Air Sick

On May 26, 2021, the U.S. Air Force School of Aerospace Medicine released a study titled, “Cancer Incidence and Mortality Among Fighter Aviators who Served on Active Duty In the U.S. Air Force between 1970 and 2004: A Comparison to Other Officers and the General U.S. Population.”

Less than five months later, the man who helped lead the push for that study was gone.

Thomas “Boot” Hill flew F-4s and F-14s in the Navy over the course of a 23-year career, before going on to work with Booz Allen Hamilton and other defense contractors. A decade ago, however, he was diagnosed with esophageal cancer. 

Over the next 10 years, Hill dedicated himself to tracking the rates of cancer among military personnel, especially aviators, and advocating on those aviators’ behalf. His early work focused on Navy pilots, but over time, he became involved more broadly with the Red River Valley Fighter Pilots Association (RRVPA) and its Aviator Medical Issues Committee.

“There’s nothing like a guy who is fighting cancer to have a conversation with about military aviator cancer,” retired Air Force Col. Vince Alcazar, head of the committee, told Air Force Magazine.

For months, Alcazar, a former F-15 pilot, and his fellow committee members worked with Hill, even as the former Tomcat pilot went “from 200 pounds down to 120 and just [faded] away.” Yet despite his poor health, Hill’s passion for the cause never waned.

“Here’s Tom, he’s going for chemo treatments, [saying] ‘Hey, fellas, you know, I gotta knock off the Zoom call, my wife’s driving me across town over here to the cancer center over here in Phoenix,’” Alcazar recalled.

On Oct. 15, 2021, former Navy Cmdr. Thomas Hill died peacefully, surrounded by his family. But the issue he championed isn’t going away—indeed, the Air Force study he helped push for could be just the start of a sea change, advocates say.

INCREASED RATES

For years, Hill, Alcazar, and others said they noticed a distressing trend: fellow aviators contracting cancer at unusually high rates, many dying from the disease.

Within a few years of retiring, Alcazar said, he started to hear about cancer among his squadron mates. “I heard at the rate of one to two per year,” he said. “Half of them died of cancer within two or three years.” 

Even relatively young pilots and crew members have been diagnosed at high rates, advocates say. It’s what brought the issue to the attention of Tom Porter, executive vice president of government affairs at Iraq and Afghanistan Veterans of America.

“We generally hear a lot of input from service members on social media,” Porter said. “We’ve probably got over 600,000 followers across our social media channels. That’s how we reach most of our folks. … And we hear lots about toxic exposure. But also pilots—I mean, we’ve heard enough from those that were affected that it caused us to want to engage.” 

Nationwide, about 39.5 percent of American adults can expect to be diagnosed with some form of cancer during their lives, according to National Cancer Institute estimates. But even within that context, the trend among aviators stands out. 

“Looking at some of the people that we’ve seen pass away, and also Air Force individuals who have died because of cancer … the rate of cancers in the Air Force period is astounding, astounding,” said Chelsey Simoni, an Army veteran and clinical nurse researcher with the HunterSeven Foundation, which specializes in medical research and education for veterans.

In late 2019, an investigative series by journalist Tara Copp, then with McClatchy, found clusters of cancer cases across the country tied to Air Force and Navy aviation bases. Copp’s articles brought the issue out of the shadows, but advocates lacked the data or medical expertise to be taken seriously by the research community. 

“Medical professionals and nuclear science medicine professionals … would immediately discount them for the same sort of almost paternalistic, ‘there, there,’ kind of reaction,” Alcazar said. “A lot of sermonizing about biases, and you don’t know about epidemiological studies, or multi-cohort, or cross-longitudinal [studies]. ‘None of you guys are practicing physicians, so you’re not board certified, you can’t talk. You’re no one to be trusted. You’re essentially a child running with scissors.’”

But the issue caught the ear of then-Air Force Chief of Staff Gen. David L. Goldfein and then-Surgeon General of the Air Force Lt. Gen. Dororthy A. Hogg. After speaking with members of the Red River Valley Fighter Pilots Association, Goldfein and Hogg authorized an official Air Force study of the issue.

USAF’s School of Aerospace Medicine, under the Air Force Research Laboratory, studied fighter pilots and backseat aircrew from 1970 to 2004 who either had at least 100 hours in any seat of any fighter or “a Rated Distribution and Training Management code or a Major Weapon System code consistent with fighter aviation.” They then compared those Airmen to other Air Force officers and the general U.S. population, adjusting for race, ethnicity, sex and age, using cancer rates pulled from Pentagon, Veterans Affairs, and National Cancer Institute databases.

