The Iraq War killed former Minnesota Air National Guard Tech Sgt. Amie Muller. It just took a decade to do it.

That, at least, is how Muller’s family and friends see it. The 36-year-old’s pancreatic cancer, they believe, was caused by exposure to the massive burn pit used to dispose of waste at Joint Base Balad, 40 miles north of Baghdad. Her doctors said there was a strong possibility the burn pit was to blame, but no way to definitively prove a link with the available evidence.

Regardless, a young mother of three died in February from a disease that typically is diagnosed at age 71.

“It makes me really mad,” Muller told the Minneapolis Star-Tribune in June 2016, a month after learning she had Stage III pancreatic cancer. “I inhaled that stuff all day, all night. Everything that they burned there is illegal to burn in America. That tells you something.”

Muller was a beautiful person whose “nature was to care about others,” her friend Julie Tomaska told Task & Purpose. “She loved animals, loved people. On deployment, she would draw out the misfits, because she was an ear and a shoulder, listening without judgment.”

Star Tribune photo by Elizabeth Flores
One day after a chemotherapy treatment at Mayo Clinic, Amie Muller rested at her home with her husband Brian Muller and their two children, June 17, 2016.

Even as her life came to an end, Muller sought to prevent others from suffering a similar fate. Despite being in physical pain from the cancer, and agonizing over the thought of leaving her children without a mom, she established a foundation with her husband, Brian Muller, to support military families fighting pancreatic cancer. She also became a voice for veterans who believe that the modern battlefield, with its burn pits, fine dust, and metal-laden soil, is an environmental killer.

“Amie Muller served this country with distinction, and we owe her our gratitude,” Sen. Amy Klobuchar, a Democrat from Minnesota, said in a statement following Muller’s death on Feb. 18. “My heart goes out to her family and friends.”

Klobuchar had gotten to know Muller during her illness, and just 10 days before Muller died, the senator teamed up with Republican Sen. Thom Tillis of North Carolina to sponsor legislation that would require the VA to establish a center of excellence to study and improve the diagnosis and treatment of burn pit-related illnesses.

“There are an increasing number of our brave men and women returning home from Iraq and Afghanistan citing illnesses potentially caused by burn pits exposure,” Klobuchar said. “I am going to keep fighting so that these veterans receive the care and support they need.”

Added Tillis: “This bipartisan bill is the beginning of that commitment, providing resources to the VA to study the health effects caused by the burn pits and to provide treatment to veterans who became sick after exposure.”

“It always felt like no matter what shift you worked, the wind always switched and followed you, so it was there when you were at work, it was there in your tents. There was no escaping it.”

To date, 34 members of the House and Senate have added their names to the Senate bill, S. 319, Helping Veterans Exposed to Burn Pits, and its companion House bill, H.R. 1279, in support.

 Veterans have long reported health issues thought to be related to combat deployments, and Congress has discussed the associated health risks at 30 hearings since 2009. In 2013, the legislators even ordered the VA to establish a registry to track veterans who believe they are sick as a result of exposure to burn pits or other environmental factors in Iraq and Afghanistan.

But as with everything involving burn pits and deployment-related health conditions — from the lack of air quality data to the dearth of research on potential health consequences and even questions over who is responsible for what was burned — VA’s Airborne Hazards and Open Burn Pit Registry has drawn its share of criticism.

More than 174,200 veterans have signed onto the registry, and 104,999 have completed its lengthy questionnaire. But in a report released in February, the National Academies of Sciences, Engineering and Medicine concluded that the project had “limited value for improving individual patient care.” The report found flaws in the registry’s reliance on volunteer participation and self-reporting and criticized it for having poorly written questions. It also called into question the lengthy lengthy personal and lifestyle questionnaire prior to the health questions that the National Academies panel said may contribute to the high incompletion rate.

U.S. Air Force photo
Senior Airman Frances Gavalis, 332nd Expeditionary Logistics Readiness Squadron equipment manager, tosses unserviceable uniform items into a burn pit, March 10, 2008.

