Cleanup of U.S. Military Burn Pits in Iraq and Afghanistan

  • Date: Nov 03 2015
  • Policy Number: 20155

Key Words: Military, War, Environmental Health

Abstract

The US military has used open-air burn pits to manage waste in overseas combat operations for many years, most currently in the military actions in Iraq and Afghanistan. Concerns about environmental and health damages stemming from open-air burn pit exposures have prompted the US Congress to pass laws prohibiting further burn pit use and mandating that the Veterans Administration address health concerns regarding exposure. Burn pit emissions have been shown to contain toxins that can threaten health even in small exposures, such as dioxins, volatile organic compounds, particulate matter, and many more. The Environmental Protection Agency and the United States Central Command are on record acknowledging that exposure to toxins emitted by burned waste can undermine health and safety. The cessation of burn pit use is recommended, along with the repair of ecological damage created by their use. The Veterans Administration burn pit registry must be made functional, and health care should be provided to both veterans and the residents of Iraq and Afghanistan exposed to burn pits. Further research on the health effects of burn pit exposure is recommended. We also urge a long-term commitment to United Nations principles to preserve and enhance the human environment.

Relationship to Existing APHA Policy Statements

Since 1969, APHA has responded to threats to the health of populations in settings of war, in relation to toxic exposures, and in settings where vulnerable people are particularly threatened. This statement resides at the intersection of all three.

Prior APHA statements addressing environmental threats to health, especially in conflict settings, include the following (from oldest to newest):

  • APHA Policy Statement 6902: Childhood Lead Poisoning
  • APHA Policy Statement 7021: Principles for Environmental Protection
  • APHA Policy Statement 7211: Lead in the Environment
  • APHA Policy Statement 8111: Disposal of Hazardous Wastes
  • APHA Policy Statement 8531(PP): The Health Effects of Militarism
  • APHA Policy Statement 8912: Public Health Control of Hazardous Air Pollutants
  • APHA Policy Statement 8917: Public Health Hazards at Nuclear Weapons Facilities
  • APHA Policy Statement 8909: Reducing Health Risks Related to Environmental Lead Exposure
  • APHA Policy Statement 9006: Occupational Lead Poisoning
  • APHA Policy Statement 9124: Continuing Consequences of the Vietnam War
  • APHA Policy Statement 9511: The Environment and Children’s Health
  • APHA Policy Statement 9911: Declare Proposed National Permanent Nuclear Waste Repository Site Unsafe
  • APHA Policy Statement 9923: Opposing War in the Middle East
  • APHA Policy Statement 20075: Agent Orange
  • APHA Policy Statement 200617 Opposition to the Continuation of the War in Iraq
  • APHA Policy Statement 20095: The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War
  • APHA Policy Statement: Hazardous Waste Victim Compensation

Problem Statement

Background and history of burn pits in Iraq and Afghanistan: Open-air burn pits are a method of waste management and disposal often used for military waste management in areas where there is little or no existing waste management infrastructure. Burn pits are distinguished from incineration in that they are situated out in the open, either on flat ground or in excavated depressions, rather than contained in an incinerator apparatus. The US military has used open-air burn pits in many overseas combat situations, including the Persian Gulf War and peace-keeping missions in the Balkans. More recently, the military has operated burn pits in Iraq and Afghanistan since the beginning of each conflict in 2003 and 2001, respectively.

Health and environmental complaints led to new US laws restricting burn pits in Iraq effective at the end of 2010, but burning continues unrestricted in Afghanistan.[1,2] In addition, in 2014 the Veterans Administration created a burn pit registry so that veterans exposed to burn pits can register health problems they believe were created through exposure to burn pit smoke and fumes.[3]

As of November 2009 (prior to the new regulations), there were 63 open-air US-owned burn sites in Iraq. The size of these sites varies by the size of the operations they service. One third (14 of the 41) of small military sites have such pits, with small sites defined as those housing fewer than 100 US service members. There were burn pits at close to two thirds (30 of the 49) of the medium-sized sites (those housing between 100 and 1,000 service members). Three fourths of the 25 large sites (those housing more than 1,000 service members) have pits.[1]

There were 197 burn pits operating in Afghanistan as of 2011. More than 90% (126 of 137) of small sites, three fourths (64 of 87) of medium-sized sites, and nearly half (7 of 18) of large sites have pits.[1]

