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New trial tracks long-term effects of burn pit exposure among veterans
The practice of burn pits left thousands of veterans with advanced lung damage. A Northwell researcher wants to find them and understand how they were affected.
Juan Serrano’s concern for his health began when he saw a young soldier covered head-to-toe in black ash.
“It was in that moment when I realized maybe we have to do a better job covering ourselves,” the Marine Corp veteran said. “But I didn’t realize burn pits can lead to cancer, or perhaps lung or heart failure. It was just a part of war.”
Serrano was in the active military then, stationed briefly in Kuwait at the outset of the Iraq War. His military unit, 2nd Battalion, 6th Marines, was tasked with reconnaissance. With all the moving around that this entailed the troops ran the risk of their excess supplies being captured and repurposed by the enemy. They had to cover their tracks.
So they did what generations of U.S. soldiers did before them. They used burn pits: massive, football field-sized lots where everything that couldn’t be carried was burned. “Fuel, ammunition, radios, cars — everything went in and went up,” Serrano recalled.
These pits threw vast plumes of thick, choking smoke far and wide, coating everyone in the vicinity — like the young man Serrano saw that day — with layers of ash and soot. The true danger, however, lay beneath the surface every time this toxic brew of chemicals entered their lungs.
Veterans like Juan are now seeing the impact on their health years and even decades later. He was among the first wave of soldiers to return from Iraq in summer 2004. Some presented with symptoms immediately, but no one understood why these young, fit and previously healthy soldiers suddenly developed issues with breathing and sleeping – some even developed cancers. “We’ve seen a number of stage 4 cancers in individuals under 30, and it’s the same, exact type of cancer,” said Serrano, who now leads Northwell Health’s Military Liaison Services. “And when you look at the geography of where they served, it's the same, exact locations.”
His journey to diagnosis, like so many, is only starting years after his service ended and is thanks to a clinical trial led by Anthony Szema, MD. The pulmonologist is a leading expert on burn pit exposure and, through his study, hopes to improve the screening process for these health hazards – both short and long-term. He recently joined the 20-Minute Health Talk podcast to discuss his trial, along with three of its participants, including Serrano.
Adding alternatives
Of the approximately four million veterans who have been exposed to burn pits while deployed overseas in the last three decades, more than 330,000 have signed up for the Airborne Hazards and Open Burn Pit Registry (AHOBPR) as of September 2022. This database, created in 2014 by the Department of Veterans Affairs (VA), includes an online questionnaire with an option for a health evaluation performed by a VA or military health provider. In addition to helping veterans understand the effects burn pits can have and, for some, receiving a diagnosis, the evaluations are used to support research.
“What our military needs today is to have a partner in the community and not delay any screening or any testing, which is extremely important,” Serrano said. “They only have 12 months to get all the labs, all the workups, which are often done outside of the VA, so that they can present their claim for compensation and benefits.”
Dr. Szema wants to expand the options for screening, evaluation and treatment available to veterans outside of the VA and his new trial, he says, is a step in that direction. “Why is it important? Well, the Open Air Burn Pit Registry, which is pages and pages of surveys by the VA, is actually being sunsetted in 2024. They won't even have a way to link that to your medical record.”
The clinical trial finding veterans in need
In 2023, Dr. Szema developed the Szema Burn Pit Respiratory Questionnaire (BPRQ), an eight-question survey given to veterans known to have been exposed to burn pits. Experts like Dr. Szema currently use questionnaires that screen for conditions resulting from that exposure, like sleep apnea and asthma, as well as more serious conditions like cancer. Through this Feinstein Institutes for Medical Research trial, he hopes to add a quick, effective screening tool customized for veterans health, while collecting data on their symptoms.
Participants will fill out the BPRQ annually for three years to track any progression of disease. To validate the BPRQ, Dr. Szema said his team is collecting two additional sets of data to compare against responses to the new survey:
- Continuous pulse oximeter: Participants are given this ring-shaped device called a pulse oximeter, worn like a ring, to wear during sleep and exercise. It measures oxygen content in the blood, heart rate, blood pressure and even temperature. “There is even a one-lead EKG on it. That's a lot of data that will be helpful in monitoring this population longitudinally.”
- Standardized surveys: Participants will also fill out existing questionnaires, which screen for specific conditions like respiratory illnesses (the four-page St. George’s Respiratory Questionnaire) or poor sleep quality (the four-page Pittsburgh Sleep Quality Index).
The ultimate goal of the trial, Dr. Szema said, is to establish whether a correlation exists between the responses to his survey and data collected from the other trial materials. He also hopes to build a better understanding of how long-term respiratory disease develops. Along the way, participants like Juan have appreciated a more immediate benefit.
“It's eye-opening because it gave me the ability to really understand my lung function,” Serrano said. “The suspicion that maybe things are not like they used to be is becoming more of a reality.”
Many of the 34 trial participants are veterans working for Serrano at Northwell Health’s Military Liaison Services. “I didn't know, honestly, when I came home, that I was messed up,” said Patrick McCaffrey, a Marine veteran who served in Iraq and recently joined Serrano’s office as a care management coordinator. “Whatever else was already broken on me, that was the focus. Let me deal with the back issues, any of the PTSD, and all that. But my lungs were the last thing on my mind.”
