Most likely those reading this commentary will have seen Oppenheimer, the 2023 Academy Award-winning film about J. Robert Oppenheimer who led the Manhattan Project as it developed the first atomic bombs and launched the Atomic Age. The first bomb was tested at the Trinity Site in White Sands, New Mexico on July 16, 1945; the second—Little Boy—was dropped on Hiroshima, Japan on August 6, 1945; and the third—Fat Man—was released at Nagasaki, Japan on August 9, 1945. The immediate death tolls from the bombings at Hiroshima and Nagasaki were enormous: For Hiroshima, estimates range from 70,000 to 126,000, and for Nagasaki from 60,000 to 80,000. Over the longer term and continuing to today, the atomic bomb survivors have suffered from excess numbers of cancers and shortened lives. Beyond the tragic consequences of the Hiroshima and Nagasaki bombings, the nuclear age that began with the Manhattan Project has had profound implications for the health of nuclear workers and the public throughout the world. In his quoting of the Bhagavad Gita after the Trinity blast— “Now I have become Death, the destroyer of worlds” —Oppenheimer anticipated what was to come.

Nuclear Threat 

With awareness of nuclear weapons not only heightened by the film but also by Russian President Putin’s nuclear saber rattling, this is a moment to reflect on how public health has been affected since 1945 by nuclear weapons and how we are helping those who have been harmed. Worldwide, compensation is provided for some of those exposed, but not all, and in the United States, Congress is currently considering renewing and expanding legislation on compensation.  

Nuclear weapons have touched the lives of all of us, invoking concern about the possibility of their use and the unimaginable aftermath. In my case, I grew up with the nuclear threats of the Cold War and with frequent reminders that I was to cower under my school desk if warning sirens sounded. I remember my son’s distress when we watched the 1983 film— The Day After —an account of what might follow a nuclear exchange. The current New York Times series At the Brink describes what could happen if a single nuclear weapon were dropped now. Anxieties about nuclear war have been reawakened generally by the progressive erosion of geopolitical stability and specifically by Putin and North Korea’s Kim Jong-Un. The existential threat of nuclear war and the worries that it provokes stand as a ubiquitous concern for all of us. Here, I focus on disease risks and how the United States has addressed them with compensation for those injured. Note: This commentary will not address nuclear power and its consequences for public health, a topic saved for a subsequent commentary. 

Understanding the risks of atomic radiation has been central in my career, influenced by my start at the University of New Mexico in 1978. As viewers of Oppenheimer know, New Mexico has had a central role in the story of nuclear weapons. In 1978, underground uranium mining was booming, and I led the development of an ongoing epidemiological study of the state’s uranium miners—workers still experiencing a four-fold excess of lung cancer caused by radon. With that career start, I was soon engaged in characterizing the risks of indoor radon, using data from the New Mexico and other studies of radon-exposed miners. I also led an advisory group when the Department of Energy launched a joint US/Russia program of research on the health risks of the Mayak nuclear weapons complex in the Southern Urals. Most influential for me has been several decades of engagement as a board member with the Radiation Effects Research Foundation, located in Hiroshima and Nagasaki, which carries out the studies of the atomic bomb survivors. The lives of the survivors (the hibakusha) were irrevocably transformed in 1945, as were the lives of their children who worry about possible genetic risks passed on to them by their parents.  

The Hiroshima Peace Memorial (Genbaku Dome) is the only structure left standing near the hypocenter of the first atomic bomb which exploded on August 6, 1945. 

