IEDS, Burn Pits, Sandstorms: The Etiologic Mechanisms of Iraq Afghanistan War Lung Injury (IAW-LI)

When I still had no grey hair, my clinic comprised elderly, white, male Long Island veterans in wheelchairs with oxygen–with the oldest patient 94-years-old! The “Lieutenant” was a former Prisoner-of-War in Austria after he bombed most of Salzburg during the throes of World War II and his plane was shot down! However, when I got back from summer vacation in 2004, a sea change transpired. The Dean closed the Allergy Division; the Vice-Dean axed the fellowship; my boss quit. So, we lost all our six fellows and three voluntary faculty. Rather than having ten doctors in clinic, the task now fell solely to me. To add insult to injury, the Vice-Chair of Medicine asked me to mentor a medical student who was planning on dropping out to go to business school. Walking in the day after Labor Day, med student Mike Peters and I stumbled upon a waiting room full of combat-uniformed young women and men (college age) of all ethnicities: Hispanic, African-American, Chinese-American, Asian-Indian-American, Caucasian, and all raised from Long Island’s socioeconomic middle class. They were all short of breath, and none of them wanted to be expelled from the military. Unanimously the cohort wanted to get back to the fight in Iraq. “What are you doing here?” I questioned the sentinel patient. “Sarge” was an All-State football player from Garden City. He was previously healthy his entire life! He did not want to get out of the military. He wanted to get fixed and go back to his job. He did not want anyone to know he was short of breath. Mike Peters then remarked, “Dr. Szema, I think we need to study this!” That ended Mike Peter’s enchantment with Harvard Business School; and, now, I am happy to report, Dr. Peters is a Pulmonary and Critical Care Fellow at the University of California at San Francisco.

What Mike and I subsequently did was to study soldiers post-deployment to Iraq and Afghanistan and determine if new-onset asthma rates were increased. As of 2004, troops were not allowed to enlist if they had asthma in the absence of a medical waiver. We found out that very few waivers were granted. By counting numbers of diagnoses of asthma among stateside vs. deployed forces, we found that new-onset asthma rates were increased 50% among Long Island soldiers who shipped out to Iraq and Afghanistan, compared to those serving stateside. For those who were diagnosed with asthma, all had passed through Balad, Iraq, which, we knew was near sandstorms; but, unbeknownst to us, was also the site of a ten acre inferno: there was a “Burn Pit” which essentially was a ten acre trench where every piece of trash was lit on fire with jet fuel, called JP-8, and burned. A cost-saving General had even decided to power all vehicles—tanks, Humvees, trucks—with JP-8! Half of these so-called newly-diagnosed, previously healthy/fit-for-deployment military personnel had improvement in their airway obstruction with asthma medicines, but the other half did not. The U.S. Senate in 2009 asked me to testify about why we should not burn trash. Our family friend remarked, “Are these politicians so stupid that they need a doctor to them you are not supposed to burn trash?” Actually, the burn pit in Balad was not shut down until the day after my testimony and that of others.

Mike graduated. He was followed by Walid Salihi, an intern who happened to be Afghani-American. On his first day of internship, he showed up in my office, asking to join the team. I was elated because he now was the team. So, Walid came up with the concept that multi-factorial exposures were accounting for this lung problem, which not simply was asthma, in the un-reversible obstructed patient. This was lung injury. I spent the weekend coming up with an acronym. Since we are from Long Island, we called this Iraq Afghanistan War Lung Injury (IAW-LI). Sandstorms, mortar-fired rounds, improvised explosive devices, indoor and outdoor aeroallergens, all may be intermediates along the causal pathway of IAW-LI.

