The whole issue of health hazards potentially faced by military forces in the Balkans is a complex one that is currently the subject of wide debate in the nations involved and in the press. NATO has paid much attention to the sub-issue of the potential health effects of DU.

Spurred by the reports of a higher incidence of leukemia and various health complaints associated with exposure to DU, the Committee of the Chiefs of Military Medical Services in NATO (COMEDS) called a special plenary meeting on January 15, 2001, to discuss issues related to DU. The meeting resulted in a report on the initial impression of the health issues as seen by the Surgeons General of the NATO nations’ military medical services. Preliminary data provided by the nations at that meeting indicated no causal link between exposure to DU and the health complaints or pathologies, and no link between DU exposure and leukemia or other cancers in Balkans veterans.^[11]

The COMEDS report also emphasized the need for scientific, peer-reviewed analysis (including independent studies), a common NATO medical policy evolved from purely national concerns to common international principles, and participation by all Troop Contributing Nations (TCNs). NATO and non-NATO TCNs are presently included in the North Atlantic Council’s Ad Hoc Committee on Depleted Uranium (AHCDU), which meets regularly to coordinate the free exchange of information on depleted uranium.

Nations have begun medical monitoring and epidemiological assessments of many of their Balkan veterans to determine if there is any increase in medical problems in troops who served in the region when compared to troops who served elsewhere. Recognizing the difficulty of comparing mortality and morbidity data gathered under different standards, the COMEDS tasked its Working Group on Military Preventive Medicine to develop a coherent strategy for processing and standardizing procedures so that future health hazards can be identified and assessed. COMEDS insisted that any investigations and measurements should only be undertaken if they can be scientifically validated, considered ethically acceptable, and peer-reviewed.

After the COMEDS special plenary session, a meeting of medical experts from NATO and non-NATO TCNs convened on February 9, 2001. The purpose of the meeting was to provide a forum for the exchange of medical information about the health effects of DU.^[12] In all, 29 nations were represented. Representatives from COMEDS, NATO military staff and the WHO also attended. Some medical experts proposed epidemiological and bioassay programs and some presented the results of personnel testing for the presence of DU or uranium levels above normal background levels. No experts implicated DU as a cause of illness or reported elevated urine uranium levels. The data presented at this meeting were later presented to the AHCDU.^[13] Table 1 is a summary of the results of the personnel testing.

The Medical Service of the Belgian Joint Staff performed its own risk assessment for riot control agents and DU. Although Belgian troops were not deployed in a zone where DU munitions were used, every Belgian military person returning from the Balkans has had a 24-hour urine uranium analysis. By December 2000, the Belgian Medical Service had conducted 3580 urine uranium analyses, with none exceeding the normal Belgian population urine uranium level. A comparative analysis of the cancer statistics for Belgian troops deployed to the Balkans and the Belgian civilian population is underway. Preliminary indications are that the rate of malignancies observed in the military personnel who served in the Balkans lies below the projected expectation for the Belgian population of the same sex and age.^[15]

Bulgaria reported that on January 5-6, 2001, medical personnel tested 39 soldiers who had served at Suva Reka, Kosovo, and found no health problems. The Bulgarian data included both urine and blood tests, but did not indicate whether uranium tests were conducted.^[16]

The Danish Armed Forces Health Services instituted a lead surveillance program at the beginning of 2000 for those Danish troops deployed to the area around Mitrovica, Kosovo. That area is heavily polluted by large factories working with lead. On January 9, 2001, the Danish government decided to also offer a health exam to all soldiers deployed to the Balkans in order to respond to the leukemia scare among the Balkan veterans and their relatives. The Danish program focused on blood tests for leukemia and did not involve urine uranium tests. The results of the health exam program are not yet available.^[17]

Estonia’s medical screening program as of February 9, 2001, had examined 91 of 422 Estonian peacekeepers deployed to the Balkans between 1996 and 2000. None of the individuals had health complaints and the test results did not disclose any abnormal pathologies.^[18]

The Health Care Division of the Finnish Defence Staff reported that 50 of their Balkan veterans were tested for urine uranium levels. Test results indicated that uranium levels in the group of Balkan veterans were no higher than that of the general Finnish population and that there were no abnormal health effects.^[19]

France plans to screen all current and former soldiers and civilians who deployed to the Balkans. Depending on the collected health histories, symptoms, and exposures, the French plan calls for additional medical clinical studies and, if necessary, additional biological studies, including screening for DU in 24-hour urine samples and, in some cases, stool samples.^[20] The French have screened 54 soldiers for DU. Eight of those were current or former soldiers who had served in the Gulf; roughly 20 were current or former soldiers who were exposed or likely exposed to DU; and 6 were soldiers who had been in the Balkans and had unspecified blood diseases. The remaining soldiers were not categorized. There were no elevated urine uranium levels in those tested. In a retrospective investigation, the French found no tumors in the French contingent currently deployed to the Balkans and found the incidence of leukemia in its armed forces to be consistent with the incidence in the general population.^[21]

