The PACT Act will take the burden of proof off US veterans exposed to burn pits

In 2004, during his nine-month deployment as a Civil Affairs Specialist in Mosul, Iraq, Jeffrey Danovich got used to the stench of burnt rubber. Twice per day, for 45 minutes, black plumes of smoke billowed into the air as his unit doused all their trash with jet fuel and lit it on fire. “It stank to high heaven,” the former Army sergeant says. 

Danovich didn’t think too much of it at the time. Occasionally, he would get short of breath and have to pull out an inhaler, which he’d never had to use prior to deployment—but he figured that might have to do with the smoking habit he’d picked up. 

Then, two years ago, Danovich was diagnosed with early-stage chronic lymphocytic leukemia, a type of blood cancer often related to chemical exposure. When tests came back showing no genetic precursors to the condition, which suggested that the diagnosis might be the result of an environmental exposure, Danovich immediately thought back to those burn pits at Mosul. 

Today, President Joe Biden signed a new bill into law that will address health concerns related to burn pits like the one at Mosul. The PACT Act, which passed the Senate last week, is one move towards filling in a gap in health policies for veterans by relieving them of the burden of proof.

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In the decades since Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF), nearly 300,000 veterans have reported exposure to pollution from burn pits like the one at Mosul, according to the US Department of Veterans Affairs (VA). Among the debris thrown into the pits were batteries, plastics, rubber, chemicals, amputated limbs, and ammunition, according to Burn Pits 360, an organization that advocated for the PACT Act. Chemical pollutants released during these burns include volatile organic compounds, which are associated with cancer, kidney disease, and damage to the nervous system, and polychlorinated dibenzo-dioxins, a class of chemicals known to contribute to blood cancer. Thousands of soldiers have experienced illness ranging from chronic shortness of breath to rare, deadly cancers—often diagnosed in young, previously fit individuals. 

Yet the VA has denied up to 75 percent of disability claims related to burn pit exposure. That’s because until now, the agency left it up to veterans like Danovich to prove that their condition resulted from their service. That’s about to change. The PACT Act shifts that burden of proof onto the state. The legislation lists 24 different conditions and illnesses, from chronic obstructive pulmonary disease to brain cancers. Under the act, these conditions are “presumptive,” meaning that affected veterans are automatically eligible for insurance coverage and disability compensation from the VA—without having to prove a thing.

Proving that the burn pits cause the lung conditions and cancer experienced by OEF/OIF veterans is nearly impossible to do for scientists, much less patients seeking medical care. For one, it’s unclear what specific chemicals these veterans were exposed to and to what degree, says Nicholas Lezama, a healthcare policy consultant and former Air Force physician who once oversaw the registry of people exposed to burn pits and other airborne hazards. “It’s hard to quantify that whole relationship between exposure and disease when we can’t even quantify the exposure,” he says. 

In a National Academy of Sciences (NAS) 2011 report on the long-term health consequences of burn pits, most of the studies referenced explored the impact of individual chemicals likely released from burn pits—a problem, because these chemicals likely have a cumulative effect, the report acknowledged. Many of these studies were conducted in animals, which aren’t perfect proxies for humans. And very little research relied on epidemiologic data—studies comparing health issues experienced by those exposed to burn pits versus the general population. Those that did faced confounding variables. Veterans of Iraq and Afghanistan, for instance, were exposed to many different kinds of chemicals, including battlefield smoke, diesel exhaust, sand storms, and explosions, says Robert Miller, a pulmonologist at Vanderbilt University Medical Center. 

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One study published in the Journal of Occupational and Environmental Medicine compared respiratory symptoms in 1,816 veterans deployed to Iraq and Afghanistan to the symptoms of 5,335 people deployed elsewhere. Among those deployed in Iraq and Afghanistan, 14.5 percent needed spirometry, a test to examine lung function, compared to 3.3 percent in the other group. Regardless, the authors of the 2011 NAS report wrote that they were unable to say conclusively whether emissions from burn pits caused long-term health issues. 

But insufficient evidence doesn’t mean no evidence, Miller says. When a team of physicians led by Miller conducted 49 lung biopsies on OIF/OEF veterans experiencing shortness of breath, all of those samples came back abnormal. Thirty-eight of them showed signs of constrictive bronchiolitis, a condition where the lungs’ smallest airways harden and stop functioning. The rare disease, which became a hallmark complication in veterans exposed to burn pits, is normally found in patients who have rheumatoid arthritis or have undergone a transplant. “It doesn’t occur spontaneously,” Miller says. The disease’s frequency in this population is “very strong” evidence for the long-term health effects of deployment, he adds. 

It’s impossible to say whether an individual’s illness—Danovich’s leukemia, for instance—was triggered by any one cause. The PACT Act acknowledges that, Miller says. Its full name—the SFS Heath Robinson Honoring Our PACT Act to Support Veterans Exposed to Toxic Substances—honors one young “otherwise perfectly healthy” veteran who was diagnosed with a highly aggressive lung cancer following deployment, never having smoked. 

Even in Robinson’s case, whether his diagnosis was related to burn pits is uncertain. “This is where the PACT Act comes in. It says, ‘We’re not going to place this burden of proof on Heath Robinson or his family,’” Miller says. “You will never get enough data. Or you won’t get the data in a timely way to help those who are suffering.”

Danovich, alongside another member of his unit who was diagnosed with bladder cancer after deployment, is still fighting to have his medical care covered by the act. Neither he nor his colleague’s conditions are listed as presumptive. “The fight’s not over. It’s absolutely not over,” Danovich says. Still, the PACT Act’s passage is vindication—a sign that people are finally listening to him and other veterans. 

Correction (August 17, 2022): A detail about the percentage of smokers counted in the Journal of Occupational and Environmental Medicine study was removed after the researchers pointed out that the number was not statistically significant.