In all, the medical records of nearly 35,000 aviators and roughly 316,000 officers were compared over that 34-year time frame. The results were grim: 

Male fighter aviators were 29 percent more likely than other officers to be diagnosed with testicular cancer, 24 percent more likely to get melanoma skin cancer, and 23 percent more likely to have prostate cancer. When compared to the general population, those aviators were 25 percent more likely to get melanoma and 19 percent more likely to have prostate cancer, as well as 13 percent more likely to have non-Hodgkin lymphoma.

Airmen were also more likely to die from their cancers. While cancer mortality rates were similar between fighter aviators and other Air Force officers, Airmen were more likely to die than members of the general population as a result of melanoma skin cancer, non-Hodgkin lymphoma, and prostate cancer.

F-100 pilots were particularly afflicted. Researchers found that “male fighter aviators who flew the F-100 had greater odds of being diagnosed and dying from colon and rectum cancer, pancreas cancer, melanoma skin cancer, prostate cancer, and brain cancer” than aviators who never flew that aircraft. “They also had greater odds of dying from thyroid cancer and non-Hodgkin lymphoma, despite similar odds of diagnosis.”

“The request by the RRVFPA was to specifically evaluate cancer incidence and mortality among fighter aviators,” said Maj. Brian Huggins, chief of disease surveillance and research support in the Air Force Research Laboratory’s 711th Human Performance Wing, in a statement to Air Force Magazine. “The RRVFPA also requested emphasis on Vietnam-Era airframes, as this represents a significant portion of their membership.”

While the data in the study is neither complete nor comprehensive—the authors acknowledged they were missing birth data for some officers and that cancer diagnoses for some were likely missed—advocates say the study validated their concerns.

“No one was paying attention” before, Alcazar said. “It wasn’t getting a warm reception, or it was not embraced.” Now the issue is being taken more seriously, he said. 

POSSIBLE CAUSES

Having identified that fighter aviators suffer statistically greater rates of certain cancers, the Air Force must now try to decipher what the cause may be. Researchers have highlighted six potential exposures associated with fighter aviation—galactic cosmic radiation, radium and other isotopes, ultraviolet radiation, radar radiation, jet fuel, and mechanical forces—as potential factors, but it has not measured or compared these exposures or measured other lifestyle or behavioral risks.

“We are therefore unable to draw any conclusions about possible causes for the increased rates identified in the study,” Huggins said in a statement.

Theories, however, abound. Simoni pointed to studies that show jet fuel and jet fumes to be potentially toxic—as well as the Air Force’s firefighting foam that had PFAS [polyfluoroalkyl substances]—chemicals linked to a variety of health problems. 

“Those fumes alone, right? … Just being exposed to the fuels, you know, it seeps into your skin, into your blood,” said Simoni. Future studies could expand the research to include ground and aircrew who are likewise exposed.

Alcazar and his committee are developing a hypothesis document, in consultation with medical experts, that will posit that higher cancer rates are the result of a combination of “not entirely understood, nor fully researched chronic occupational exposures to ionizing radiation (IoR) and non-ionizing radiation (NIoR)” along with “factors potentially unique to military operating environments.”

The working hypothesis views non-ionizing radiation exposure as potentially “another causal path for DNA damage at the cellular level that elevates cancer risk.” 

Non-ionizing radiation includes “visible, infrared, and ultraviolet light; microwaves; radio waves; and radio frequency energy from cell phones,” according to the National Cancer Institute, along with emissions from such technologies as radars and jamming equipment. There is little research data available about how much non-ionizing radiation such equipment emits, indicating the need for more study, the working hypothesis document states.

Alcazar is calling for “vertically designed studies cohorted over time that look at chemicals, agents, environmental causation factors in military operating environments, because military operating environments in Southeast Asia, Southwest Asia, Iraq, Afghanistan, … they’re not all the same, they’re not monolithic,” he said.

ANOTHER STUDY COMING

Copp’s investigative series also got the attention of Sen. Dianne Feinstein (D-Calif.), who represents Naval Air Weapons Station China Lake, where one of the cancer clusters was located. Her office got a provision into the 2021 National Defense Authorization Act, Section 750, which requires the Defense Department to conduct another study, similar to the Air Force’s, to determine if aviators have a higher incidence of cancer. Instead of just fighter pilots, however, this study covers “any air crew member of fixed-wing aircraft and personnel supporting generation of the aircraft” across all the military services, and it must reach back to include anyone who served from Feb. 28, 1961, to the present.