In both countries, open-air burn sites are geographically dispersed. Volumes and types of materials vary by site, but the Department of Defense (DoD) estimates that between 65,000 and 85,000 pounds of solid waste are burned each day at large bases.[1] A 2010 study conducted by the Army Institute of Public Health described the general composition of burn pit waste in Iraq and Afghanistan as follows: 5%–6% plastics, 6%–7% wood, 3%–4% miscellaneous noncombustibles, and 81%–84% combustible materials.[1]

Open-air burn pit management and oversight in Iraq and Afghanistan varies. The DoD manages some sites, while civilian contractors oversee others.[4] In either case, very little is done to mitigate risk or reduce exposures. Efforts are made to ensure that burn pits are placed downwind of military bases if possible. In addition, restrictions are sometimes placed on “outdoor activity during periods of heavy smoke.”[5]

Exposures generated by burn pits: Burn pits cause a number of environmental exposures that can be detrimental to human health. Within the United States, the Environmental Protection Agency (EPA) warns that backyard burning creates pollutants that are harmful to human health, including even small amounts of dioxins, particle pollution, polycyclic aromatic hydrocarbons, volatile organic compounds, carbon monoxide, hexachlorobenzene, and ash.[6] According to the EPA, burned waste emits harmful toxins that contribute to respiratory diseases, kidney disease, liver disease, developmental diseases, and cancer. The EPA’s stance also aligns with United States Central Command (CENTCOM) regulation 200-2, which states that “burn pits give off toxic fumes that can affect the life, health and safety of base camps and personnel.”[7] (CENTCOM provides environmental guidance and best management practices for US bases.) Burn pit emissions can be particularly toxic to vulnerable populations, such as pregnant and lactating women.[8]

Particulate matter in samples collected for the Institute of Medicine report at Joint Base Balad in Iraq was characterized as having an “average [concentration] above the U.S. air pollution standards…most likely derived from local sources.”[4] Polychlorinated dibenzodioxins and furans are also present at average concentrations higher than in polluted urban areas and are most likely attributable to burn pits.[4] These pollutants have varying implications for health.

Various peer-reviewed studies have suggested an association between burn pit proximity and respiratory illnesses. One study compared service members stationed in camps and bases near burn pits in Iraq with those stationed in locations in Kuwait where there are no similar burn pits. The findings showed a higher adjusted incidence rate ratio for asthma among those stationed near burn pits.[9] Another study acknowledged that while inhalation exposures during deployment come from a variety of sources, the three main pollutants identified in a PM2.5 fraction of air samples taken from six sites in Iraq and Afghanistan were geological dust, smoke from burn pits, and heavy metals.[10] Similarly, Szema et al. cited burn pits as one of the “plausible causes of Iraq-Afghanistan war lung injury.”[11] Finally, significant associations have been found between asthma and oil well fire smoke exposure among US Army service members deployed in the Gulf War.[12]

Outcomes such as neurological disorders, cardiovascular disease, and cancer have been explored in association with the chemicals and pollutants emitted from open-air burn pits, particularly through proxy occupations that expose workers (e.g., firefighters and incinerator workers) to similar pollutants. Further study is needed among US soldiers who served in Iraq and Afghanistan to explore associations between levels of exposure and adverse health outcomes. Most studies until now have involved small sample sizes and have not addressed the fact that many health outcomes take years to develop. In addition, many investigations focus on only a few pollutants and do not explore the multiplicative effects of numerous toxic exposures.

Much of the existing literature on open-air burn pits and health in Iraq and Afghanistan focuses on health outcomes among US soldiers, but Iraqi and Afghan citizens face equal, if not greater, risk from exposure to burn pit pollutants. Nationals of the countries where these conflicts have taken place cannot leave as easily as occupying soldiers and must cope with the environmental aftereffects of war. Little literature exists on the specific associations between burn pit exposure and specific health outcomes among Afghan and Iraqi nationals. However, considering evidence on burn pit exposure outcomes among US soldiers, it is likely that Iraqi and Afghan citizens are experiencing and will continue to experience similar outcomes, although without the same high level of medical care. Beyond health outcomes specific to burn pits, there have been multiple studies on general poor health outcomes related to US occupation among citizens of these two countries, including birth defects caused by heavy metal exposure and an increase in childhood leukemia incidence that peaked in 2006.[13,14] It is essential to conduct more research on the relationship between inhalation exposure from burn pits and health outcomes among local people in Iraq and Afghanistan.