Muller and Tomaska both signed up, but Tomaska, who has a PhD in public health, said she could sense that the survey would be of little use to researchers. “They asked a lot about prior exposures, overall health and personal habits and not a lot of specifics about deployment … it looks like they created it intentionally to have flaws. The VA never intended for it to be anything of value,” Tomaska said.

Another problem is that the registry only allows veterans to complete the form — not spouses or family members of those who have died, says Rosie Torres, who co-founded the advocacy group BurnPits 360 with her husband, retired Army Capt. LeRoy Torres.

“I know of at least 5,000 cases that aren’t in there because the veteran either died or there are reporting restrictions,” Torres told Task & Purpose.

+++

At their peak, burn pits numbered 22 in Iraq and 251 in Afghanistan. In 2009, after concerns were raised about their potential health consequences, the Defense Department issued a directive requiring any base with more than 100 U.S. troops assigned for more than 90 days to have a waste disposal alternative.

But that directive was routinely ignored, and through early 2016, burn pits remained a commonly used method for waste disposal.

“It is indefensible that U.S. military personnel, who are already at risk of serious injury and death when fighting the enemy, were put at further risk from the potentially harmful emissions from the use of open air burn pits,” the special inspector general for Afghanistan reconstruction, John Sopko, wrote in late 2015 after discovering that a number of incinerators built by the U.S. government were never used and that burn pits remained in operation.

The burn pit at Balad, the base where Muller worked as a videographer for several months in 2005 and 2007, covered 10 acres and gobbled up more than 240 tons of trash a day. Everything at the sprawling base went into the pit: computer parts, animal carcasses, medical waste (including body parts), lithium ion batteries, furniture, plastic bottles, insecticide canisters, DEET-soaked tents, human excrement, plastic drums, food waste, even whole vehicles — all of it dumped, soaked in JP-8 and lit afire.

The pit released large clouds of black smoke that drifted across runways and airfields, over and through tents, across the desert, often leaving fine, green-black soot on everything. “Iraqi talcum powder,” some troops called it.

“It always felt like no matter what shift you worked, the wind always switched and followed you, so it was there when you were at work, it was there in your tents. There was no escaping it,” recalled Tomaska, who deployed with Muller and has her own deployment-related health problems. She calls it “The Balad Cough.” Others speak of “The Iraqi Crud.”

Did the burn pits cause their illnesses? Nobody knows for sure. At this point, the research that might prove a connection — or disprove one — has yet to be conducted.

U.S. Army photo
U.S. Army Sgt. 1st Class Jimmy Cunningham, of Pontotoc, Miss., assigned to the 1st of the 230th Air Cavalry Squadron, Golf Troop, 2nd Fuel and Armor Platoon, stokes a fire pit while burning documents at Combat Outpost Nimer, near Sinjar, Iraq, Sept. 30, 2009.

Although it is known that burning plastics and other industrial waste can release cancer causing dioxins and volatile chemicals into the air, the Institute of Medicine, in 2011, reviewed all available reports on burn pit utilization and exposure to combustibles in civilian occupations and concluded that while there was evidence that exposure could cause short-term, reduced lung function, the panel lacked the data or research needed to draw any conclusions about long-term respiratory health consequences. Moreover, the IOM found “inadequate or insufficient evidence” of any relation between burn pit exposure, cancer, respiratory disease and neurological diseases.

The six-year-old report continues to be the basis for the VA’s ongoing refusal to grant disability compensation for many illnesses in post-9/11 troops who lived and worked near burn pits.

“It’s disheartening,” Tomaska said. “It’s like we’ll have to wait another 10 years to prove connection and causation. Look how long it took Agent Orange vets — 20, 30 years.”

LeRoy Torres calls it the “war that followed us home.” A former marathon runner, he can no longer roughhouse with the kids or cross a parking lot without getting winded. He was finally diagnosed last year with constrictive bronchiolitis, a rare, irreversible scarring of the lungs.

“Since returning from Iraq, I have had over 225 medical visits and was hospitalized immediately after returning from war,” Torres said while testifying before the Texas state legislature in March. “As a man, a husband and father I have felt deprived of my dignity honor and health.”

