‘If in doubt, don’t. If still in doubt, do what’s right.’ – Donald Rumsfeld (1932-2021)
Editor-In-Chief, Chester “Trip” Buckenmaier III, MD, COL (ret.), MC, USA
There were mornings during my deployment in Iraq in 2003 when I would wake up covered in fine dust and black ash on my cot in our communal tent. One typically slept wearing only shorts. Sweat would cut rivulets through the talcum powder dust on my chest, creating interesting modern art mosaics. The smell of burned plastic and human waste often permeated the air. It is an odor that is indelibly etched in my mind from my time in Balad, Iraq, at the 21st Combat Support Hospital (CSH). Mornings like this suggested an unfavorable wind had blown from the Balad Air Base burn bit located across the street from the CSH. The smoke from the burn pits was a part of existence at Balad, unsavory and unavoidable. I would often spend five minutes in the morning trying to clear my sinuses of all the crud, and sore throats were a constant symptom of the air we breathed. I often felt the air in Balad was thick enough with particles that it could seemingly be cut with a knife.
Occasionally, a group of docs and nurses would walk up the side of a nearby military bunker that would set us about 75 feet above the airfield. The bunker was in the MEDEVAC flight path, so we always knew if fresh casualties were coming. We would take camp chairs and a few cigars to watch the sun settle over the desert and share some tall tales. At this height, you could see the thick yellow-grey haze that hung over the sea of military tents at the base as the sun sunk ever lower in the sky. The evening was when the toilets were cleaned by pulling out the excrement metal barrels, adding diesel fuel, and setting the concoction afire. Some poor servicemembers had to stir the contents to ensure complete combustion. These fires would light up throughout the airfield as the light faded. It was a rather beautiful vision, if you set aside thoughts of what you were smelling and breathing.
War is dirty. Filth is everywhere. I was constantly amazed at the ability of the 21st CSH operating room staff to keep the surgical spaces spotless with all the dust and dirt that invaded everything else. In our food, it was the grit when we chewed. It was a part of our clothes and always present in the air we breathed. It was inescapable (except in the operating rooms–bless you, nurses). It was physically irritating, but the younger, more-robust version of myself took it in stride, because I wanted to be there at that time doing my job. I had trained a lifetime to care for wounded servicemembers during wartime, and I was finally proving I could do what I had trained to do.
Was the environment literally crap? Sure. Were the poorly aimed enemy mortar shells annoying? Absolutely. That was a small price to pay when others were paying so much more from trauma sustained in combat. I had the skill to do something about it. I was happy to be there and would go again tomorrow if called. These sentiments are certainly not unique to me. I was continually amazed when the first words from a wounded servicemember were not about their future, family or going home. They almost always asked about their unit and when they could return. It was the defining honor of my career to be breathing the same filthy, dusty, depleted uranium, burned plastic, undefinably unhealthy air as they were.
Casualties in war are inevitable. Those that come from the violence of combat, we as a society understand the requirement to care for these individuals who put their country before safety. We owe these heroes our highest praise and finest healthcare. Unfortunately, some war casualties are not so obvious, and their wounds are often silent and hard to see. These individuals lack the proverbial “red badge of courage” of the physically wounded, but their pain and suffering are no less real and, in many cases, no less lethal.
Exposure to burn pits, so ubiquitous in Iraq and Afghanistan, is taking its toll among those who served in the last 18 years of conflict. A recent special by Jon Stewart, “The Problem with Jon Stewart,” highlighted the growing issue among many servicemembers exposed to burn pits during their deployments and are now suffering numerous unexplained respiratory ailments and cancers. As a lobbyist before Congress, Stewart crusaded for the first responders of the 9/11 disaster. Many workers developed health issues after exposure to the toxins from the collapse of the World Trade towers in New York. At issue now is the government’s unwillingness to support servicemembers who were exposed to burn pits and are now ill because their illnesses cannot be proven linked to burn pit exposure. I find it interesting and tragic that history is now rhyming with the Agent Orange issue and Vietnam veterans.
In September, a recent National Academy of Sciences report could not link burn pit exposure to cancer and other illnesses. Nor could they prove there was no link. In full disclosure, I am on the VA Burn Pit registry. I admit that my opinions regarding this issue are not free of personal bias. Since my deployments, I have been diagnosed with sleep apnea and have experienced two cases of pneumonia. I do not feel the lungs I deployed with are as healthy as the lungs I have now (accounting for age). Can I be sure my issues are related to the toxic brew I was breathing in Iraq and Afghanistan? Nope. If you ask my wife, she has no doubt, since she has listened to my breathing for years before and after my deployments. She saw the sticky talc that adhered to the side of the washing machine after washing clothes that came home with me after both deployments. That coating had to be physically scrubbed off the washing machine with cleaner and elbow grease.
Although I rarely agreed with Rumsfeld politically, I have always had tremendous respect for the man. I had the honor of caring for him as a military anesthesiologist during his lifetime. He was the only high-ranking civilian government official who sent a handwritten thanks for the care I provided (classy). I think Rumsfeld was famous for his pragmatic brand of leadership. I believe the VA and U.S. government would do well to take a page from his pragmatic playbook. While there certainly is doubt that the burn pits contribute directly to the suffering of all these exposed servicemembers, common sense would point to the burn pits, if no other causal event can be found. Forgive the pun but, where there is smoke, one should look for fire. According to Rumsfeld, we should “do what’s right” when confronted with the situation of ongoing doubt. Assuming the cost of presumptive care for burn pit casualties of war is the right thing to do.
We should never shirk our responsibilities to those who place their health in jeopardy in defense of our Constitution and way of life. As federal health providers, we must become familiar with this issue and query our veterans regarding exposure. It is time we, Congress and society at large start recognizing these new war casualties at our door. After all, is this not what we all spent a lifetime training to do? Caring for casualties of war? The conflicts may be over, but the consequences to those who served are certainly not. We should stop doubting these wounded warriors and start providing them the care they need and deserve.
