Albuhishma, Iraq: The smoke above the American air base was sometimes thick enough to blot out the sun. At first, residents had no idea what the foreign troops were burning. Before long, they were struggling to breathe.

Farmers would return home with soot streaks on their forearms and stories about what soldiers had tipped into the burn pit that day: batteries, human waste, plastic ration packs, even refrigerators.

“We were always coughing,” recalls Tamim Ahmed al-Tamimi, who worked the fields back then outside Joint Base Balad, 80 kilometres north of Baghdad. “But we didn’t know that this smoke could kill people. We thought that only rockets could kill people.”

Twenty years on from the American-led invasion of Iraq, the scars are still visible in shot-up walls and bombed-out buildings. But there is another legacy too, more insidious and enduring than violence. Where soldiers established military bases, they burned their rubbish in the open, poisoning the air all around them. As American physicians and scientists started to worry about the health impact on returning troops, Iraqis were also falling sick and dying.

“The thing is, no one told us,” said Tamimi, now 35, as he took a deep breath and tried not to cry.

Though US veterans prevailed recently in a long fight for government recognition of burn pit exposure, there has been no American effort to assess the local impact, let alone treat or compensate Iraqis who breathed the same air.

On a recent trip to the area, Washington Post reporters interviewed more than a dozen residents who said they had developed cancer or respiratory problems while working on the Balad base or living nearby. Most said that they had been young and fit when they fell ill, without family histories of similar ailments. Their accounts are corroborated by experts who have studied burn pit exposure and by local doctors, who observed an alarming rise in illnesses consistent with such exposure in the years after the invasion.

Nearly two decades after American burn pits first smouldered in Iraq, President Joe Biden signed legislation last year acknowledging a likely link between the toxic exposure and life-threatening medical conditions – dramatically expanding benefits and services for more than 200,000 Americans who believe they suffered permanent damage from the open tip fires of the post-September 11 wars.

Known as the PACT Act, the bill transformed how Washington treats US victims of exposure, whose injuries and illnesses can take years to develop.

For Biden, the issue is personal. He has long believed that burn pits caused the brain cancer that killed his son Beau, who served in Iraq as a member of the Delaware National Guard.

The burn pit at Joint Base Balad was Iraq’s largest, spanning almost 10 acres (four hectares). By 2008, almost 140 tonnes of waste were incinerated there daily, the Military Times reported. In a memo to colleagues in 2006, Lieutenant Colonel Darrin Curtis, a bio-environmental engineer, described it as “the worst environmental site” that one teammate had ever seen.

Countersigning the report, Aeromedical Services Chief Lieutenant Colonel James Elliot added his own warning: “The known carcinogens and respiratory sensitisers released into the atmosphere by the burn pit present both an acute and a chronic health hazard to our troops and the local population.”

In repeated requests to the Defence Department and Veterans Affairs, spokesmen told The Post they no longer held information on operations at the air base, and that they did not know which, if any, American institutions did. “I don’t [know] where Joint Base Balad is or if it still [exists],” one Pentagon public affairs officer said in an email.

“You’re too late,” said Ahmed Abdel Mutlaq, a farmer whose land overlooked the base. “People have died already.”

A burning city unto itself

To the Americans, the base was known as Camp Anaconda, a seat of military occupation as US-backed troops hunted down Saddam Hussein and his followers, then struggled to contain a spiralling insurgency.

The base was a city unto itself – US officials said in 2011 that it hosted 36,000 military personnel and civilian contractors at peak operations – with a movie theatre and fast-food courts.

Outside, the burn pit burnt day and night. Without a plan for solid waste management, the Defence Department had outsourced the problem to US and local contractors, who dug the hole, poured in the base’s dregs, added jet fuel and set it ablaze.

By 2010, a study found that nearly 7 per cent of troops deployed at Balad were returning home with respiratory ailments.