“I inhaled that stuff all day, all night. Everything that they burned there is illegal to burn in America. That tells you something.”

U.S. troops began reporting health symptoms nearly the moment they set foot in the Iraqi desert, and in Afghanistan, near large installations such as Bagram Air Base and Kandahar Airfield, where burn pits were established to dispose of trash.

Within a week of being in theatre, members of Tomaska and Muller’s unit, the public affairs shop of the 148th Fighter Wing, hacked up black phlegm. Their noses ran and eyes swelled. They wheezed, developed asthma and bronchitis and couldn’t catch their breath. They had headaches and skin infections. They were given Zithromax and sent back to work. But despite efforts to keep their living and work environments clean, they constantly battled the soot, not to mention the driving sand and particles kicked up by dust storms.

At first, returning service members reported symptoms of asthma and difficulty taking deep breaths, despite testing that showed they had normal lung function. A pulmonologist at Vanderbilt University Medical Center, Dr. Bob Miller, suspected constrictive bronchiolitis and started testing for it, conducting lung biopsies in soldiers from Fort Campbell, Kentucky, who had responded to a sulfur mine fire at Al-Mishraq in 2003. Later, other troops, including those who worked near burn pits, were diagnosed with the condition. According to the VA’s Burn Pit Registry, 1,056 post-9/11 troops say they now have the disease.

The VA does not currently list constrictive bronchiolitis as presumed to be service-connected, but troops who were at the sulfur mine fire and who apply for VA disability compensation are more likely to be reviewed positively, as the Defense Department has ruled the condition is “plausibly associated” with the mine fire.

Respiratory issues, however, are far from the only environmental health threat that troops may have faced. In 2006, Air Force Lt. Col. Darrin Curtis, a bioenvironmental flight commander at Joint Base Balad, said the pits represented an “acute health hazard for individuals.” He cited a number of cancer causing agents, including benzene, formaldehyde and xylene, in the toxic clouds, as cause for concern.

+++

At the age of 44, Army Sgt. Maj. Robert Bowman passed away after an 18-month battle with cholangiocarcinoma, or bile duct cancer. His wife, Coleen Bowman, said she’s not sure whether to blame the burn pits or some other environmental source, such as toxins stirred up each time her husband’s Stryker vehicle was hit by an improvised explosive device or a round. Of her husband’s platoon of 32 men, more than a third have “some strange illness,” she told us, running through the list: Crohn’s disease, liver issues, follicular lymphoma, unexplained tumors, brain cancer … ”

Courtesy photo
Robert Bowman

As to the cause, Bowman insisted, “It’s environmental. Whatever environment it was, we could argue all day long, but I hardly think they got it at Fort Lewis, Wash.”

The exact number of Iraq and Afghanistan veterans with uncommon cancers, respiratory illnesses or chronic conditions is unknown. The VA only keeps data on patients who have been diagnosed and treated at VA health centers. According to their numbers, of the 1.22 million Operation Iraqi Freedom, Enduring Freedom, and New Dawn veterans who have used VA health care at some point from 2002 to early 2015, 16,304 were diagnosed with cancer, roughly a third with non-melanoma skin cancer, 16% with prostate cancer, another 10% with melanoma, 8% with testicular cancer and the remainder with lymphoid, colon, thyroid, breast and undetermined cancer.

According to data provided to Task & Purpose by the VA, the cancer rates for Iraq and Afghanistan treated at VA hospitals, the rates are actually lower than among civilians across the board. However, those numbers may be misleading, since cancers often take many years to develop.

Moreover, this data only includes post-9/11 veterans who have used VA health care at least once during the time frame and were either diagnosed or treated by VA, explained Bobbi Hauptman, a public affairs specialist with the Veterans Health Administration. “VA continues to monitor health status of the exposed population to assess incidence and prevalence of disease for evidence of increased risk of health outcomes that may be associated with service related exposures.”

The Defense Health Agency’s Armed Forces Health Surveillance branch reviewed cancer diagnoses among active-duty and reserve personnel from 2005 to 2014 and found “no specific increasing or decreasing trends.” According to the AFHS, 8,973 troops were diagnosed with cancer, and 1,054 died from the disease, during the time frame, the most prevalent, by incidence rate, being female breast cancer, followed by testicular cancer, malignant melanoma, prostate cancer and non-Hodgkin’s lymphoma.