Compliance with regulations: The US Government Accountability Office has ruled that burn pits were not managed in accordance with CENTCOM’s 2009 regulations. Burn pits were used to dispose of chemicals, paint, medical and human waste, metal/aluminum cans, munitions and other unexploded ordnance, petroleum and lubricant products, plastics and Styrofoam, and rubber. CENTCOM regulation 200-2 prohibits all of these materials from being burned. Chapter 13 of the regulation, which provides guidance applying to burn pits, burn boxes, and incinerators, clearly states: “No Petroleum, Oils, and Lubricants (POL) products (other than waste fuel to start a fire), rubber, tar paper, asphalt shingles, tires, treated wood, batteries of any type, unexploded ordnance (UXO), aerosol cans, compressed gas cylinders, plastic (except de minimis amounts), paint, paint thinner and strippers, pesticides, pesticide containers, asbestos, appliances and electrical equipment, electrical wires, or other materials that create unreasonable amounts of smoke, fumes, or hazardous air pollutants will be burned in a burn pit, burn box, or incinerator.”[7]

Long-term monitoring of effects: As discussed earlier, the Veterans Administration has established a burn pit registry. However, the Government Accountability Office has expressed concern that US forces in Iraq and Afghanistan “have not established systems to sample or monitor burn pit emissions, as directed by CENTCOM’s 2009 Regulation.”[2] As a result, very few data are available to assess long-term health effects among US veterans or Iraqi or Afghan nationals.

Ethical Concerns

Burn pits are not located in isolated regions of Iraq and Afghanistan. They are widely distributed geographically, often in close proximity to Iraqi citizens, exposing them to emissions. The most vulnerable of these citizens, women and children, are experiencing detrimental health effects. One study showed that, between the first gulf war in 1991 and 2005, the rate of cancer cases in Iraq increased from 40 per 100,000 people to at least 1,600 per 100,000 people.[15]

After the invasion of Iraq in 2003, with quite poor outcomes in terms of the health of the population overall,[15] it seems particularly important that the ongoing occupation of Iraq be conducted in a way that refrains from inflicting further harm, especially in relation to women and children.

In addition to ethical considerations surrounding human life and well-being, there are ethical considerations around stewardship of the earth and environmental degradation of the planet. Principles of environmental justice dictate that all people, including those who reside in low-resource settings and those who are members of vulnerable populations, have a right to clean air and involvement in environmental laws, regulations, and policies. This is consistent with the 1972 Declaration of the United Nations Conference on the Human Environment, also known as the Stockholm Convention, which outlines a “common outlook and…common principles to inspire and guide the peoples of the world in the preservation and enhancement of the human environment.”[16]

Evidence-Based Strategies to Address the Problem

The US military’s work often produces toxic byproducts. Unfortunately, the military also has a poor environmental record for cleaning up its operations, especially those in war zones. It produces more toxic waste than the top three US chemical manufacturers combined, and, in 2008, 25,000 of the Pentagon’s US properties were reported to be contaminated. The US military has produced a trail of toxic chemicals in the Pacific islands, the Philippines, Germany, Central Europe, and several oceans.[17] Vieques, the Puerto Rican island that was used as a Navy bombing range for years, remains contaminated with polychlorinated biphenyls (PCBs), solvents, and pesticides, with an estimated cleanup cost of $50 million.[18]

However, under Section 120 of the Comprehensive Environmental Response Compensation and Liability Act, the Department of Defense is required to take responsibility for all remedial action necessary to protect human health and the environment caused by its activities in the past.[19]

The 2003 US-led invasion of Iraq resulted in the installation of more than 500 military bases in that country, along with several hundred burn pits, which have introduced a major source of environmental contamination. There is evidence that burn pit emissions have damaged the health of the Iraqi people as well as that of US military personnel.[4] The mass media and scientists have helped create a sense of urgency regarding the public health consequences.              

