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Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan Committee on the Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan Board on the Health of Select Populations

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract V101 (93) P-2136 (Task Order 19) between the National Academy of Sci - ences and Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-21755-2 International Standard Book Number-10: 0-309-21755-5 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Cover photo by Michael Gisick. Used with permission from Stars and Stripes. Copyright 2010, 2011 Stars and Stripes. Suggested citation: IOM (Institute of Medicine). 2011. Long-term health consequences of exposure to burn pits in Iraq and Afghanistan. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in sci - entific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad com - munity of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the gov - ernment, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.nationalacademies.org

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COMMITTEE ON THE LONG-TERM HEALTH CONSEQUENCES OF EXPOSURE TO BURN PITS IN IRAQ AND AFGHANISTAN DAVID J. TOLLERUD (Chair), Professor and Chair, Department of Environmental and Occupational Health Sciences, University of Louisville, School of Public Health and Information Sciences JOHN R. BALMES, Professor of Medicine, School of Medicine, Division of Occupational and Environmental Medicine, University of California, San Francisco ARUNI BHATNAGAR, Director, Diabetes and Obesity Center, Professor & Distinguished University Scholar; Medicine/Cardiology, University of Louisville EDMUND A. C. CROUCH, Senior Scientist, Cambridge Environmental, Inc. FRANCESCA DOMINICI, Professor of Biostatistics, Department of Biostatistics, Harvard School of Public Health ELLEN A. EISEN, Adjunct Professor of Environmental Health Sciences and Epidemiology, School of Public Health, University of California, Berkeley MARY A. FOX, Assistant Professor, Johns Hopkins Bloomberg School of Public Health MARK W. FRAMPTON, Professor of Medicine and Environmental Medicine, University of Rochester School of Medicine & Dentistry PETROS KOUTRAKIS, Professor of Environmental Sciences, Department of Environmental Health, Harvard School of Public Health JACOB McDONALD, Scientist and Director, Chemistry and Inhalation Exposure Program, Lovelace Respiratory Research Institute GUNTER OBERDÖRSTER, Professor of Environmental Medicine, University of Rochester School of Medicine & Dentistry DOROTHY E. PATTON, U.S. Environmental Protection Agency (Retired) WILLIAM M. VALENTINE, Associate Professor, Department of Pathology, Vanderbilt University Medical Center BAILUS WALKER, Professor, Environmental and Occupational Medicine, Howard University Cancer Center Staff ROBERTA WEDGE, Study Director JENNIFER SAUNDERS, Program Officer (through September 2010) DOMINIC BROSE, Associate Program Officer CARY HAVER, Associate Program Officer MARGOT IVERSON, Program Officer JONATHAN SCHMELZER, Program Assistant CHRISTIE BELL, Financial Officer FREDRICK ERDTMANN, Director, Board on the Health of Select Populations v

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Reviewers This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individual’s for their review of this report: Judy Chow, Atmospheric Sciences Division, Desert Research Institute David Christiani, Department of Environmental Health and Department of Epidemiology, Harvard School of Public Health David Cleverly, North Falmouth, MA Douglas W. Dockery, Department of Environmental Health, Harvard School of Public Health Philip K. Hopke, Center for Air Resources Engineering & Science, Department of Chemical & Biomolecular Engineering, Clarkson University Morton Lippmann, New York Univerity, Langone Medical Center Michael McClean, Department of Environmental Health, Boston University School of Public Health Melissa A. McDiarmid, Department of Medicine, and Department of Epidemiology & Public Health, University of Maryland School of Medicine Armistead G. Russell, School of Civil and Environmental Engineering, Georgia Institute of Technology Jamie Schauer, Water Science and Engineering Laboratory, University of Wisconsin-Madison Richard Schlesinger, Department of Biology and Health Sciences, Pace University Kenneth R. Still, President and Scientific Director, Occupational Toxicology Associates Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Mark R. Cullen, Stanford University, and Lynn R. Goldman, vii