One Iraqi resident described the smoke like a “poisoned blanket” over the town. Downwind, it hung thick in the air. Animals got sick. The elderly started wheezing. When US-led troops imposed curfews and the summer heat rose, families sweltered in their homes as noxious fumes crept in through the doors and window frames.

“It made things fuzzy,” said 34-year-old Qammar Haitham, who was 14 when the invasion began. “My chest became very heavy.” She felt a swelling in her neck, then it was hard to swallow. The smoke inflamed a thyroid condition that had given her little grief before the war, her family recalls, and soon she was making regular visits to the hospital.

Rates of lung, head and neck cancer and chronic obstructive pulmonary disease had been rare before the invasion, local doctors said, but suddenly they were showing up in young people. Haitham became one of them after scans found a tumour in her thyroid.

“The thing is, the area around Balad air base is a rural area,” said Hassanain Hass, a cardiology specialist at Balad Hospital. “And these were illnesses that we had learnt to detect in industrial areas, or near big cities.”

In the health centre at Albuhassan, a village on the southeastern edge of the base, doctors were observing the same symptoms. “We had many children with respiratory problems, asthma and bronchitis,” said the clinic’s director, Laith Rasheed, citing “a noticeable increase after 2005 and 2006.”

In his Balad office, Hass ran his finger down the list of cancers and respiratory problems now identified by the US PACT Act as conditions that can stem from toxic exposure. “Yes, yes,” he mumbled under his breath as he paused on each one, nodding. He looked up and sighed. “It’s all correct,” he said.

“If it happened to the soldiers then logically it happened to the neighbouring area too. But if they barely paid attention to the American citizens, why would they pay attention to the Iraqis?” Hass said.

The American military had not planned for a prolonged war in Iraq, assuming its soldiers would be welcomed as liberators. But as a government of US-backed Iraqi exiles settled into power in Baghdad, a violent insurgency was born, with the area around Balad air base at its centre.

As the violence intensified, experts now say, the question of how to deal with waste fell further and further down the list of priorities.

By the time US forces withdrew from Iraq in 2011, they had used more than 150 burn pits of varying sizes nationwide, according to the Burn Pits 360 advocacy group.

“The closer you were, the higher your risk is going to be. It works in concentric circles,” said Anthony Szema, who has spent years studying burn pit exposure as the director of Northwell Health’s International Centre of Excellence in Deployment Health and Medical Geosciences. “We see rapid acceleration of asthma, we see cancer at an earlier age even if you didn’t smoke cigarettes, we see cancer at a rapidly progressive age if you did smoke cigarettes.”

There were no comprehensive medical records kept in Balad during the first years of the war, according to Iraq’s health ministry, and later records were destroyed when the area was occupied by the Islamic State. Conclusively proving the link between burn pits and chronic illness in Iraq will require the support of elite US research institutions, experts say.

American researchers have found a way to use a powerful light source to examine lung tissue samples from individuals who died after burn pit exposure.

“Then we are able to determine if there are metals in the piece of lung, and if the metals were burned before they were inhaled,” said Szema, whose team conducted the research.

What is certain in the villages around Balad, according to doctors, community leaders and residents, is that those living downwind of the flames were exposed to the smoke for at least eight years – a tour of military duty was often just one.

“These people breathed it day and night,” Hass said.

Working in dead fields

Outside the air base today, the burn pit has been planted over with green grass, but the fields around it look dead.

They had always been the lifeblood of the area, so no one stopped farming when the Americans invaded.

In Albuhishma, the first person out among the tomato plants each morning was Tamimi’s mother, Attiyah. A widow since her husband died fighting against Iran more than a decade earlier, she had scoffed when friends urged her to remarry, telling them her sons were more important.

Tamimi and his family would arrive not long after, and together they shook ash from the vines as they tended to the fruit. His wife carried their two-year-old, Mehdi, on her back as she worked, as her parents had done with her when she was little.

The air smelled noxious and people coughed frequently. Attiyah got sick first, around 2007. She felt pain in her pelvis. She tired quickly. Within a few months, she could only stand for short periods and was confined to their home. Although no one knew what was wrong with her, Tamimi, a bright student, was certain that the farm was his responsibility now. He dropped out of college and tucked his books away in his bedroom.

