President Joe Biden on Wednesday signed into law a broad expansion of health care benefits for millions of veterans exposed to toxic burn pits, and for Robert Miller, MD, professor of Allergy, Pulmonary and Critical Care Medicine, and his Vanderbilt University Medical Center colleagues, the action is a long-awaited victory.
For the past 17 years, Miller has gathered evidence, testified before Congress and medical panels, and worked with both the military and his colleagues to explore concerns that soldiers were exposed to airborne toxins in Iraq and Afghanistan that left them with potentially permanent lung damage.
“I feel good about this; this is a victory,” Miller said. “My biggest concern was that this not become like the response to Agent Orange exposure in Vietnam, where doing what was right came 40 years after the fact. This is still 17 years after the fact. So, that’s not ideal, but it’s not 40 years.”
The Sgt. First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics Act, otherwise known as the PACT Act, was first approved by the House of Representatives in July and then by the Senate earlier this month.
The PACT Act expands Department of Veterans Affairs medical care to an estimated 3.5 million post-9/11 veterans who were exposed to airborne toxins largely from burn pits, trash sites that disposed of waste through open burning.
“The big thing this act does is that it specifically relieves the veteran of the burden of proof that an illness associated with toxic substances is service connected,” Miller said. “If you have a qualifying diagnosis, with the passage of this act, it will be treated as if it is deployment related.”
The act also adds 23 new medical conditions to the VA’s presumptive list for toxic exposure and will lead to new health care facilities being added across the United States to diagnose veterans seeking care as a result of the legislation.
A medical mystery began in 2003 when soldiers from the 101st Airborne Division based in Fort Campbell, Kentucky, returned from deployment in Iraq complaining of shortness of breath. Many were so winded during 2-mile runs they could no longer pass the standard physical requirement to remain in active service.
Conventional medical tests — lung imaging and pulmonary function tests — were performed at Fort Campbell, and the results of nearly all the tests were normal. Fort Campbell sent more than 50 soldiers to Miller for further evaluation between 2003 and 2005.
Miller made the unconventional recommendation of surgical lung biopsies. All but a few of the biopsied soldiers received pathology reports diagnosing constrictive bronchiolitis, a narrowing of the smallest and deepest airways of the lungs. It is an irreversible, chronic condition, and can currently only be diagnosed through biopsy.
One of the soldiers who underwent a lung biopsy at VUMC is Jim Raines who served in the 82nd Airborne Division of the U.S. Army. He was deployed to Afghanistan from December 2006-December 2007, during which time he was often on duty near burn pits and other air pollutants.
“Then, I could run 2 miles in 16 minutes — I was in excellent physical shape,” he said. “After I came back, I started having problems. I was slowing down on my runs, and I would develop chest congestion and flu-like symptoms after I would complete my physical fitness tests.”
As soldier after soldier had similar biopsy results, Miller and his VUMC colleagues published their findings in the New England Journal of Medicine in 2011. The paper generated a lot of interest, both within the military and in the media. Miller believed this would set the ball rolling toward confirming a connection between military deployment to the Middle East and lung injury, but action on the issue stalled.
Miller said it became a personal “cause for advocacy,” and he has remained in touch with many of the soldiers and encouraged them to enroll in studies at VUMC seeking to identify less invasive methods to diagnose small airways disorders.
VUMC pulmonologists Michael Lester, MD, and Bradley Richmond, MD, PhD, both of whom specialize in chronic obstructive pulmonary disease (COPD) and other small airways diseases, have recently completed a small pilot study enrolling some of the veterans who underwent lung biopsies as well as a control group. They are looking at whether new imaging techniques can eliminate the need for a surgical biopsy for diagnosis.
“We are working with a vendor called 4DMedical that has developed a technology that allows real-time lung imaging,” Lester said. “Instead of getting static images of the chest as we do with typical CT scans and comparing them through some of the more advanced CT methods that are available, the new technology allows us to build a map of the chest and then watch how a patient breathes and how air moves in different parts of the lung during the respiratory cycle. We are now doing a final analysis of those results.”
In December 2021, a VUMC team led by Sergey Gutor, MD, PhD, and Vasiliy Polosukhin, MD, PhD, published a study in the American Journal of Surgical Pathology with in-depth histopathological analysis of the veterans’ lung biopsy samples.
Their findings not only supported the initial conclusion of constrictive bronchiolitis, but they also noted additional abnormalities such as diffuse fibrosis of surrounding alveolar tissue, thickening of the arteries adjacent to the small airways, fibrosis and thickening of visceral pleura and a three-fold increase in the presence of immune/inflammatory cells.
Because of these findings, they proposed “post-deployment respiratory syndrome (PDRS)” as a better descriptor of the combination of inhalational exposure to toxins during deployment, post-deployment respiratory symptoms, and complex pathology in all distal lung compartments.
“It has been a 17-year journey, and all of us at Vanderbilt have had to defend our findings with a number of entities,” Miller said. “We have regularly re-evaluated our findings and return to the same conclusion; deployment has caused lung injury in a lot of those deployed to Iraq and Afghanistan.”
But Miller is certain the journey doesn't end here.
“I think we’re still going to have to advocate for people,” he added. “We need to make sure that the implementation of this legislation goes the right way and goes far enough to help veterans with respiratory disorders. And processes have to be put in place to appropriately evaluate this group of people. We’re not done yet."
Military veterans like Raines feel indebted to Miller and his colleagues.
“I’m very appreciative to Dr. Miller and the other doctors there at Vanderbilt,” Raines said. “They’ve been bulldogs, and they’ve not let this go. I’m thankful for everything they’ve done for me and for all the other veterans.”
