# Response to Comments for the Department of Veterans Affairs To Assess Exposures and Conditions of Interest for Veterans Who Served at Karshi-Khanabad Air Base
**AGENCY:**
Department of Veterans Affairs.
**ACTION:**
Notice; response to comments.
**SUMMARY:**
On November 27, 2024, the Department of Veterans Affairs (VA) solicited public comments on exposures and conditions of interest related to veterans who served at Karshi-Khanabad Air Base (K2). That notice provided an opportunity for veterans, caregivers, survivors, and the public to share relevant information with VA to inform decisions regarding presumptive benefits that could impact the roughly 16,000 veterans who served at K2 from 2001 to 2005. In this notice, VA provides responses to comments received.
**FOR FURTHER INFORMATION CONTACT:**
William J. Culpepper, Ph.D., Director, K2 Surveillance Program, Health Outcomes of Military Exposures, Veterans Health Administration, (202) 821-5294.
**SUPPLEMENTARY INFORMATION:**
K2, or Camp Stronghold Freedom, is a former Soviet air base located in Uzbekistan. The United States Army, Air Force, and Marine Corps used the base to support missions into Afghanistan. The base was 1 square mile in Southeastern Uzbekistan, near the border of Tajikistan, and Service members located at K2 may have been exposed to contaminants. For further information on K2 exposures, visit *https://www.publichealth.va.gov/exposures/karshi-khanabad.asp.*
On November 27, 2024, VA published a notice in the *Federal Register* to inform the public that it had plans to assess exposures and conditions of interest related to military service at K2. VA provided a 30-day public comment period, which ended on December 27, 2024, and received 185 comments from individuals and organizations. Overall, these comments supported VA's plan to assess the scientific literature and historical claims data regarding the determination of whether there is an association between military environmental exposure to toxic substances related to military service at K2 from 2001 to 2005 and medical conditions.
**Comments From Veterans Service Organizations (VSO)**
VA received two comments from VSOs describing a combination of K2 exposures as a “toxic soup”, and they requested many conditions be classified as presumptions. Specifically, the VSO requested presumptive status for 9 cancers; 18 conditions they categorized as immune dysregulation disorders; 2 immune suppression disorders, atopic dermatitis and numerous undiagnosed skin diseases; 33 “inflammatory diseases;” 12 neurological diseases; 16 hematological or bone type conditions; 14 endocrine conditions (including women's health concerns); “legacy issues” (such as congenital disorders); and 9 respiratory conditions including “breathing conditions.”
*VA Response:* Many of these conditions are currently covered under the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT) Act, Public Law 117-168, or are currently under consideration as a presumption following VA's new presumptive process. The K2 Surveillance Program (K2SP) is designed specifically to assess the health effects of those Veterans that deployed to K2 and is a key source of the scientific evidence base. Data from K2SP and from claims submitted to the Veterans Benefits Administration (VBA) will be reviewed to assess whether conditions not currently covered occur at sufficient rates to warrant a formal evaluation. Some conditions are non-specific and unable to be addressed, such as “endocrine conditions” and “inflammatory diseases.”
One VSO requested that VA provide more detailed data in future reports; specifically, a breakdown of studied conditions within major diagnostic groups and prevalence ratios of morbidity. The commenter suggested reviewing additional target organs and considering rare diseases not currently captured. The commenter also recommended an analysis of historical VBA K2 Veterans' claims data for valuable insight.
*VA Response:* VA is submitting a manuscript on the initial morbidity and all-cause mortality findings from K2SP for publication in a peer-reviewed scientific journal and will be publicly available in the future. VA has additional scientific papers currently underway for publication. K2SP updates data on an annual basis, which allows for morbidity and mortality analyses to be repeated at regular intervals as well as for rapid response to emerging health concerns. VA plans to maintain K2SP for the next 10 or more years. A review of VBA claims data was used to aid in the selection of outcomes evaluated by K2SP. These data sets will be reviewed again prior to the next K2SP data extraction and analyses.
