Mortality among Norwegian military Veterans from peacekeeping service in Kosovo during 1999-2020

Abstract: INTRODUCTION: Peacekeeping service in conflict zones might increase soldiers' risk of death as a consequence of physical and psychological exposure following in the wake of the actions of war. Exposure to potentially hazardous environmental agents in Kosovo, such as depleted uranium used in armor-piercing ammunition and air pollution from combustion of coal, have been reported. Our study assessed cause-specific mortality among Norwegian veterans who participated in international peacekeeping operations in Kosovo led by the North Atlantic Treaty Organization. MATERIALS AND METHODS: A cohort comprising virtually all Norwegian men (n=5,920) and women (n=279) veterans who were deployed to Kosovo between 1999 and 2020 was followed for the incidence of death from their first day of service in Kosovo through 2023. We calculated standardized mortality ratios (SMRs) with 95% confidence intervals from national population rates among men and women separately during the entire follow-up. Among men, SMRs for all causes combined and for external causes were also calculated during deployment and postdischarge from service in Kosovo, separately. RESULTS: We observed 115 deaths in men and three in women. Except for 2 deaths in men caused by accidents during deployment, all deaths occurred postdischarge. The 3 deaths in women, of which 2 were from external causes, yielded a nonstatistically significant all-cause SMR of 0.59. In men, mortality from all causes combined was lower than expected during the entire follow-up (SMR=0.56), during deployment (SMR=0.26), and postdischarge (SMR=0.58). Disease-related mortality was half of the expected value, because of very low risk of non-neoplastic mortality (SMR=0.31). External cause mortality was also lower than expected, because of few accidents, while risk of suicide was close to that in the general population. CONCLUSION: Peacekeeping service in Kosovo was not associated with increased risk of mortality during deployment and postdischarge. A virtually complete cohort and linkage with independent and complete national outcome registries should ensure unbiased results. However, lack of specific exposure data, such as particulate air pollution at the duty locations and data on tobacco smoking at the individual level are study weaknesses.