The Germans conducted 271 24-hour urine tests on 122 German soldiers using high-resolution inductively coupled plasma mass spectrometry. This group included members of past and current contingents to the Balkans. The German researchers collected and analyzed pre- and post-deployment urine uranium samples for a 50-soldier subset of the group. In most cases, they collected and tested more than one urine sample (usually on successive days). The test results showed that none of the German soldiers had elevated urine uranium levels, indicating they did not have excess levels of uranium in their bodies. The researchers noted no adverse health effects.^[22]

The 1800 Greek soldiers tested included those who were in Bosnia-Herzegovina and Kosovo. The Greeks did not specify the nature of the tests, but all results were reported as normal.^[23]

Approximately 3200 Hungarian soldiers served with NATO forces in the Balkans. Of these, 335 had blood tests and 81 had urine tests. Hungarian researchers investigated the urine samples for beta-2-microglobulin. The Hungarians plan to analyze the urine samples for uranium, but as of February 9, 2001, the analyses are not yet completed. The blood and urine tests that were conducted found no pathological abnormalities.^[24]

The Italians tested 40 personnel under a new deployment protocol announced by the Italian Ministry of Defence in December 2000. The protocol calls for a series of blood and urine tests before and immediately after deployment, and each year thereafter for five years. The Italians tested the 40 soldiers using radiotoxicological^[25] and whole body counter analyses and found no contamination.^[26] The Italian Ministry of Defence also established two major studies. In the first, a Commission of Experts was appointed to evaluate the medical and scientific aspects of emerging cases of leukemia and other cancerous diseases among military personnel, with particular attention to those deployed in the Balkans. The Italian Commission of Experts (also known as the Investigative Commission) examined all the medical and scientific aspects of the tumor cases among military personnel who received medical attention in order to verify if the tumors were connected to DU munitions used in Kosovo and Bosnia-Herzegovina. The Investigative Commission published its preliminary report March 19, 2001. The report describes 28 confirmed cases (in a study population of 39,450) of malignancies. The following were reported: 4 non-Hodgkin’s lymphoma, 9 Hodgkin’s lymphoma, 2 acute lymphatic leukemia, and 13 solid malignant tumors. The Investigative Commission reached the following conclusions:^[27]

• Considering the number of cases of malignant tumors (hematological and otherwise) in the general population, the number was lower than expected (28 confirmed versus 53 expected);
• There was a statistically insignificant increased incidence of Hodgkins lymphoma and acute lymphatic leukemia; and
• There is nothing to lead to the conclusion that Italian troops were significantly exposed to DU.

In the second Italian study, researchers are conducting an epidemiological study of all Italian military personnel who have been deployed in the Balkans (about 50,000). The epidemiological study is in progress.^[28]

In January 2001, the Lithuanian military medical service tested urine uranium levels in 68 of their veterans who had served in Kosovo. An unspecified number of the 68 were also tested for transuranic elements. The results of the tests indicated that the urine uranium levels were not elevated and that transuranic elements were not present.^[29]

The Grand-Duchy of Luxembourg has participated in the Balkans peacekeeping effort since 1992, deploying 528 personnel. As of February 9, 2001, the Luxembourg Army Health Service has received no reports of health problems related to deployment, except traumatic injuries from accidents. Beginning October 4, 2000, the Luxembourg Army Health Service has given clinical examinations and blood tests to 146 Luxembourg soldiers who served in the Balkans, with no leukemia reported.^[30]

The Republic of Macedonia has been conducting regular radioactive contamination monitoring of its environment for the past three decades. When the Kosovo crisis began in March 1999, the number of tests increased—especially those measuring total uranium. Because the results have indicated no increased uranium concentration, the Macedonian government concluded that there is no requirement for additional preventive measures to protect its population.^[31]

The Netherlands Military Medical Service Agency identified 6 personnel who "came in contact with a DU-containing round" in August 1999. Urine samples were collected from these individuals and tested. The tests found no signs of increased urine uranium levels.^[32] The Netherlands Military Medical Service Agency also reported that of the 17 cases of leukemia in their armed forces, only 4 cases involved personnel who had been deployed to the Balkans, which was the expected rate considering leukemia rates in the general population.^[33]

Poland has been conducting urine and blood tests for its Balkan veterans since December 2000. They have not reported the number or type of urine and blood tests conducted but did report that the results were negative.^[34]

Portugal’s Balkan medical assessment program provides medical examinations for its military forces who served in the Balkans, as well as Portuguese Ministry of Foreign Affairs personnel and journalists posted to that area. The Portuguese estimate that this group totals about 5,335. As of February 7, 2001, the Portuguese had examined 2056 personnel, and, of these, 341 also provided 24-hour urine samples. The urine samples were analyzed for uranium and other heavy metals. No malignancies or elevated urine uranium levels were found.^[35]