**Comment From Stronghold Freedom Foundation**
Stronghold Freedom Foundation, an organization focused on advocacy related to K2 exposures, commented that veterans who served at K2 have reported numerous health issues linked to environmental toxic exposures, including many of those identified by the two comments received from VSOs. Additionally, Stronghold Freedom Foundation requested that VA take four specific actions.
First, Stronghold Freedom Foundation asked VA to quickly publish an interim final rule establishing a presumption for K2 veterans for multiple conditions, including rare conditions. They requested that the rulemaking acknowledge exposure to all documented toxic substances and include all diseases plausibly associated with these exposures.
*VA Response:* K2SP is designed specifically to assess the health effects of those veterans who deployed to K2 and is a key source of the scientific evidence base.
Stronghold Freedom Foundation also requested that VA develop specialized training for VA health care practitioners on the synergistic effects of the “toxic soup” substances at K2.
*VA Response:* Training has been an integral part of PACT Act implementation, and as a requirement of the PACT Act, VA continues to refine and update training for its employees.
Stronghold Freedom Foundation further wanted VA to create a dedicated Toxic Exposure Risk Activity (TERA) K2 cohort to evaluate the long-term health impacts of these exposures.
*VA Response:* K2SP includes nearly all of the K2 veterans and is designed to assess and monitor health effects over the next 10 or more years. Additionally, VA published a proposed rule on October 1, 2024, which stated that VA would consider certain K2 exposures to be a TERA. 89 FR 79815, 79820. Examples provided by VA in the proposed rule included exposure to jet fuel (as a result of leaking Soviet-era underground jet fuel distribution systems); volatile organic compounds found in air samples; particulate matter and dust; depleted uranium from non-U.S. ammunition destroyed in fires; asbestos roofing tiles and lead-based paint; and lead in water samples. However, this rulemaking is not final and is subject to change.
Finally, Stronghold Freedom Foundation requested that VA engage an independent agency to correlate exposure data with reported illnesses and ensure unbiased assessments.
*VA Response:* K2SP was independently reviewed by the Centers for Disease Control and Prevention's Agency for Toxic Substances and Disease Registry (ATSDR), which also convened an external review panel. Both ATSDR and the external review panel endorsed K2SP.
**Comments From Veterans and Survivors on K2 Exposures**
VA received comments from veterans and survivors expressing concerns with several substances such as blood, nerve, and other chemical agents; black goo; contaminated water; small burn pits; burning of trash and soil; aircraft fumes; smoke; dust; asbestos; fuels; particulate matter; and benzene. Additional concerns included the remains of a reported Russian rocket fuel dump, vaporizing chemicals, use of mefloquine (an anti-malarial drug), and insecticide exposures.
*VA Response:* A variety of contaminants were identified at K2. Additionally, ATSDR reevaluated all samples collected at K2 by comparing levels to modern standards. See *www.publichealth.va.gov/docs/exposures/K2_Contaminants.pdf.* K2SP used this information to augment the outcomes assessed to provide a comprehensive evaluation.
Although radiation is not an exposure confirmed by the Department of Defense (DoD), several veterans reported concerns with radiation exposures, including both depleted and enriched uranium. VA engaged with DoD regarding potential radiation exposure at K2. Additionally, there is no evidence that enriched uranium was present at K2.