Effective cleanup of military bases: Fortunately, the US military also has demonstrated its capacity to manage past environmental disasters. In 2005, the United States successfully cleaned up two of its former bases in western and southeastern Germany.[20] After the remediation and closure of those bases, the land was returned to German authorities. Before the return of the land to Germany, comprehensive studies investigated the effectiveness of the environmental, health, and safety management program prior to the closing of the bases. Hazardous waste removal was accomplished at both bases. Sustained monitoring of surface water, groundwater, soil, and air will continue to ensure the safety of the area for human habitation.

Similarly, the US military has started to remediate the damage caused by use of the dioxin-containing defoliant Agent Orange during the American war in Vietnam that ended in 1975.[21] More than 2 million Vietnamese residents were directly exposed to the toxin, which was distributed over 76,800 square kilometers. The United States is now spending $43 million to clean up the 47-acre Đà Nẵng Airport; in April 2014, Vietnam and the United States jointly commissioned a thermal treatment system to remediate dioxin-contaminated soil in this heavily contaminated former US military base.[22–24]

During the US war in Vietnam from 1961 to 1971, the United States sprayed nearly 80 million liters of dioxin-containing herbicides over Vietnam. Dioxins are known human carcinogens. Three million Vietnamese are currently suffering from adverse health effects due to dioxin exposure.

An estimated 80,000 cubic meters of dioxin-contaminated soil will be processed to destroy dioxins in Đà Nẵng. The Đà Nẵng Airport cleanup is scheduled to be completed in 2016. According to the Vietnam News Agency, the US government is also helping Vietnam clean up other sites in addition to the airport.

The soil and sediment remediation of Đà Nẵng will be accomplished via in-pile thermal desorption (IPTD) technology. With IPTD, the contaminated solids are placed in covered piles, where they are interlayered with heater pipes and vapor extraction screens. The piles are then treated with electrical heaters, which increase the temperature to around 330ºC to decontaminate dioxins and furans. IPTD is a preferred process for dioxin decontamination of soil and sediment because it eliminates the necessity of transporting contaminated soil and sediment offsite. The benefits of on-site treatment are many; they include no off-site transport costs and the elimination of potential vehicular accidents associated with off-site disposal.[25]  

Successful and effective cleanup (restoration) of domestic US military bases is also under way in many states across the country. In 2014, the California Department of Toxic Substances Control (DTSC) published its strategic plan for pollution prevention to protect California’s people and communities.[26] The DTSC’s report records the successful completion of cleanup and transfer of large amounts of acreage from former military bases to local governments and private entities. Some examples are as follows.

The former McClellan Air Force Base, near Sacramento, was one of the largest employers and industrial facilities in California until it closed in 2001. This site contained industrial solvents, radium paint, pesticides, toxic metals, and PCBs as well as other pollutants. Cleanup and restoration of two thirds of this land has been accomplished, and the Air Force has agreed to pay $25 million to clean up the remaining areas.

The Mather Air Force Base closed in 1993, and the DTSC’S cleanup and transfer of the former base to Sacramento County authorities took two decades. The area has now been transformed into the Mather Commerce Center, where it is home to a veterans’ medical center, a sports complex, a homeless housing program, residential neighborhoods, wetlands, and open space for public use.

The Alameda Point Naval Air Station contained contaminants such as solvents, fuel, lead, other heavy metals, pesticides, herbicides, and even ammunition. In June 2013, after the successful cleanup of approximately three quarters of the land, it was transferred to the city of Alameda. The remaining 617 acres will be restored and transferred to Alameda County.

The US Army Corps of Engineers recommends regular environmental monitoring of the restored area to ensure continued public health protection.

Similar military base restoration and cleanup projects have been completed in Texas, Colorado, and Michigan, among other states.

Cleanup of toxic military sites: For a variety of reasons, including the reluctance of US science agencies to investigate hazards associated with other US government agencies, sources of documentation of environmental damage tend to be more journalistic than scientific. Still, there is evidence that cleanup and restoration of previously contaminated military sites have yielded benefits for public health.

The primary cleanup mission at overseas US military locations is to remediate “known” imminent and substantial endangerment to human health and safety, specifically any endangerment attributable to environmental contamination from past military operations. Protection of human health is another important mission. 

