Vanderbilt Physicians Champion for Veterans with Lung Illness
Every war has its illness. Vietnam had Agent Orange. Desert Storm had Gulf War Syndrome. It is becoming apparent that respiratory problems are the illness of our current wars in the Middle East.
Every war also has its advocates - medical experts who champion uncovering of the truth behind the ailments that veterans suffer. For soldiers returning from Iraq and Afghanistan with a new and mysterious lung disorder, those advocates are Robert Miller, M.D., associate professor of Allergy, Pulmonary and Critical Care Medicine, and his Vanderbilt colleagues.
Quietly, over the last seven years, Miller has been building evidence, testifying before Congress, reaching out to the military and to his medical colleagues to explore concerns that soldiers are being exposed to airborne toxins in Iraq and Afghanistan that leave them with potentially permanent lung damage.
“These people return with a real history of limitation. After you see several soldiers who tell you, ‘I could run two miles in 13 minutes and now I can’t run at all,’ you have to believe something is going on,” Miller said.
This war’s medical mystery began in 2003 when soldiers from the 101st Airborne Division returned from deployment in Iraq complaining of breathing trouble. Sallie Lewis, a nurse practitioner at Blanchfield Army Community Hospital in Fort Campbell, Ky., noted the number of soldiers reporting, with alarm, that they were so short of breath during their two-mile runs they could no longer pass the standard physical requirement.
“I am pretty good at cardio-pulmonary nursing, and these guys were not making it up. I saw one every week and thought, ‘We have to do something,’” Lewis recalled.
All the conventional tests for shortness of breath – lung imaging, pulmonary function and exercise tests – were performed at Fort Campbell. Almost all of those tests were normal. Under the advice of her commanding officer, Lewis and Fort Campbell physicians sent more than 50 soldiers to Miller between 2003 and 2005.
Each soldier had a history of shortness of breath, and each, a former supremely fit soldier, was having trouble passing a running test. They also shared similar stories of exposure to massive amounts of smoke from sulfur fires in 2003, or breathing air fouled by dust and smoke from burn pits across Iraq.
Miller made what he calls an “unconventional” move to recommend surgical biopsies without tests containing tangible evidence of disease.
“So far, all but a few of these soldiers we have biopsied have come back with pathology diagnosing constrictive bronchiolitis,” Miller said.
Constrictive bronchiolitis is a narrowing of the tiniest and deepest airways of the lungs. It is rare, and can only be diagnosed through biopsy. Cases documented in the medical literature show striking similarities to what is seen in these soldiers’ biopsies.
“These are inhalation injuries, suffered in the line of duty,” Miller said.
J.D. Williams, an aviation maintenance officer who retired in 2008 after a 32-year career with the 101st Airborne Division, is the typical example of what may be an emerging profile: a soldier who was fit, a lifelong non-smoker, and who returned from deployment in Iraq with permanent lung damage.
“We slept an eighth of a mile from the burn pits. Those fires burned the whole year, just huge bonfires where they burned metal, tires, trucks, body parts, human waste, everything,” Williams said.
Williams toured throughout Iraq with the Blackhawk helicopter pilots, ensuring the equipment and landing zones were safe for flight. He was exposed to massive sulfur fires in Mishraq, Iraq, in 2003, and the most infamous burn pit in Iraq – at Balad – in 2008. He returned from his last tour changed.
“I never used to get exhausted. Now simple work around the house or yard, or even playing with our grandchildren, makes me so short of breath I have to lie down and rest,” Williams said.
Williams came to Vanderbilt University Medical Center in January seeking an invasive procedure — one that won’t do anything at all for his health, but one he hopes might help younger soldiers.
He underwent surgical removal of a small section of lung for biopsy to explain why he and many of his fellow soldiers can no longer breathe like they used to.
Eric Lambright, M.D., assistant professor of Thoracic Surgery, used a laparoscopic technique to snip sections from three lobes of Williams’ lungs. It was a major operation, requiring a two-day hospital stay to allow surgical drains to be removed. Williams had been fully advised this procedure would expose him to any of a number of serious side effects, including infection and collapsed lung, and months of discomfort, with absolutely no gain to his health status. Like so many soldiers before him, he decided to do it anyway.
Joyce Johnson, M.D., professor of Pathology, who has been working with Miller to examine the soldiers’ biopsies since the beginning, examined Williams’ slide. She said he has one of the more serious cases of constrictive bronchiolitis she has seen.
Johnson has built up a slide file jammed with hundreds of micro-thin “slices” taken from dozens of soldiers’ biopsies. She has become a key interpreter of Vanderbilt’s findings to military and medical authorities looking into the respiratory problems of soldiers.