Because of the press reports about a higher occurrence of leukemia in NATO troops who served in the Balkans, Slovakia began an expanded medical examination program for its Balkan veterans on January 15, 2001. A variety of blood and urine tests with principal focus on tumors and heavy metals are included in the Slovakian medical examination program. Based on the results from tests on 63 Balkan veterans, the study concluded that there was no indication of leukemia and no indication of exposure to DU.^[36]

Because of its medical screening program, Spain has practically discarded DU as a possible cause for diseases. Spain has examined more than 10,500 people who spent time in the Balkans, performing 600 urine uranium tests, all with normal results. Spain has also established a Scientific Committee to conduct a comprehensive epidemiological study coupled with a clinical records study. Preliminary results of the committee’s work indicate no scientific evidence of a relationship between any diagnosed diseases and DU exposure.^[37]

In January 2001, Sweden sent a letter to the 12,000 Swedish veterans who served in the Persian Gulf and the Balkans. The letter contained information about the use of DU munitions and included a short questionnaire about the veteran’s general health status. The collected data will be matched with the Swedish register for illness and cancer to correlate the veteran’s health status with the Swedish population. Any veteran with an acute illness will be asked to have a medical examination.^[38] Thirty-nine Swedish soldiers, believed to have been exposed to DU in the Gulf in 1991, have been given health check-ups—with no results reported to date. Sweden has not yet reported on the status of urine uranium tests.^[39]

The UK Ministry of Defence (MOD) has not yet tested personnel who have deployed to the Balkans as a risk assessment and environmental monitoring indicates that there is a negligible risk of personnel coming into contact with DU. As of this writing, the MOD is considering proposals for screening Balkans veterans. There are validated procedures for testing and monitoring people who may have been exposed to uranium and DU within the past few years and the intention is to develop validated procedures for assessing historic exposures.^[40] Monitoring of workers in the nuclear industry and in the nuclear weapons and DU munitions trials programs have confirmed the adequacy of their current radiation protection knowledge and practices. Clinical indications are used as the basis for decisions on DU testing and two Gulf veterans were tested to see if elevated urine uranium levels could be a factor in the medical problems they were experiencing. Both veterans had total urine uranium levels that fell within the range of normal background levels.^[41]

Two United Kingdom professors conducted a study of DU in Balkans residents for the British Broadcasting Corporation (BBC). The study included four Bosnia-Herzegovina and twelve Kosovo residents in addition to one BBC employee who had spent five days in the Balkans. All of the participants were volunteers. The study did not include a control group normally included in such research to determine if the measurements in the subjects under study differed significantly from measurements of unexposed populations. There is no evidence that the study has been peer reviewed. The professors reported that all subjects tested showed some level of DU excretion in the urine. A high-resolution multi-collector, inductively-coupled plasma mass-spectrometry instrument was used to analyze the samples to measure the DU content in the presence of natural uranium. They concluded that this most likely indicates DU was present in the food chain of the study group. In assessing the significance of this result, they concluded that the radiation doses received were dominated by natural uranium, which in turn, were smaller than the doses from other more common alpha-emitting radionuclides in the body including radon and polonium.^[42]

The WHO has reported that it has found no firm medical evidence to link medical cases in Kosovo to DU exposure.^[43] On January 8, 2001, the Head of Mission, WHO Pristina, issued a report that finds there has been no rise in leukemia in the Kosavar population in the past four years.^[44] The WHO also reported that current evidence indicates it is unlikely that soldiers who served in Kosovo are at a higher risk of leukemia from radiation exposure to DU. The report does suggest that there is a theoretical possibility that exposure to alpha and beta radiation from inhaled insoluble DU particles might lead to lung tissue damage and increase the probability of lung cancer.^[45]

The UK Royal Society report on DU, released on May 22, 2001, concluded that:^[46]

• Except in extreme circumstances, any extra risks of developing fatal cancers from internal radiation exposure to DU arising from battlefield conditions are likely to be so small that they would not be detectable above the general risk of dying from cancer over a normal lifetime;
• In situations with the greatest potential exposure (e.g., in a vehicle struck by a DU penetrator) and assuming the most unfavorable conditions, the lifetime risk of death from lung cancer is unlikely to exceed twice that in the general population;
• Under all likely exposure scenarios, the extra lifetime risks of fatal leukemia are too small to be observable;
• Even if the estimates of risk are one hundred times too low, it is unlikely that any excessive fatal cancer would be detected within a group of 10,000 soldiers followed over 50 years.

The medical and environmental assessments and investigations made by the various countries, international organizations, and private groups have had generally similar results. None have found a connection between DU exposure and leukemia or other medical problems in people, and none have found widespread DU contamination sufficient to impact the health of the general population or deployed military personnel.

Most of the NATO and non-NATO troop contributing nations have in place DU awareness programs that highlight potential risks and stress commonsense cautions. The majority of the nations have begun, or are planning to begin, epidemiological studies to further explore health risk issues.