Opposing Arguments

The Veterans Administration currently maintains that the danger from exposure to burn pits is temporary, and the negative health effects dissipate once a soldier is removed from the source (burn pits). Most of the Veterans Administration’s evidence for this assertion comes from the Institute of Medicine’s 2011 report, which found “insufficient evidence” to make a direct link between negative health outcomes and burn pit exposure. Unfortunately, the Institute of Medicine was forced to make the “insufficient evidence” statement because there were large gaps in the data provided by the DoD, making a robust analysis impossible. According to the IOM, “The DoD was unable to provide specific information to characterize waste streams at large and small forward operating bases.”[1]

The position of the United States government regarding the usage of burn pits is not uniform. For example, in a 2010 report to Congress, the US Government Accountability Office stated that “[w]aste management alternatives could decrease the reliance on and exposure to burn pits, but DOD has been slow to implement alternatives or fully evaluate their benefits and costs, such as avoided future costs of potential health effects.” In that same report, the office also outlined the systematic failure of the DoD to properly document and monitor burn pit usage, emissions, and exposures as mandated by CENTCOM regulations.[1]

Because of these data gaps, the Institute of Medicine could only extrapolate the health risks of occupational exposures from studies involving workers in other professions, such as firefighters and incinerator workers. Several of these studies looked at negative health outcomes in relation to occupational exposures in the United States. and Europe. Cautious scientists were forced to conclude that the materials being incinerated, the methods of incineration, and the protective gear provided to firefighters and incinerator workers in the United States. could be different from the materials, methods, and gear protection in and around burn pits in Iraq and Afghanistan, thus suggesting that levels of exposure may differ as well.

More research is needed on burn pit exposures and outcomes before a commitment to definitive action steps is made. It is crucial to gain a robust, evidenced-based, scientific understanding of the effects of burn pit exposures, which is why one of our action steps explicitly details the type of research required. In the interim, while research regarding burn pits is being carried out, the current “uncertainty” about health outcomes linked to burn pit exposures suggests that the precautionary principle be applied to burn pit policies in Afghanistan and Iraq. This principle (based on situational risk-benefit analysis) recommends that, in situations of scientific uncertainty, actions be taken that favor prevention of harm.[27] In this case, applying the precautionary principle would require the US government to cease open burning operations at all burn pits still in use, enact remediation efforts in the areas affected, and take action to address health conditions suffered by veterans that have been linked in studies to burn pit exposure.

Finally, one must consider whether the financial burden of improved waste management, including constructing dwellings at a greater distance from burn pits, outweighs the cost of long-term health consequences. Krefft et al. argue that “the investment in lung health would likely reduce other long-term costs,”[10] making it on balance a wise investment.

Alternative Strategies

In the absence of US military progress in finding alternatives to burn pits and cleaning up hazards, legal strategies have emerged. In 2014, Congress passed legislation requiring the Veterans Administration to create an airborne hazard and open burn pit registry.[28] This law was first introduced as companion legislation in 2011 in the House and Senate by Representative Todd Akin (R-MO) and Senator Tom Udall (D-NM). In 2011, Senators Charles E. Schumer (D-NY) and Bill Nelson (D-FL) engaged in a campaign to provide protective gear for soldiers working around burn pits, stating in a letter to then Defense Secretary Robert Gates that “these masks can, at a minimum, serve to mitigate the harm being caused by these burn pits.”[29]

The Supreme Court of the United States ruled that cases can proceed against Kellogg Brown & Root (KBR) and Halliburton, the main construction contractors employed by the US government in the Iraq and Afghanistan theaters during the most recent US armed forces operations.[30] KBR v. Metzgar (a lawsuit consisting of 58 consolidated suits in which thousands of plaintiffs allege that they suffered harm resulting from the contaminated air and water produced by KBR- and Halliburton-constructed burn pits[18]) will make its way through the lower courts, as the Supreme Court has ruled that contractors are “not entitled to derivative sovereign immunity.”[31]

Finally, in January 2015, the Supreme Court ruled that lawsuits involving open-air burn pits in Iraq and Afghanistan can proceed.[32] This decision will encourage thousands of US veterans—who were exposed to burn pit emissions and have signed up with the Department of Veterans Affairs registry[33]—to sue US military contractors (i.e., KBR and Halliburton) for negligence in the disposal of waste on bases in Iraq and Afghanistan.  

