Editor's note: Second in a three-part series
Combat had changed him.
Yet Andrew Rounds was still the adoring son his mother had sent off to war. He was still the hard worker who had helped her deliver newspapers after school. He was still the amiable soul who knew the names of everyone in the tiny village of Waterloo, Ore., from the mayor to the man who lived under the narrow bridge that crosses the river on the east side of town.
And he was home. That's all Lisa Rounds needed to know. After a year at war in Iraq, her son was safe.
Then his headaches began.
Then his sight went blurry.
Then he began to cough up blood.
Then he collapsed on the floor of his parents' home.
By the time it was diagnosed, Andrew Rounds' leukemia had progressed so far that doctors didn't figure he'd last more than a few weeks. Ever the soldier, he fought on for nine months.
But the nation for which he had gone to war did not fight by his side.
From the testing of chemical and biological weapons on soldiers and some civilians during the Cold War, to the vast use of toxic herbicides such as Agent Orange in Vietnam, to the unexplained illnesses suffered by veterans of the first war in Iraq, military service has sickened generation after generation of U.S. service members.
But when confronted with ill and dying veterans, the nation's military leaders have turned to a time-honored tradition: denial.
The dismissals are sometimes followed -- years and even decades later -- by acknowledgment that an ailment was linked to military service and belated offers of care and compensation. But for many veterans and their families, the help comes far too late.
Now, responding to a new generation of sick and dying veterans, government leaders say they've learned from past mistakes. "My interest is how do we change what has been the 40-year journey of Agent Orange, the 20-year journey of Gulf War Illness," Veterans Affairs Secretary Eric Shinseki said in 2009.
But acknowledging the problem may be the easy part. Changing history won't be.
'Nobody is served by denial' » For years flames lapped at the sky, sending thick black plumes of smoke into the air across Iraq and Afghanistan. Yet even as the military's own environmental health experts quietly warned that the toxic fumes from open-air burn pits, located at every major U.S. base across the war zones, might sicken troops, military health officials stood their ground. The pits, they said, were not a danger.
But veterans groups, families and members of Congress pressed for a more thorough investigation as thousands of warfighters returned suffering from respiratory illnesses, skin diseases, cancers and blood diseases.
Finally, in August, a change from the top: In a meeting with military reporters, President Barack Obama pledged a thorough investigation into the pits.
"Nobody is served by denial or sweeping things under the rug," Obama said. "My overriding mandate to my agencies is that you get the best science possible, and then you make decisions on how we can protect our men and women in uniform."
Within months, the military's senior public health official, Craig Postlewaite, acknowledged it was "likely" that burn pit exposure was to blame for at least a small number of long-term illnesses. Later this year the Pentagon will launch a major study into the issue.
But the president's promise -- and the military's approach -- won't change a fundamental challenge with the way the government responds to its warriors' wounds.
The U.S. Department of Veterans Affairs has a thick rulebook, called a "schedule for ratings," that tells officials how to compensate military members for hundreds of war injuries -- from the loss of a limb to a loss of hearing -- right down to the penny.
Federal lawmakers occasionally make changes to the schedule -- mandating, for instance, that the VA treat many veterans' injuries and illnesses as "service connected" if ailments are reported within a year after they leave service. But it has been 64 years since the schedule was thoroughly revised, according to a report by the Institute of Medicine of the National Academies.
And the rules don't cover those who get sick years after they served, or those who are waiting on science to confirm the link between their ailments and their service. And so, in many cases, VA bureaucrats have no choice but to deny veterans' claims.
That's what happened to Andrew Rounds.
'Sometimes things just happen' » Physicians at Oregon Health & Sciences University could tell Lisa Rounds a lot about her son's cancer -- for instance, that it was likely caused by environmental, rather than genetic factors. And they suspected that an exposure to toxic chemicals might be to blame. But they couldn't say for certain that it had been caused or aggravated by his service in Iraq -- and military service alone is not a guarantee of VA care.
So while VA officials tried to find a way to bring the 22-year-old combat veteran into the fold of the nation's largest government-run health care provider, they kept coming up empty.