Bomb Survivors 

Turning to the health consequences of atomic weapons, let’s start with the atomic bomb survivors, many of whom have been participating in epidemiological studies that began in the late 1940s and continue today. They, and subsequently their children, have gifted the world by allowing their health to be tracked. We learned from them how radiation increases cancer risk, and that information has long been the foundation for radiation protection. Following the bombings, the survivors experienced an almost immediate epidemic of acute leukemia followed later by a radiation-dose-related rise in risks for most cancers developed by adults. Decades after the blasts, the survivors experienced an unexpected increase in heart disease risk and a general shortening of their lifespans. Research is in progress to understand how radiation could have these adverse effects. The survivors receive medical care and other support under The Atomic Bomb Survivors’ Support Law. For the survivors’ children, a critical and still incompletely addressed question is whether they will experience transgenerational effects. These studies are carried out by a unique bi-national organization, the Radiation Effects Research Foundation, the successor to the Atomic Bomb Casualty Commission. Looking forward, the foundation’s researchers will build on the survivors’ legacy by using 21st century science and more than two million biological samples, e.g., blood, to deepen understanding of how radiation injures the body.  

Uranium Mining 

The starting point for making nuclear weapons is uranium. For the Manhattan Project, much of the uranium was from the Belgium Congo (now the Democratic Republic of the Congo), but some came from Colorado and Canada. After World War II, demand for uranium soared as the nuclear arms race drove the build-up of ever larger stockpiles of bombs. The launching of nuclear power added to the need for uranium. By the 1950s, thousands worked underground as miners and above ground as millers, operating the mills that produced yellowcake, a powdered uranium oxide, which was shipped elsewhere for processing. By the time that uranium mining took off in the Colorado Plateau, evidence indicated radon as a potential cause of lung cancer and the US Public Health Service undertook an epidemiological study of miners in the region. By the early 1960s, that study showed excess lung cancer. Because all uranium was mined for the Atomic Energy Commission, the US government had jurisdiction for protecting the health of miners but did not do enough. A radon exposure standard for miners was eventually implemented but too late to prevent a still ongoing epidemic of lung cancer among the former miners. The millers were exposed to radon and uranium and are at risk for cancer, and lung and kidney problems. There is also a legacy of environmental contamination at uranium mining and milling sites, a particular concern for the Navajo Nation, which is dotted with abandoned mining sites.  

Uranium mining boomed and then busted in the Colorado Plateau after World War II; the industry’s colorful story is well told by Raye Ringholz in Uranium Frenzy. Uranium mill tailings piles were cleaned up at multiple sites in Colorado under the Uranium Mill Tailings Remedial Action (UMTRA) program, including Grand Junction, Durango, Rifle and others. Plutonium cores or pits for atomic weapons were manufactured at Rocky Flats, a facility that experienced upsets, including an almost catastrophic fire. While the site is now “cleaned up” and largely open as the Rocky Flats National Wildlife Refuge, concerns persist about residual plutonium contamination.   

Atomic Veterans 

There are other points for radiation exposure in the cycle of producing and testing nuclear weapons. At the start of the atomic age, there were fatal accidents during the Manhattan Project at Los Alamos. Workers were exposed to radiation in other Manhattan Project facilities, including those at Oak Ridge and Hanford. Workers at Rocky Flats were exposed to plutonium and also to beryllium, a problem described by Dr. Lee Newman, a Colorado School of Public Health faculty member. Military personnel, stationed as observers at test blasts, are another broad class of exposed individuals. In a notorious incident, the crew of the Japanese fishing boat, the Lucky Dragon, was coated with radioactive ash when a bomb was tested at the Marshall Islands. 

Thus, nuclear weapons have harmed the health of diverse groups in the United States: the “atomic veterans” who were present at above-ground testing; the downwinders exposed to fallout from test blasts; Atomic Energy Commission and later Department of Energy workers; and uranium miners and millers. Compensation schemes are in place for these groups, albeit too late for many. The Department of Energy workers are covered for beryllium-related problems and radiogenic cancers. The atomic veterans can participate in a Veterans Administration program and are also eligible for compensation from the Radiation Exposure Compensation Act (RECA).  

The Hiroshima Peace Memorial Park.