Action Steps

Therefore, APHA:

  1. Urges the Department of Defense and CENTCOM to implement a joint education and planning program with Afghan forces that leads to a cessation of burn pit use and complies with the DoD regulation on management of environmental compliance at overseas installations.[34] In general, US armed forces practices should have the lowest possible environmental and occupational health impacts and employ the most sustainable methods; landfills and open pit burning are the least acceptable methods for waste management.
  2. Recommends that Congress fund collaborative research on the effects of burn pits, including models that can measure prospective exposures; this research should be conducted by independent universities and nongovernmental organizations in Iraq and Afghanistan. Rigorous studies of the environmental and health effects of US military toxic waste and disposal methods in Iraq and Afghanistan are required to improve the health of the people of Iraq and Afghanistan as well as American veterans and their families. Studies should include environmental and personal exposure monitoring of toxic chemicals related to burn pits.
  3. Urges Congress to pass legislation requiring the United States armed forces to repair ecological damage created as a byproduct of invasion and/or occupation. The US government and involved contractors (KBR and Halliburton) should take responsibility for remediation of the areas affected by burn pits in Iraq and Afghanistan. We further urge the legislative and executive branches to create a dedicated line item in the federal budget to support overseas base cleanup. Without a dedicated line item, it is unlikely that post-invasion and post-occupation environmental remediation will be accomplished.    
  4. Urges the Veterans Administration to make the airborne hazard and open burn pit registry fully functional. APHA further urges the DoD to enforce the use of personal protective equipment among those working in close proximity to burn pits and to enter these personnel into medical surveillance for long-term health effects. The DoD should ensure predeployment and postdeployment screening of both active-duty and civilian personnel, enroll active-duty members in the Veterans Administration burn pit registry, and reach out to eligible veterans to ensure that they are registered, as currently many veterans do not participate. Registered veterans should be provided high-quality medical care.