"Thank God for the Oregon Health Plan," Lisa Rounds said. The state-run health safety net, intended for the working poor, covered her son's medical care for nine months until his death on Oct. 19, 2007. "I don't know what we would have done without it."
Lisa Rounds did her best to accept the VA's decision -- and tried to make peace with her son's death. "Sometimes things just happen," she said. "I just figured this was one of those things."
Then she learned of the burn pits. And soon she learned of other Iraq War veterans diagnosed with the same form of leukemia that took her son's life. Now, Rounds is convinced that her son wasn't a victim of chance, but a casualty of war.
"You look at all these other kids who are dying exactly the way Andy died, and it's obvious, right?" she asked. "What else could it be?"
From an epidemiological standpoint, however, the world is not so absolute. Although it is rare in younger adults, acute myeloid leukemia is the most common form of adult leukemia.
About 2 million American military members -- and hundreds of thousands of additional civilian contractors -- have served in Iraq and Afghanistan. Understanding whether they become ill at a higher rate than those who have not served will take time and study.
"The epidemiology might be 10 or 20 years down the road before we can say, scientifically, 'Yes, this is a hazard,' " said Darrin Curtis, an environmental engineer and former Air Force officer who wrote a seminal memo to senior health officials warning of the risks of the burn pits in 2006. "What about the people who need help now? How many of them have to get sick for the government to stand up and take responsibility?"
'I look at the risk' » Curtis dislikes being called a whistleblower.
The Arkansas native was content in his low-profile role at Hill Air Force Base, in northern Utah, where his duties included evaluating health and safety hazards -- including potentially cancer-causing chemicals found underground in one base housing area. Although he supported the base commander's decision to remove the soil, at a cost of millions of dollars, he didn't think it was necessary.
"I'm not one of those people always out there saying the sky is falling," said Curtis, who holds a doctorate in environmental engineering. "I look at the data, and I look at the risk. That's all I do."
But at Balad Air Base, in northern Iraq, Curtis found a public health disaster that could not be ignored. Each week, hundreds of tons of refuse -- including toxic chemicals, plastics, vehicle parts and medical waste -- were set ablaze in a 10-acre, open-air burn pit at the northern corner of the largest U.S. military base in the region.
The smoke plume was such a constant that software engineers writing a program to help pilots navigate onto the base made it part of the simulated skyline.
On most days at Balad, the air smelled like diesel fuel and tasted like burned rubber. When the desert winds blew the smoke south, medics would treat dozens of patients for what was often called "Iraqi Crud:" coughing up dark phlegm and troubled breathing.
Three months into his tour, Curtis wrote his memo calling the pit an "operational health risk" and warning it could cause immediate and chronic health problems. For thousands of service members who had fallen sick after returning from the war -- and who had no other way to account for their symptoms -- Curtis' warnings were a possible explanation. The memo was copied, faxed, e-mailed and even translated into Spanish.
But it didn't make its way into Emily Rainwater's hands. Not until she fell ill herself.
'You have leukemia' » No one forced Rainwater to go to war.
But when her supervisors at the Defense Contract Management Agency sought volunteers to track the billions of military dollars being spent in Iraq, she stepped forward. She wanted to help the people of Iraq. And she wanted to support her country.
By 2008, when Rainwater left Arizona for her first tour of duty in Iraq, many service members had seen the Curtis memo. As a civilian, she hadn't. She was well aware of the obvious dangers of going to Balad -- sometimes called "Mortaritaville" for the frequency of indirect fire attacks on the base. "But it didn't occur to me that I might get sick," Rainwater said.
Rainwater returned from her second deployment in 2009 feeling sore and tired. When she realized she couldn't sit in front of a computer monitor without feeling exhausted, she went to a hospital.
"The doctor came in and said, 'I know what's wrong with you and the news is not good,' " recalled Rainwater, who is 41 years old. "He said, 'You have leukemia,' then he gave me a big hug and he left."
Rainwater is now undergoing chemotherapy and other treatment at Tucson Medical Center.
Part of her Defense Department job includes overseeing contracts with companies disposing of waste in Iraq. The same contractors have been sued by some who believe they were sickened by exposure to burn pit smoke, so Rainwater doesn't feel it would be appropriate to speculate on the cause of her suffering.