“I didn’t want to, but what choice did I have?” he said.

Not long after, Mehdi started choking. His skin was blue by the time his parents got him to the hospital. “His breath was wheezing,” Um Mehdi, his mother, now 29, remembers. “The hospital said that his oxygen levels were too low.”

He died two days later. Tamimi, others recall, “went crazy”.

“Mehdi was like a small bird and we lost him,” said Tamimi’s brother, Zakaria.

Attiyah’s first cancer diagnosis followed just a few months later. Ovarian, then thyroid, then ovarian again. She is a survivor, but a shadow of who she was. “It broke her,” Zakaria said. “It broke everyone.”

Zakaria, 36, was the only member of the family to avoid health issues, and he thinks he knows why: “It’s simple, I’m a policeman,” he said. “I wasn’t deployed around here.”

Sickness was a constant for those who could not leave. The medical bills were often crippling. Some families, like that of Ezzedin Abdulnabih, were forced to sell their farmland. Mahmoud Majeed Ali gave up the family car to fund his youngest son’s treatment; it was difficult then to visit the grave of his other son, who was shot dead by American soldiers.

The Defence Department did not keep clear records of what was burned in the waste pits, meaning that the exact toxins released remain unknown. But the 2006 memo from Colonel Curtis identified 20 “possible contaminants” emanating from the Balad burn pit, noting that “many of these chemical compounds have been found during past air sampling”.

Iraqi contractors who worked on the base remember a bewildering array of “things that no one should burn”, said Marwan Jassim, 32, who spent night shifts filling the pit. There was medical waste, human waste, paint and petroleum, sometimes unexploded ordnance.

“We just tipped it all into the fire, like we were told,” said Jassim, who came down with chest and lung infections that lasted for months.

The farmers were aghast when they saw that the Americans were burning refrigerators. “We couldn’t believe it,” said Hussam Mohammed Rmezan, whose chronic bronchial problems still cause him to cough blood. “Why would you burn them? People around here could have used them.”

His son Mohamed, now 30, has also struggled with asthma since he worked the land with his father. Back in seventh grade, he loved to play soccer, ending most days on the pitch with his friends. “Within a year, I couldn’t run without breathing problems,” he said.

When young men came out on a recent night for a sundown game of soccer, Mohamed watched from the sidelines.

The campaign by American veterans to have burn pit exposure officially recognised took almost 13 years. Advocates say the Defence Department and Veterans Affairs ignored or quashed research into the health impacts of airborne particulates – accusations the Defence Department and Veterans Affairs have denied.

As late as 2020, Veterans Affairs’ website said there was no evidence that exposure to burn pits caused long-term health problems, and the agency denied most benefit claims related to toxic exposure.

It reversed its position in 2021, saying in a statement that the change was less an “abrupt shift than an evolution” in its understanding of the risks.

Speaking from a packed room at the White House last August, Biden held the microphone close as he described the harm that burn pits had done to American soldiers.

“Toxic smoke, thick with poisons, spreading through the air and into the lungs of our troops,” he said. “When they came home, many of the fittest and best warriors that we sent to war were not the same … My son, Beau, was one of them.”

Loading

When he signed the bill into law, families of the sick and the deceased broke into applause. Some cried.

About 3900 kilometres away, in the villages around Balad, no one had heard of the PACT Act, or knew that American soldiers had fallen sick too.

“I think they consider those soldiers more human than us,” Zakaria said quietly. “There’s no door for us to knock on.”

A photo of Mehdi, his little nephew, still hangs on the wall of his brother’s living room. He would have been 17 this year.

“He would have been in school,” Um Mehdi tells people. When she kneels down for prayer, she thinks of him.

The Washington Post

Get a note directly from our foreign correspondents on what’s making headlines around the world. Sign up for the weekly What in the World newsletter here.