“These are striking abnormalities in this otherwise young and healthy population. We need broad, national recognition that this is a complication of being in this theater,” Johnson said.
Johnson calls Miller’s decision to request biopsies “gutsy.” Lambright said it was a leap of faith to agree to open-lung biopsies on these soldiers who lacked test results showing a mass or anything else; both are now strong supporters of this effort. They hope their work will help soldiers like Williams – who has a challenge ahead of him. His compensation papers list a bad back and knees as a result of years of service and worthy of lifelong compensation, but there isn’t a mention of a lung condition. This means Williams is currently receiving no compensation for his lung condition, the injury he says has the greatest effect on his everyday life.
Williams said a representative of a VA facility in Huntsville recently told him he would likely have to prove the lung injuries are related to his service to get service compensation benefits for his constrictive bronchiolitis, since his diagnosis came after a one-year, post-retirement deadline. Williams, who spent his entire adult life in the service, is frustrated the weight of proof rests on him.“It may take years for me to get any compensation from this, but we need people like Dr. Miller to help out the younger guys who are being told now they have to leave their career in the military. It’s an injury, but it’s on the inside, something they can’t see. But it has changed us,” Williams said.
In the last three years, attention to the work of the Vanderbilt team has gained momentum. In 2007 the Army Public Health Command requested information from Miller to launch an investigation of exposures to soldiers during the Mishraq sulfur fires.
In May 2008 Miller and Matthew King, M.D., a resident in the Division of Allergy, Pulmonary and Critical Care Medicine, presented their evidence at an American Thoracic Society (ATS) meeting. Twenty-six of 31 lung biopsies at that time confirmed constrictive bronchiolitis.
By October 2009, there was growing national alarm about the huge Balad burn pit as servicemen and women exposed to the fires reported a growing number of illnesses, including cancers. Miller testified before a congressional hearing committee on Oct. 8, 2009. Three weeks later the National Defense Authorization Act passed, including a law prohibiting disposal of medical or hazardous waste in open-air burn pits.
Vanderbilt involvement in the investigation grew in November 2009 when William Valentine, Ph.D., D.V.M., associate professor of Pathology and a member of the Vanderbilt Center in Molecular Toxicology, was invited to sit on a committee to study long-term health consequences of exposure to burn pits in Iraq and Afghanistan. The group, called together by the Institute of Medicine’s (IOM) National Academies, held its first meeting on Feb. 23 and plans to present findings in the fall.
As the IOM began their work on burn pits, Miller, King and James Tolle, M.D., assistant professor of Medicine, traveled to National Jewish Health Hospital in Denver to work with an exclusive group of medical and military experts. The result of that meeting is a white paper, due out this summer, outlining the range of exposures and respiratory complaints reported by soldiers returning from both the war in Iraq and Afghanistan.
“The message is: now is the time to figure out this post-deployment respiratory illness. There is a lot of concern that this is the tip of the iceberg. We are asking what’s causing these illnesses and what prevention and management can we offer soldiers in the future,” King said.
In a statement e-mailed to VUMC, Coleen Baird Weese, M.D., environmental medicine program manager, U.S. Army Public Health Command (Provisional), said the Army investigation has turned up no specific evidence that exposure to the sulfur fires in Mishraq increased pulmonary risk for soldiers, but there is evidence that deployment itself has increased respiratory complaints from soldiers.
Miller is doing his part to advocate for a comprehensive approach to determining eligibility for compensation. He was recently contacted by Kerry Baker, the Legislation and Policy Section Chief of the Compensation and Pension Service within the Veterans Benefits Administration (VBA). Baker, who met Miller at the congressional hearings last fall, said Miller’s work is helpful to the VA as they draft a training letter to educate field personnel on various exposures, among them the sulfur fires.
“What I am hearing today is encouraging, and I believe they will help the guys in the sulfur fires, but the soldiers will have to have a diagnosis of constrictive bronchiolitis. That means people like J.D. Williams should be able to get compensation regardless of proof of exposure, but how they will approach this on bigger scale – that will be a challenge,” Miller said.
Miller, King, Lambright, Tolle and Johnson plan to publish their findings in an academic journal later this year. Miller hopes Vanderbilt can be instrumental in designing a test to identify the likelihood of constrictive bronchiolitis without having to open up the chests of any more soldiers.
“I believe these people have paid a huge price to serve as much as they have served, and if they are now as limited as we are observing, they deserve the best of care,” Miller said.