After returning home, McCaffrey ignored signs like chronic pain, shortness of breath and trouble sleeping. ”I just felt like that was normal.”
“The tricky thing about identifying these diseases is that, in many cases, they are latent,” Dr. Szema said. “This means that they take a long time to develop.” Lung disease, for instance, may not arise for decades. The current unpredictability of latent disease underscores the importance of research to better understand it.
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In addition to data collected from his survey and pulse oximeter, McCaffrey has taken a series of additional tests at Dr. Szema’s clinic, from CT scans and allergy tests to an advanced breathing test called impulse oscillometry. “It will determine if you have narrowing of the airways or not, and if it's reversible or not.”
The results, McCaffrey said, were shocking. “Hearing that I have asthma and sleep apnea, I probably didn't speak for two hours. It was overwhelming to find out that I had something that was not diagnosed or not even brought to the table as a possibility until now.”
Looking down the road 10 or 20 years, Juan and Patrick are concerned how these conditions, linked to burn pit exposure, will affect their quality of life. Right now, both are intent on connecting others to Dr. Szema’s trial, hoping to help fellow veterans find peace of mind – and hopefully catch any issues before they escalate.
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If his trial can prove his BPRQ is effective, Dr. Szema said it could not only uncover more veterans living with undiagnosed illnesses related to their exposure, but also help educate physicians unfamiliar with this issue and even inform the care they deliver. “We need to be able to educate providers who are going to be caring for the millions of veterans coming home on how to screen for exposure to airborne hazards, including burn pits.
“We want to be able to present this new survey, for example, at all of the emergency departments in Northwell when they get identified as being a Veteran so we can screen them for burn pit exposure, or when they come into Military Liaison Services.”
Dr. Szema currently has funding for 75 participants but hopes to open his trial up to every one of New York City’s affected veterans. “We estimate that there are about 8,000 veterans in the Greater New York metropolitan area who served in Iraq and Afghanistan and were exposed to burn pits,” Dr. Szema said. “We want to see all of them.”
The lasting health toll of burn pit exposure
Research and advocacy undertaken by Dr. Szema and fellow researchers has proven that the severity of burn pit-related conditions can be attributed to the toxicity of fuels and the frequency, duration, and intensity of exposure to heavy doses of particles. Continuous inhalation of particle-heavy air, Dr. Szema said, “can cause death, cardiovascular mortality, heart attacks, strokes, and COPD not related to cigarette smoking... a lot of things.”
When airborne particles are inhaled, they enter the lungs and irritate or constrict their internal passages. This can inhibit the lungs’ ability to introduce oxygen to the bloodstream. Toxic particles may also enter the bloodstream through the lungs. There are a number of sources of air pollution in a warzone, like improvised explosive devices and heavy vehicle exhaust. What made burn pit smoke uniquely toxic was the combination of potent hazards.
“The jet fuel JP-8, when burned, releases benzene and naphthalene, both of which are linked to bladder cancer,” Dr. Szema said. Plastic water bottles contain n-hexane, a neurotoxin, which is also released into the air upon burning.”
Each of these on its own would pose an immediate threat to health, but as Dr. Szema recounted, “you're throwing everything in, batteries, computers, vehicles, medical waste, body parts... it’s just not good.”
Much of what is known today about the effects these toxins can have on those exposed is due to Dr. Szema’s research. His published works caught the attention of advocacy groups and, notably, the U.S. Armed Services Committee. His contributions are part of a larger effort that led to the creation of the PACT (Promising to Address Comprehensive Toxics) Act. Signed into law in 2022, it expands the list of conditions automatically presumed by the U.S. Department of Veterans Affairs to stem from burn pit exposure.
Prior to the PACT Act, 80% of disability claims for now-presumptive conditions were denied by the VA.
Protecting veterans, now and future
Dr. Szema’s study is currently projected to conclude after three years of data collection and observation. Beyond that, he is hopeful that the data collected in the clinical trial will prove helpful in future studies oriented around treating burn pit-related disease.
If you have a presumptive condition and you haven’t yet filed a disability claim with the VA, you can do so here. If the VA previously denied a claim you filed for a condition which has since become presumptive, you can file a supplemental claim here.
The list of presumptive conditions covers 11 cancers:
- Brain cancer
- Gastrointestinal cancer of any type
- Glioblastoma
- Head cancer of any type
- Kidney cancer
- Lymphoma of any type
- Melanoma
- Neck cancer of any type
- Pancreatic cancer
- Reproductive cancer of any type
- Respiratory (breathing-related) cancer of any type
In addition, the VA considers the following non-cancerous conditions presumptive:
- Asthma that was diagnosed after service
- Chronic bronchitis
- Chronic obstructive pulmonary disease (COPD)
- Chronic rhinitis
- Chronic sinusitis
- Constrictive bronchiolitis or obliterative bronchiolitis
- Emphysema
- Granulomatous disease
- Interstitial lung disease (ILD)
- Pleuritis
- Pulmonary fibrosis
- Sarcoidosis
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