Radiation Exposure Compensation Act 

Turning to RECA, it was first passed in 1990, amended in 2000, and extended for two years in 2022. It covers those exposed to fallout (downwinders), those exposed to radiation at test sites, and uranium miners (and later millers). It includes an apology: “The Congress apologizes on behalf of the Nation to the individuals described in subsection (a) and their families for the hardships they have endured.” That apology came because the government had not acknowledged the risks to the downwinders nor protected the miners and millers who were producing uranium for the government.  One key step towards compensation was the case Begay v. United States, filed on behalf of a group of Navajo uranium miners with lung cancer and other diseases and their families. The case was decided for the government, but the presiding judge noted that the situation “cries for redress”. For the miners, that redress came with RECA. The Act is receiving attention now because it is due to expire and both extension and expansion of RECA have been proposed. The broadened coverage would include those exposed to fallout from the first blast at the Trinity Site who were not previously included, people exposed to Manhattan Project waste at certain sites, and underground uranium miners employed for at least a year through 1990, extending the current cut-off date of 1971.  

The Trinity Site is a key setting in Oppenheimer, now located in the White Sands Missile Range north of White Sands National Park. The site was remote at the time, but about a half million people lived within a 150-mile radius. Nonetheless, the fallout spread to major population centers throughout New Mexico and was heaviest in the nearby Tularosa Basin, where those exposed and their families are seeking compensation through an extension of RECA. The magnitude of radiation exposure to these people remains unclear, and, in fact, recent modeling suggests that fallout from the Trinity Blast may have reached more widely than previously estimated. The National Cancer Institute carried out a dose reconstruction exercise and estimated the number of cases of cancer that might have been caused by the blast; the estimate was that several hundred cases, primarily thyroid cancer, might have been caused by the blast through 2020.  Whether RECA will be extended and expanded to cover the Trinity Site is unclear. Recently, there has also been discussion of covering people exposed to waste from Manhattan Project activities in St. Louis.   

Nuclear Weapon Production 

Unfortunately, it is clear that the production of nuclear weapons will continue—in the United States and elsewhere. There are currently nine countries with nuclear weapons, totaling almost 13,000. In the book Countdown, Sarah Scoles describes how we are making a new wave of nuclear weapons and the stories of those involved in designing them. We have also resumed making the plutonium pits, once made at Rocky Flats, but now to be produced at Los Alamos and the Savannah River Site, near Aiken, South Carolina.   

The existence of nuclear weapons has been posed as a deterrent since the consequences of their use result in civilization ending. We have enough post-apocalyptic fiction and film to help us imagine a bleak future after an exchange of atomic weapons. For the present, there are people who have been harmed by the production and testing of nuclear weapons, including many bystanders, and we should continue to provide fair and just compensation.  

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Resources 

Sara Scholes: Countdown. The Blinding Future of Nuclear Weapons, Hachette Book Group, 2024. A recent book that addresses future nuclear weapons development in the United States.

Tom Zoellner: Uranium: War, Energy, and the Rock That Shaped the World, Penguin Paperback, 2010. A comprehensive history of uranium and its utilization. 

Peter H. Eichstaedt: If You Poison Us. Uranium and Native Americans, Red Crane Books, 1994.  An accounting of the impact of uranium mining on Navajo miners and communities.

M. Susan Lindee: Suffering Made Real, University of Chicago Press, 1994. The book addresses the aftermath of the atomic bombings in Japan and the complex history of the Atomic Bomb Casualty Commission.

Judy Pasternak: Yellow Dirt: A Poisoned Land and the Betrayal of the Navajos, Free Press, 2011. A history of uranium mining on the Navajo reservation and its legacy of sickness and government neglect.

This article is part of a monthly column, The Jon Samet Report, on the biggest issues facing us today in public health, written by the former dean of the Colorado School of Public Health, Jon Samet, a pulmonary physician and epidemiologist, and Professor of Epidemiology and Occupational and Environmental Health. Dr. Samet is a global health leader, shaping the science and conversation on issues ranging from tobacco control to air pollution to chronic disease prevention and more. Each month he shares expert insights on public health issues from local to global.