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viii REVIEWERS George Washington University, School of Public Health and Health Services. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were care - fully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface During deployment to a war zone, military personnel are exposed to a variety of environmental hazards, many of which have been associated with long-term adverse health outcomes such as cancer and respiratory disease. Many veterans returning from the current conflicts in Iraq and Afghanistan have health problems that they believe are related to their exposure to the smoke from the burning of waste in open-air “burn pits” on military bases. Particular attention has been focused on exposure to smoke, dubbed “Iraqi crud,” from the open burn pit at Joint Base Balad (JBB), one of the largest U.S. military bases in Iraq. In response to these concerns, the Department of Defense (DoD) has been conducting environmental monitor- ing and health studies at JBB since 2004. Screening health risk assessments, publicly released in 2008 and 2009, stated that the burn pits at JBB and other U.S. military locations in Iraq, posed an “acceptable health risk” to per- sonnel. Nevertheless, articles in the popular press have generated widespread public concern 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.” These articles, in addition to concerns expressed by military personnel and veterans and their families, helped trigger congressional hearings and legislative proposals requiring further study of burn pits. Ultimately, the Department of Veterans Affairs (VA) asked this committee to determine the long-term health effects from exposure to burn pits in Iraq and Afghanistan. Throughout the course of its deliberations, the committee received useful information from the DoD and others that helped in the conduct of this study, such as the raw data for the air monitoring campaigns at JBB in 2007 and 2009. Unfortunately, other information that would have assisted the committee in determining the composition of the smoke from the burn pit and, therefore, the potential health effects that might result from exposure to possible hazardous air pollutants, was not available. Specifics on the volume and content of the waste burned at JBB, as well as air monitoring data collected during smoke episodes, were not available. The committee appreciates the importance of this issue for many veterans, and it owes a tremendous thanks to the many individuals and groups who generously gave their time and expertise to share with committee members their insight into particular issues, to provide reports and data sets, and to answer queries about their work on this issue. The committee is especially grateful to the many veterans who shared their personal stories about serving on bases with burn pits, and to the many people who provided other helpful information including: Congressman Tim Bishop (D-NY); R. Craig Postlewaite, DoD Office of the Assistant Secretary of Defense (Health Affairs); Joseph Abraham, Coleen Baird Weese, Adam Deck, and Jeffrey Kirkpatrick, U.S. Army Public Health Command; Tyler Smith, National University Technology and Health Sciences Center; John Kolivosky and Scott Newkirk, U.S. ix

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x PREFACE Army Institute of Public Health; William Haight and Bill Mackie, Engineering Division, The Joint Staff, Pentagon; Neema Guliani and Lisa Cody, House Committee on Oversight and Government Reform; Victoria Cassano, VA; and James Ball, American Red Cross. The committee also greatly appreciates the efforts of Rima Habre, Harvard School of Public Health, for her assistance with the positive matrix factorization modeling. The committee is also very grateful to Roberta Wedge, who served as study director for this project, and to all of the Institute of Medicine staff members who contributed to this project: Dominic Brose, Cary Haver, Margot Iverson, Jennifer Saunders, and Jonathan Schmelzer. A thank you is also extended to William McLeod who con - ducted database and literature searches. David J. Tollerud, Chair Committee on the Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan

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Contents SUMMARY 1 1 INTRODUCTION 11 2 CURRENT AND HISTORICAL USES OF BURN PITS IN THE MILITARY 15 3 APPROACH TO THE TASK 23 4 EVALUATION OF AIR MONITORING DATA AND DETERMINANTS OF EXPOSURE 31 5 HEALTH EFFECTS OF AIR POLLUTANTS DETECTED AT JOINT BASE BALAD 47 6 HEALTH EFFECTS ASSOCIATED WITH COMBUSTION PRODUCTS 63 7 SYNTHESIS AND CONCLUSIONS 109 8 FEASIBILITY AND DESIGN ISSUES FOR AN EPIDEMIOLOGIC STUDY OF VETERANS EXPOSED TO BURN PIT EMISSIONS 117 Appendixes A COMMITTEE BIOGRAPHICAL SKETCHES 129 B REVIEW OF AIR MONITORING DATA FROM JOINT BASE BALAD 133 C EPIDEMIOLOGIC STUDIES CITED IN CHAPTER 6: HEALTH OUTCOMES 139 xi

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