**Comments From Veterans and Survivors on Health Conditions**
In addition to the exposure concerns summarized above, veterans and survivors provided comments related to specific health conditions including:
• Various cancers such as brain, breast, prostate, esophagus, renal, bladder, skin, lung, and testicular cancers, and multiple myeloma;
• Thyroid conditions;
• Bone and joint issues, including chondrosarcoma, chronic pain, severe foot pain, spinal degradation, rheumatoid arthritis, and fibromyalgia;
• Cognitive and mental disorders, including depression, brain fog, racing thoughts, post-traumatic stress disorder, early dementia of unknown origin, and insomnia;
• Ruptured appendix;
• Liver conditions;
• Multiple skin conditions;
• Neurological issues, including burning sensations, peripheral neuropathy, severe neuropathies, tremors, seizures, and carpal tunnel syndrome;
• Undiagnosed illnesses;
• Gallbladder disease;
• Dental issues;
• Various tumors, such as those affecting the kidneys, eyes, skin, and chest;
• Myasthenia gravis;
• Monoclonal gammopathy of undetermined significance;
• Chronic fatigue;
• Hypertension;
• Endocrine disorders;
• Pancreatitis;
• Diabetes;
• Cataracts;
• Lung and respiratory conditions, including asthma, sinusitis, sleep apnea, lung nodules, chronic obstructive pulmonary disease (COPD), various coughs, chronic bronchitis, and a benign lung nodule;
• Hashimoto's disease;
• Atrial fibrillation;
• Autoimmune diseases;
• Various gastrointestinal conditions, including gastroesophageal reflux disease, inflammatory bowel disease, colon polyps, Crohn's disease, ulcerative colitis, and celiac disease;
• Erectile dysfunction;
• Brain aneurysms;
• Kidney stones and kidney disease;
• Gynecomastia;
• Dysfunctional eustachian tubes and tinnitus; and
• Metabolic disorders.
*VA Response:* Many of these conditions are covered under the PACT Act. VA will evaluate additional conditions as scientific evidence accrues to determine whether there is sufficient evidence to recommend presumption of exposure.
One veteran commented that military working dogs at K2 were always sick.
*VA Response:* In collaboration with DoD, VA has created a Military Working Dogs Database that includes morbidity, mortality, and post-mortem data. A total of 16 dogs have been identified as having deployed to K2, and preliminary analyses did not reveal any significant findings. Further analysis is ongoing.
Two veterans stated that they would be willing to undergo medical testing to further help K2 veterans. Several veterans requested that all military personnel who served at K2 automatically receive a service-connected disability rating, while other veterans commented that any condition they developed should be covered under a presumption.
In addition, one veteran commented that anyone who ever flew in or out of K2 deserves coverage. One veteran reported that their child had thyroid issues and connective tissue disease. Many commenters requested help for their conditions, stated that K2 veterans should receive benefits, or asked for additional research.
One commenter stated that K2 should be recognized as a TERA site; VA practitioners should be trained on the specific environmental concerns at K2; VA should conduct outreach and establish a K2 cohort; an independent review of the unique K2 toxic environment should be conducted; and VA should review the female cohort to investigate specific reproductive conditions. Finally, one commenter suggested that VA should reach out to the government of Uzbekistan on issues dealing with past chemical weapons.
VA further responds to these comments in the “Moving Forward” section below.
**Comments Containing Documentation**
VA received several photographs covering various topics, including a bag of medications; chemical agent warning signs; soil excavations; large puddles of water near tents; a dust cloud near heavy equipment in use; unknown yellow powder in soil being removed; a bottle of yellowish water; what may be a small inactive burn pit; two workers in hazardous materials suits; a smoke plume; what appears to be oil on the soil; heavy dust in the air at dusk; a “welcome to K2” sign with air pollution; and a female soldier using what appears to be a chemical agent detection kit.
One veteran provided a slide deck from the Center for Health Promotion and Preventive Medicine that listed radiation, fuels, and asbestos among other exposures, along with mitigation steps.
Additionally, the U.S. Military Exposure Research Organization submitted a document titled “Factors Contributing to Toxic Exposure Risk Activity at Camp Stronghold Freedom,” which suggested in part that all veterans should get TERA benefits and health care; there was extensive flooding at K2; the validity of conclusions of K2 health risk assessments is questionable due to the inability to measure all exposures; and known health effects include exposures to particulate matter and other concerns. This document also listed numerous possible chemical exposures.
VA responds to these comments in the following section.
**Moving Forward**
VA has considered, and will continue to consider, all comments that were received during the comment period. K2SP is ongoing and will continue to assess morbidity and mortality outcomes over the next 10 or more years. K2SP captures morbidity data from DoD and VA from 2000 to the present and compares disease outcomes, using similar data, to veterans who deployed in support of Operation Enduring Freedom during 2001 to 2005 but did not go to K2 and a separate group of veterans who served on active duty during the K2 occupation but never deployed anywhere in Southwest Asia. VA has submitted a report to Congress; provided VSOs with information about the mortality and morbidity study; and submitted a manuscript for publication to a peer-reviewed, scientific journal.