Before we even got to work, Dr. Cecile Rose from National Jewish Health invited us, at our own expense, to be part of the Denver Working Group on this topic. Astonished when such pre-eminent icon in our profession could locate an unknown country doc (I had spent 1/5 of my time in Hampton Bays treating the last of the potato farmers from Riverhead), we were on the plane in a week. Walid had to call as we landed in Denver—high altitude sickness, sick that he was not training in Denver–because he was not granted time off from hospital call. The inner sanctum conference room was full of high-ranking officers from the Navy, Army, and famous names in medicine. My jaw dropped when Captain Mark Lyles, the Navy’s Astronaut Candidate, who is an oral surgeon with a PhD in Microbiology and three master’s degrees in chemistry, homeland security studies, and education, went through an epic Powerpoint lecture on bacteria and viruses in toxic sandstorms, leading to lots of small particles harmful to human health. Some were even burned hollow particles from Saddam Hussein’s fires on the border of Kuwait. The military was classifying this so terrorist could not use these as lethal weapons. These data, now since declassified, had been presented to the highest levels of government during both the Bush and Obama administrations.

We published our findings comparing 1,000 Long Island soldiers deployed to the Persian Gulf (Iraq/Afghanistan) to 5,000 Long Island soldiers deployed anywhere else on the planet earth. Iraq/Afghanistan-deployed troops had a higher risk of new-onset respiratory symptoms leading to ordering of lung function tests. Critically important, the average values of both the anywhere else deployed vs. the Iraq/Afghanistan-deployed troops were similar, supporting the concept that the doctors were not overdiagnosing either group. Rates of traumatic brain injury and post-traumatic stress disorder were sky high; these are both risk factors for lung injury, since improvised explosive devices (IEDS) send blast overpressure or shock waves to not only the brain, but also to the chest wall, leading to shear stress on the delicate air sacs in the lung. Moreover, the Humvee that gets blown up by a phosphate bomb, according to my patients, is vaporized in seconds, leading to airborne metal—ready to inhale. The worst case I have seen has led to a soldier with titanium and iron in his lungs. He now has a double lung transplant and I have his native lungs in my freezer. His lungs sunk to the bottom of a tube of formalin when we inflated them. Normally, lungs float.

Doctors usually do not know any Geologists. In my case, not knowing how to cook led to an epiphany. My kids used to go to the university daycare with the geology faculty. These rock docs love to barbecue, and I love to eat. So, one summer day, while I was chowing on cedar plank salmon, homemade guacamole, and kitchen-made soda, I learned about Brookhaven National Laboratory’s National Synchrotron Light Source. Essentially this is the world’s brightest flashlight. No one had ever shined this light on human lung tissue; but, if someone did, we could detect the presence of metals. I nearly dropped my salmon!

Our latest papers show Camp Victory, Iraq dust contains metals and crystals which are toxic to mouse lung, causing systemic immunosuppression. These findings are eerily similar to lungs of patients we have examined. Congressman Tim Bishop from Southampton has submitted bills leading to the following laws: 1) banning of burn pits (this law has no teeth, since it is still bypassed in Iraq); 2) a registry for soldiers post-deployment (still waiting to get enacted despite the law); 3) National Post-Deployment Research Centers of Excellence, a bipartisan piece of legislation (still wading its way through committees).

This summer we funding from the Sergeant Sullivan Foundation, so my pre-medical students are posting videos on Kickstarter to match the research grant. In my private practice, patients are showing up from Washington, D.C., Virginia, West Virginia, and we get weekly calls from all over—Arizona, Washington, Hawaii. I treated a woman who works for the Defense Intelligence Agency. I did not even know there was a DIA. I had heard of the CIA.

A drug we are testing is manufactured in Bohemia by Garnett McKeen Labs. Another, VIP, discovered by my late mentor, Distinguished SUNY Professor Sami I. Said, M.D., has been approved by the FDA for testing. It is my distinct honor to take care of these patients who have served our country, and I hope we can obtain funding to develop new drugs to treat this IAW-LI. I am certain Dr. Said would be most pleased if the peptide he discovered in the human body, which naturally is protective of the lung, could be used to protect human health. So, this is why I have continued to muster on.