iraq testified about the presence of noxious smoke on the base and 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. In addition, medical and environmental personnel testified about the increased respiratory symptoms reported by personnel on bases in Iraq and by returning veterans seeking medical treatment stateside (U.S. Congress 2009a,b). STATEMENT OF TASK In response to the concerns expressed by service members, their families, and Congress, the VA asked the Institute of Medicine (IOM) to examine the long-term health consequences of exposure to burn pits in Iraq and Afghanistan. The IOM established a committee that was given the following statement of task: Determine the long-term health effects from exposure to burn pits in Iraq and Afghanistan. Specifically, the com- mittee will use the Balad Burn Pit in Iraq as an example and examine existing literature that has detailed the types of substances burned in the pits and their by-products. The committee will also examine the feasibility and design issues for an epidemiologic study of veterans exposed to the Balad burn pit. The committee will explore the background on the use of burn pits in the military. Areas of interest to the committee might include but are not limited to investigating: • here are burn pits located, what is typically burned, and what are the by-products of burning; W • he frequency of use of burn pits and average burn times; and T • hether the materials being burned at Balad are unique or similar to burn pits located elsewhere in Iraq and W Afghanistan. COMMITTEE’S APPROACH TO ITS CHARGE IOM appointed a committee of 14 members with expertise in occupational and environmental health, toxicol - ogy, exposure assessment and modeling, epidemiology, clinical medicine, and biostatistics to carry out the study. At its first meeting, the committee decided that its approach to gathering information would include considering data from the peer-reviewed literature; gathering data directly from the DOD and the VA and other experts in the field; reviewing government articles, reports, and testimony presented to Congress; and reviewing relevant National Research Council (NRC) and IOM reports on veterans health issues, specific chemicals of concern, waste incin - eration and combustion processes, and approaches to cumulative risk assessment. In addition, the committee held two public sessions to hear from veterans, representatives from the DoD and the VA, and other knowledgeable parties. Discussion with staff of the House Committee on Oversight and Government Reform in October 2010 on the congressional investigation of burn pits also helped to inform the committee’s understanding of the available documentation on military burn pits in Iraq and Afghanistan. Although the committee conducted extensive searches of the peer-reviewed literature in its attempts to under- stand health consequences of exposure to burn pit smoke and emissions in Iraq and Afghanistan, there was a paucity of information published in the peer-reviewed literature related specifically to health effects from such burning. In the absence of published data on in-theater burn pit emissions, the committee reviewed reports from the DoD and published literature on emissions from all types of open burning activities. The committee also requested additional data from the DoD on the environmental monitoring conducted at JBB for the screening reports. Although the com- mittee asked the DoD for information on the types and volumes of waste burned at JBB or elsewhere in Iraq and Afghanistan, the DoD was unable to provide the committee with any specific information but it did provide generic information on waste streams for burn pits at U.S. installations in Kosovo, Bosnia, and Bulgaria (Faulkner 2011).

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14 HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS ORGANIZATION OF THE REPORT This report includes the committee’s assessment of the potential long-term health effects of exposure to burn pit smoke in Iraq and Afghanistan along with feasibility and design issues for an epidemiologic study of veterans exposed to the Balad burn pit. Chapter 2 provides information on the current and historical use of burn pits in the military and the history of concerns about possible health risks related to exposure to burn pit smoke. The committee’s approach to the task is described in Chapter 3. An evaluation of air monitoring data from JBB and determinants of exposure are discussed in Chapter 4. The long-term health effects associated with the chemicals identified in the emissions from the burn pit at JBB are discussed in Chapter 5. Chapter 6 summarizes the potential long-term health effects associated with exposure to combustion products for other populations such as firefight - ers. Chapter 7 summarizes the conclusions reached in Chapters 4 through 6 and synthesizes that information into an evaluation of the long-term health effects that might be associated with exposure to burn pit emissions in Iraq and Afghanistan. Chapter 8 describes feasibility and design issues for an epidemiologic study of veterans exposed to burn pit emissions. REFERENCES AFIOH (U.S. Air Force Institute for Operational Health). Undated. Open pit burning general facts and information. Brooks City-Base, TX: U.S. Air Force Institute for Operational Health. CHPPM (U.S. Army Center for Health Promotion and Preventative Medicine) and AFIOH. 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. CHPPM. Undated. Just the facts: Balad burn pit. Aberdeen Proving Ground, MD: U.S. Army Center for Health Promotion and Preventive Medicine. Faulkner, W. M. 2011. Exposure to toxins produced by burn pits: Congressional data request and studies . Memorandum for the assistant secretary of defense for health affairs. Washington, DC: Joint Staff. March 28, 2011. Enclosure: ASD(HA) Memorandum, 17 Feb 11. Response to ASD(HA) Request for Information. 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. May. U.S. Congress, Senate, Committee on Veterans’ Affairs. 2009a. Airway injury in U.S. soldiers following service in Iraq and Afghanistan. 111th Cong., 1st Sess. October 8. U.S. Congress, Senate, Democratic Policy Committee. 2009b. Are burn pits in Iraq and Afghanistan making our soldiers sick? 111th Cong., 1st Sess. November 6. USAPHC (U.S. Army Public Health Command). 2010. Screening health risk assessments, Joint Base Balad, Iraq, 11 May–19 June 2009. Aberdeen Proving Ground, MD: U.S. Army Public Health Command. July.