Still, the DoD figures do not capture the whole story either. Many veterans, like former Army Staff Sgt. Steven Ochs, who served three tours in Iraq from 2005 to 2007, and Matt Bumpus, who served in Iraq in 2003, died in civilian hospitals, both of acute myeloid leukemia, according to Ochs’ sister, Stacy Pennington, one of the first people to testify in front of Congress — in 2009 — about the hazards of burn pits.

Courtesy photo
Steve Ochs

“We are aware of hundreds more suffering similar ailments,” Pennington said, adding that “these men are casualties of war,” and their military records should reflect that.

Those who have signed on to the VA’s burn pit registry represent 6% of the 2.7 million troops who have served in the region since 2001, slightly more than half the number diagnosed with a traumatic brain injury, including concussions. In terms of sheer numbers, head injuries outpaced all other wounds and injuries in theatre, and as a result, the condition has received a lion’s share of research, diagnosis and treatment funding – dollars that will shed light on a condition that affects not only military personnel but 1.7 million Americans every year.

Burn pits and combat-zone environmental health hazards have received far less attention. In  2015, Congress added funding to the Defense Department budget to study burn pits, in a program known as the Congressionally Directed Medical Research Program. But burn pits were dropped from the program a year later.

On May 30, Klobuchar and Tillis wrote a letter to the chairman of the Senate Appropriations Committee, Republican Sen. Thad Cochran of Mississippi asking that burn pits be added back into the mix. A decision will come later this year as Congress deliberates the fiscal 2018 budget.

The VA is conducting several long term studies on post-9/11 veterans, but nothing specifically geared toward burn pit exposure. However, a civilian scientist, Dr. Anthony Szema, a former assistant professor at Stony Brook School of Medicine, recently conducted research that detected fine heavy metal particles in the lungs of some service members, one possible explanation for their respiratory problems, fatigue, and illnesses. He also coined the phrase “Iraq Afghanistan War Lung Injury.”

“I know of at least 5,000 cases that aren’t in there because the veteran either died or there are reporting restrictions.”

“Trace metals (including titanium), calcium and silicon are present,” Szema wrote in the Journal of Environmental and Occupational Medicine in 2014. “Respirable Iraq dust leads to lung inflammation in mice similar to that seen in patients, particularly regarding polarizable crystals which, appear to be titanium.”

While serving as chairman of medical sciences and biotechnology at the Center for Naval Warfare Studies at the Naval War College in Newport, Rhode Island, Navy Capt. Mark Lyles, now retired, found that tiny micro-particles of dust in Iraq and Kuwait contain 37 metals, and 147 types of bacteria and disease-spreading fungi, which may contribute to troops’ illnesses.

Both Szema and Lyles have pressed the DoD and the VA to conduct more research on the extent of exposure and possible health consequences. The Government Accountability Office also believes the Defense Department should be doing more. In September, GAO issued a report saying it had recommended the Pentagon study the long-term health effects of burn pits in 2011, but years later, there has been little progress.

DoD photo
A bulldozer tries to maneuver refuse into the burn pit at Balad, Iraq, Sept. 24, 2004.

This year, Amnesty International USA also has taken up the cause, helping Burn Pits 360 lobby legislators starting this spring. Naureen Shah, senior director for campaigns with AI USA, said the lack of research and information dissemination violates a basic human right — the right to life. “I am astounded when I talk to congressional staff and no one has raised this with them,” Shah told Task & Purpose. “There is a glaring deficiency that DoD has ignored the health of service members. The government has a responsibility to take care of these people.”

Tomaska, who still continues to serve in the Air National Guard, agreed. She misses the great friend she spoke with every day for the past 12 years, a smiling jewel of a person who created videos for military families facing loss and designed Minnesota’s Gold Star Family license plate.

“I promised Amie I wouldn’t stop talking about talking about this,” Tomaska said. “It’s a huge loss and it shouldn’t happen to anyone else.”