Many of the conditions that veterans addressed in their comments are assessed by K2SP. VA engaged with DoD regarding potential radiation exposure at K2. As mentioned previously, there is no evidence that enriched uranium was present at K2 at this time. VA is aware of potential exposures addressed by commenters, including depleted uranium, smoke, dust, contaminated surface water, and fuels. VA has received similar feedback from VSOs, veterans, and other stakeholders during public listening sessions. DoD completed a study on mortality [^1] and preliminary findings from the K2SP have been reported by VA. [^2] To date, there is no evidence to support an increased disease or mortality risk associated with service at K2. Epidemiologic research and scientific review of military environmental exposures is ongoing.
[^1]*https://health.mil/Reference-Center/Publications/2024/06/01/K2-Mortality-Study.*
[^2]*www.publichealth.va.gov/docs/exposures/K2_AMSUS_24.pdf.*
VA encourages all veterans who feel their military service has negatively impacted their health to submit a claim for disability compensation. VA will review the claims on a case-by-case basis. When determining eligibility for benefits, VA considers all avenues of service connection, which includes direct service connection, secondary service connection, and presumptive service connection. Service connection is not limited to potential exposures; service connection is potentially warranted for chronic conditions manifesting to a compensable degree within the recognized time. All K2 veterans are eligible for VA benefits for the currently recognized conditions listed in 38 CFR 3.309(a) that manifest during service or within the recognized period. In addition, K2 veterans are also eligible for all conditions identified by the PACT Act for burn pit and other toxins. As noted previously, many of the conditions addressed by commenters are conditions currently covered as presumptive conditions for K2 veterans, including, but not limited to, asthma; sinusitis; rhinitis; COPD; chronic bronchitis; squamous cell carcinoma; and brain, reproductive, and respiratory cancers. A complete list of presumptive conditions related to burn pit exposure can be found at *https://www.va.gov/disability/eligibility/hazardous-materials-exposure/specific-environmental-hazards/#what-does-it-mean-to-have-a-pr.*
VA notes that between 2005 and March 2024, 73% of identified K2 veterans had filed a claim for disability compensation, and 68% of the total cohort (or 93% of those who had filed a disability compensation claim) received disability compensation benefits. For this cohort, the average number of service-connected issues claimed was over 20, and the number granted was 13.6. The average service-connected disability rating for this group is over 70%. Additionally, 84% of K2 veterans are enrolled in VA health care, and 91% are enrolled in either DoD or VA health care.
On August 9, 2024, VA announced several steps to expand access to VA benefits for veterans who served at K2, as well as their survivors. [^3] VA stated that it would consider all public comments received and assess if evidence supports additional recommendations. In October 2024, VA created a training module specific to K2 exposures, ensuring that toxic exposures and contaminants are fully accounted for in the VBA claims process. VA also updated TERA documents to ensure claims examiners are aware of exposure concerns and resources for K2 contaminants. From November 2024 through March 2025, VA conducted pre-decisional reviews, which included additional quality checks, to ensure K2 veterans receive all benefits to which they are entitled. VA reiterates that K2SP is ongoing and will reevaluate morbidity and mortality outcomes at regular intervals over the next 10 or more years. These findings, along with continued evaluation of VBA claims data and review of pertinent scientific literature, will provide additional data for VA's ongoing assessment of health effects associated with K2 deployment.
[^3]*https://news.va.gov/press-room/va-takes-steps-to-expand-access-to-benefits-for-Veterans-who-served-at-k2-and-their-survivors/.*
**Signing Authority**
Douglas A. Collins, Secretary of Veterans Affairs, approved this document on September 25, 2025, and authorized the undersigned to sign and submit the document to the Office of the Federal Register for publication electronically as an official document of the Department of Veterans Affairs.
Taylor N. Mattson,
Alternate Federal Register Liaison Officer, Department of Veterans Affairs.