But her sister, Mickey, is not so guarded.
"We're identical twins," Mickey Rainwater said. "We've always lived in the same cities and traveled to the same countries. The only difference is that I've been a smoker for 25 years and she's been to Iraq. And she has leukemia, and I'm just fine."
'For the rest of my life' » Florida doctors told Jill Wilkins she could take her time with the decision. But Wilkins knew what she needed to do. Just six days after her 51-year-old husband was diagnosed with a brain tumor, he was gone. It fell to her to pull the plug on his life support.
The date was April 1, 2008 -- April Fools Day.
"My husband was the one who always remembered important dates. I never could," Wilkins said. "So I figured if I did it on that day, I would never forget the day he died."
Kevin Wilkins died 363 days after he returned home from his second tour of duty in the Middle East, where he helped ferry critically wounded patients from the war zones with the 920th Aeromedical Staging Squadron. His wife didn't know it at the time, but if she had waited another three days, it may have been more difficult for her family to access VA death benefits. Her claim would have fallen outside the one-year window when the military assumes an illness is service-related.
In November, she began collecting stories on a Facebook page devoted to those exposed to burn pits during their tours of duty, including dozens of veterans who have suffered or died from rare forms of blood disorders and cancer. Many were stationed in Balad, as her husband was during his first tour. And many have reported cases of the same form of leukemia that sickened Rainwater and killed Andrew Rounds.
"It can't all be coincidence," said one of the site's members, JoAnne Och, whose son Steven also died of acute myeloid leukemia shortly after returning from Balad. "For one thing, you don't send sick troops over there, so for all of these people to be coming home with these very serious problems, there's something causing that."
'I came back like this.' Utah National Guard soldier Casey Malmborg breathed in the smoke and fumes at Balad for nearly a year. When he returned from Iraq in 2007, Army doctors warned him it might take a while to adjust to clean air. But months later, Malmborg was still fighting for breath.
For the first time ever he failed an Army fitness test. "It was like I was suffocating," he said.
Today, the young sergeant is on three medications to control his symptoms, which National Guard medical officials have given him a year to overcome. Malmborg believes he has risen to the challenge, but on some cold winter days, "I wake up in the morning and I'm already wheezing," he said.
Malmborg recognizes that many soldiers return from war in far worse shape. Nonetheless, he knows his life has been inexorably changed.
"I went on the deployment as a healthy 19-year-old," he said. "Now I'm stuck with asthma for the rest of my life."
Anthony Roles also was healthy when he left for Iraq in 2003. Shortly after he returned home, his debilitating headaches began.
The Air Force sergeant was eventually diagnosed with polycythemia vera, a rare condition in which bone marrow produces too many blood cells. The condition can cause heart attacks -- Roles had his first at age 30 -- and is sometimes a precursor to leukemia.
"I went to Iraq with no problems whatsoever," Roles said. "I came back like this."
Against his wishes, he was discharged from the military. But since Roles was still working for the U.S. Air Force as a recruiter in Florida when he fell ill, his medical expenses have been covered by the service. For that, he feels fortunate, even as he suffers.
But many others who believe they were sickened by their service will have to wait for science and government bureaucracy to link their conditions to their service. And some will die before that happens.
'A grateful nation.' If Anthony Rounds had been wounded in combat, the Army would have provided him medical care from some of the best doctors in the world. And it would have compensated him for his injuries.
If he had been killed in battle, the Army would have sent two officers to his mother's door. It would have assigned her family a bereavement support liaison. It would have paid her a "death gratuity" and helped her slice through any red tape for her son's service life insurance payment. And it would have delivered a letter from the president of the United States, acknowledging his sacrifice "on behalf of a grateful nation."
Lisa Rounds got none of that. But she's not complaining. The VA did pay for something.
"We got a nice funeral and a headstone," she said. "That was a kind gesture."
The Pentagon will launch a major study this year to evaluate whether burn pits in Iraq and Afghanistan cause long-term health problems. The Armed Forces Health Surveillance Center and the Defense Department's Deployment Health Research Center will be involved in the effort, which will look at incidence of chronic bronchitis, asthma, sleep apnea, heart problems, cancer and leukemia.