The provision had bipartisan support from Sen. John Cornyn (R-Texas) and was backed by more than 30 veteran service organizations, many of them part of the Toxic Exposures in the American Military (TEAM) Coalition. 

In November, Feinstein released a statement saying the results of the Air Force study “while limited in scope, are striking and provide further evidence of the need for a careful study and evaluation of all military flight and ground crews across all services to understand why so many are getting cancer and, importantly, how to prevent it.”

An aide to Feinstein confirmed to Air Force Magazine that her office was aware of the study when the 2021 NDAA provision was being drafted, and a subsection in that provision allows the overarching study to draw upon previous studies and data. Results of the study are expected in May. If the Secretary of Defense determines that there are higher rates of cancer among aviators, a second phase must be launched to identify carcinogens based on exposures, locations, operating environments, and other factors.

But even if the Pentagon doesn’t reach that conclusion, advocates say they won’t let the matter die. “We are fully, fully ready to go to Congress and … ask them to use public law to direct DOD to conduct nexus studies,” Alcazar said.

END GAME

Exposure to toxins during military service has a long history, dating back to radiation exposure during nuclear tests in the 1950s, Agent Orange in the 1960s and ’70s, oil fires in the first Gulf War, and burn pits in the Iraq and Afghanistan wars. 

“I’ve been through all of the evolution of awareness. I’ve seen it all happen in real time,” Porter said. “I’ve always known that toxic exposure and burn pits affect probably more veterans and service members than any other health impact. That’s not scientific, that’s just from hearing from people. … I mean, I got asthma. I was diagnosed when I got back from Afghanistan, but it hit my lungs as soon as I got there. I was on medications ever since week one of the year in Afghanistan. And I can’t breathe normally without my medications.”

Now it’s time to focus on other factors related to aircraft, Alcazar said.

“We’ve got one study, and it’s a very well-done study,” said Alcazar. “This is a hinge moment in time. … And until we get more work done, we certainly can’t go to Congress and ask for benefits for military aviators that are different than what they’re getting today.”

That, veteran advocates say, is the end goal—better care for veterans. Military aviation is a part of modern life; the issue isn’t trying to stop it, but trying to understand what effects it might have and how to manage that. 

“We’re not on a campaign to kill aviation in the military. Nobody is going to stop raising their hands to go fly Hornets and F-35A models in the Air Force and F-15 Eagles and F-22 Raptors and KC-135s and B-2s and B-21s. No one’s gonna stop doing that,” Alcazar noted. “But what they want and what they will ask for is lifetime tracking. … Military health care providers will start mapping, talking to you about cancer. And if you get diagnosed, immediately we’re going to rally around you and even if you separate or you retire, you’ve got tracking in the VA. People just want to be taken care of.”

The issue, Simoni added, is primarily about preventative care; veterans are often unaware of their potential exposures, and hospitals often don’t know or think to screen them for cancer until it has spread. “These younger people do not look like they meet the age requirements for someone who has cancer,” she said. “And I say that as a healthcare provider myself. When somebody comes into my ER, I’m going to look at them, and that’s going to be my first assessment: They’re walking, talking, breathing and they look young. They’re fit. What’s the problem with this person?” 

If doctors don’t ask the right questions of someone complaining of back pain, the patient will just get a pain killer. No one wonders if they’re a veteran and if they might have some other underlying issue that needs to be investigated. That’s why the phase 2 study, if it’s called for, would be directed to “determine the appropriate age to begin screening covered individuals for cancer.” 

Those so diagnosed should have access to “the best oncology care that is possible in America,” Alcazar said. 

To deal with things like Agent Orange exposure and the health issues that it causes, the Department of Veterans Affairs has a presumptive disabilities program under which the VA “presumes that certain disabilities were caused by military service,” such as Agent Orange in Vietnam. There is currently legislation pending in Congress that would extend more presumptive benefits to Iraq and Afghanistan veterans who had toxic exposures. No moves have been made—so far, anyway—to offer presumptive benefits to aviators. 

“Everyone needs to understand that these people [should not be] off in a hospital ward all by themselves, wondering how they got here,” Alcazar said. No one should ask, “Who cares? Who will care for me?”