References

1. Exposure to Toxins Produced by Burn Pits: Congressional Data Request and Studies. Washington, DC: US Department of Defense; 2011.
2. Afghanistan and Iraq: DOD Should Improve Adherence to Its Guidance on Open Burning and Solid Waste Management. Washington, DC: US Government Accountability Office; 2010.
3. Mulrine A. Survey: many combat vets worried about exposure to “burn pits.” Available at: http://www.csmonitor.com/USA/Military/2014/0725/Survey-many-combat-vets-worried-about-exposure-to-burn-pits-video. Accessed December 15, 2015.
4. National Research Council. Long-Term Health Consequences of Exposure to Burn Pits in Iraq and Afghanistan. Washington, DC: National Academies Press; 2011.
5.  Ambient Air Assessment for Camp Lemonier, Djibouti. Aberdeen Proving Ground, MD: US Army Center for Health Promotion and Preventive Medicine; 2004.
6. Environmental Protection Agency. Backyard burning. Available at: http://www.epa.gov/epawaste/nonhaz/municipal/backyard/index.htm. Accessed December 15, 2015.
7. Environmental Quality CENTCOM Contingency Environmental Guidance: Regulation Number 200-2. MacDill Air Force Base, FL: US Headquarters United States Central Command; 2006.
8. American College of Obstetricians and Gynecologists. Exposure to toxic environmental agents. Available at: http://www.acog.org/-/media/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/ExposuretoToxic.pdf. Accessed December 15, 2015.
9. Abraham JH, Eick-Cost A, Clark LL, et al. A retrospective cohort study of military deployment and postdeployment medical encounters for respiratory conditions. Mil Med. 2014;179:540–546.
10. Krefft SD, Meehan R, Rose CS. Emerging spectrum of deployment-related respiratory diseases. Curr Opin Pulmon Med. 2015; 21:185–192.
11. Szema AM, Reeder RJ, Harrington AD, et al. Iraq dust is respirable, sharp, and metal-laden and induces lung inflammation with fibrosis in mice via IL-2 upregulation and depletion of regulatory T cells. J Occup Environ Med. 2014;56:243–251.
12. Cowan DN, Lange JL, Heller J, Kirkpatrick J, DeBakey S. A case-control study of asthma among U.S. Army Gulf War veterans and modeled exposure to oil well fire smoke. Mil Med. 2002;167:777–782.
13. Savabieasfahani M, Alaani S, Tafash M, Dastgiri S, Al-Sabbak M. Elevated titanium levels in Iraqi children with neurodevelopmental disorders echo findings in occupation soldiers. Environ Monitor Assess. 2015;187:4127.
14. Hagopian A, Lafta R, Hassan J, Davis S, Mirick D, Takaro TK.  Trends in childhood leukemia in Basrah, Iraq, 1993–2007. Am J Public Health. 2010;100:1081–1087.
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16. Stockholm Convention on Persistent Organic Pollutants. Stockholm, Sweden: United Nations Environment Programme; 2009.
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http://www.huffingtonpost.com/2012/10/05/vieques-cleanup-bomb-site_n_1942107.html. Accessed December 15, 2015.
19. Environmental Protection Agency. Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) and federal facilities. Available at: 
http://www2.epa.gov/enforcement/comprehensive-environmental-response-compensation-and-liability-act-cercla-and-federal. Accessed December 15, 2015.
20.Torres SL. U.S. Army military base closures in Germany—evaluation of EH&S activities. Available at:
http://scholarworks.rit.edu/cgi/viewcontent.cgi?article=9179&context=theses. Accessed December 15, 2015.
21. Martin MF. Vietnamese victims of Agent Orange and U.S.-Vietnam relations. Available at: https://www.fas.org/sgp/crs/row/RL34761.pdf. Accessed December 15, 2015.
22. Fuller T. Four decades on, U.S. starts cleanup of Agent Orange in Vietnam. Available at: 
http://www.nytimes.com/2012/08/10/world/asia/us-moves-to-address-agent-orange-contamination-in-vietnam.html?pagewanted=all&_r=1&. Accessed December 15, 2015.
23.
United States Agency for International Development. Vietnam and the United States turn on treatment system to clean up dioxin in Đà Nẵng. Available at: http://www.usaid.gov/vietnam/press-releases/vietnam-and-united-states-turn-treatment-system-clean-dioxin. Accessed December 15, 2015.
24. Đà Nẵng dioxin clean-up on track. Available at:
http://vietnamnews.vn/society/260944/da-nang-dioxin-clean-up-on-track.html. Accessed December 15, 2015.
25. Baker RS, Smith GJ, Braatz H. In-pile thermal desorption of dioxin contaminated soil and sediment. Available at: http://www.terratherm.com/pdf/white%20papers/BakerSmithandBraatzpaperforDioxin2009.pdf. Accessed December 15, 2015.
26. California Department of Toxic Substances Control. 2014–2018 strategic plan. Available at:
https://www.dtsc.ca.gov/InformationResources/upload/Strategic_Plan_2013_Web.pdf. Accessed December 15, 2015.
27. Golstein B. The precautionary principle also applies to public health actions. Am J Public Health. 2001;91:1358–1361.
28. Shane L III. Veterans back bill to create registry of illnesses blamed on burn pits. Available at: 
http://www.stripes.com/news/veterans-back-bill-to-create-registry-of-illnesses-blamed-on-burn-pits-1.159539. Accessed December 15, 2015.
29. Shane L III. Senators question delay in burn pit safety measures. Available at: 
http://www.stripes.com/blogs/stripes-central/stripes-central-1.8040/senators-question-delay-in-burn-pit-safety-measures-1.143900. Accessed December 15, 2015.
30. Stohr G. Supreme Court rejects broader liability shield for military contractors. Available at: 
http://www.insurancejournal.com/news/national/2015/01/20/354431.htm. Accessed December 15, 2015.
31. Zajac A. Court says military contractors not entitled to automatic sovereign immunity. Available at:
http://www.insurancejournal.com/news/national/2014/03/07/322653.htm. Accessed December 15, 2015.
32. Druzin H. Supreme Court allows lawsuits over burn pits, electrocutions. Available at:
http://www.stripes.com/news/us/supreme-court-allows-lawsuits-over-burn-pits-electrocutions-1.324782. Accessed December 15, 2015.
33. Kennedy K. Vets may sign up for registry after dust, smoke exposure. Available at:
http://www.usatoday.com/story/nation/2014/06/23/burn-pit-registry-opens/11273885/. Accessed December 15, 2015.
34. Management of Environmental Compliance at Overseas Installations. Washington, DC: US Department of Defense; 1996.