A nuclear war between U.S.A. and Russia - or, say, one or more of the new nuclear powers to have emerged in recent years - would cause more human deaths and injuries in a few hours or days than have occurred in all the wars in the history of the world. What would concern the medical profession as regards its response to the disaster, would be the number of survivors, injured and uninjured, rather than the number of dead; but one has to remember that physicians and other medical professionals would be killed and injured in the same proportion as the rest of the population - actually a higher proportion is usually forecast. The conclusion reached by medical societies, health services, and universities, which is also my own conclusion, is that there would be essentially NO medical response. I shall come back to that point with quotations from official statements and committee reports of the Medical Associations. It is, in fact, a conclusion obvious to anyone who studies the matter.

Consider the following figures: A plane crash on an island off the Massachusetts coast resulted in less than 30 seriously injured. The disaster was handled by distributing the injured between all the major Boston area hospitals, and they were successfully treated {4}. Note, however, that 30 injured people at one time would strain the capacity of a big hospital.

A ship fire and explosion in Texas City harbour caused 800 severe injuries, which was far more than the Texas City hospital could cope with. The major hospitals in nearby Galveston and Houston were called on to help. More than 100 surgeons and many other physicians worked in shifts round the clock for 48 hours, with a full complement of consultants available at all times. That was how the situation was controlled; it took the medical services of 2 big cities working on an emergency basis {3}.

A single One Megaton Bomb on the city of Detroit is estimated to cause 1000 times as many injuries {2} as the Texas City ship disaster, and the hospitals of the whole of the United States would be overwhelmed, even if the injured could be efficiently distributed amongst them all. For example, there would be perhaps 10,000 burn cases, and the total number of specialized burn beds in the whole of North America is about 2,000. And a whole year's supply of blood for transfusion would be needed in one day.

Calculations for a Nuclear War appear unbelievably callous. The U.S. "Federal Emergency Management Agency" has described various scenarios, and a typical one might result in 86,000,000 people dead and 34,000,000 severely injured in the United States [CRPB-2 Model, quoted by Abrams & Von Kaenel{16}]. `Acceptable' or not to the military minds, there is no way that this number of injured could be accommodated or treated in all the hospitals of the world. There are about 2,000,000 hospital beds in Canada and U.S.A. combined.

Obviously no existing or conceivable medical service could handle a disaster even one tenth of this size.

What would happen to individuals in an attacked city?

The lucky ones would be those killed outright; they might be vaporized, or be left represented by a shadow burned onto a wall like the well-known picture from Nagasaki. The slightly less fortunate would be severely injured and regain consciousness in great pain and terror, in time to see and feel fire bearing down on them, and they would die without hope, but quickly.

Some would be injured in the streets, and unable to walk. No help would come to them. Others might be trapped by fallen masonry, caught by the legs, pinned down by a fallen utility pole, or enclosed in a collapsed basement, perhaps not mortally wounded but with no hope of moving the obstructions until they died from fire, radiation sickness, or thirst. The terror and desolation of hundreds of people in such a situation, in the dark, some of them in hearing of others, some alone, is difficult to conceive.

Radiation sickness is not the bland wasting away that was portrayed in the film "The Day After". It involves actual vomiting and diarrhoea. In a wrecked city few victims would have access to water either to drink or to clean themselves, and many would be unable even to move away from the resulting mess and smell. Except in the case of a massive dose, radiation takes many days to kill.

There is no end to the scenes of pain and horror that one can see in imagination. The Canadian picture of a serious injury, in an auto accident, an industrial accident, or a severe burn at home, is of pain, fright, and chaos lasting for many minutes or at most an hour or two until the ambulance arrives, skilled help is at the scene, and the problems begin to be controlled. After the destruction of a country by nuclear bombs, only a small proportion of people would ever get help. The great majority of injured would die where they lay, slowly, without any comfort or pain relief whatever; others would struggle for miles through fire and rubble, and find no help, whether they reached their home or a suburban hospital surrounded by uncountable crowds of injured and hopeless people. No-one, not even the doctors, would know who had received a serious or a fatal dose of radiation; so patients who received first aid to the extent of arresting haemorrhage and rough splinting of broken bones, would not know if slow inevitable death awaited them in a few days or weeks. They could assume that any rain that fell would be lethally full of radioactivity (even to causing beta-ray burns on the skin) but would have no way of knowing whether food, or water from other sources, was radioactive.

The effect on medical services would be disastrous. Many hospitals would be destroyed with all their staff. Missile inaccuracies, or the occasional dud where a small city had been allocated only one bomb, might leave a few city hospitals intact; some suburban hospitals would no doubt survive sufficiently undamaged to be used. For most of them there would be no main water or electricity, and no supplies of any kind - food, drugs, or equipment - arriving from outside. Normally 90% of their beds would be occupied by their own patients. Medical staff not already in the building would probably not arrive, nor the next shift of nursing staff when due. Surviving doctors and nurses would be in the same dreadful state as other survivors, mentally shocked, overwhelmingly concerned about the safety of their own families (or shattered by the loss of them), not knowing what dose of radiation they had already received or were currently getting from fall-out and contaminated patients, and not knowing whether they would get their next meal. Some, but not all, might be heroes and set about doing what they could for those of the injured that could be packed into hospital corridors and available beds, until the hospital supplies ran out. It is predicted that few survivors, even if uninjured, would be functioning effectively, and a high proportion would be incapable of any useful activity {8}. No more than a minute fraction of the injured could receive even minimal help in such a situation.

It is difficult to see how any political objective whatever could justify taking the risk of involving a country's population in such immediate suffering. The aftermath, however, might be even worse.



THE SURVIVAL PERIOD

There would be survivors, some injured some uninjured. After the bombing, `Nuclear Winter' is predicted {20}, which would cause darkness and cold for weeks or months. Communication would be defective or absent; transportation rapidly failing as local fuel supplies ran out; psychological shock would be extreme; millions of injured would be dying; millions of corpses would lie unburied; radiation fallout would be universal, and downwind of all near-surface nuclear explosions and disrupted nuclear generators it would be intense.

There follows a formidable catalogue of health-related problems, some of which have been semi-quantitatively estimated, and others which are no more than intelligent speculation. It appears that the destruction of all human life by radioactive fallout, as described in the novel "On the Beach" by Nevil Shute, is still out of reach of military capability by a factor of somewhat less than 100 {6}. This of course does not exclude the possibility that the human race might die out from the combined effects of all the predicted, and possible unpredicted, factors {18}.

In my opinion nearly all the medical problems would be utterly impossible of solution in the conditions that would obtain. There are, for example, some rather sinister remarks in the literature relating to the impossible task of caring for all the sick. "Unless there were an undesirable change in attitudes towards the ill, they would represent a large and continuing drain on resources" (Middleton {5}). Compare Dr. Patricia Lindop: "One needs to calculate, and no doubt this has been done by every country preparing to defend itself in war, the optimum number of people to be allowed to survive. ... In the recovery period each survivor must be fit and well; otherwise, he is a large drain on the rest." {7}

The *most immediate health-related requirements* would be: morphine for the injured; protection from rain (radioactive); protection from fall-out; finding water for drinking; monitoring water for radioactivity; first aid for haemorrhages and fractures; help for the newly blind; warmth. The most important of these, morphine, would not be available in sufficient quantity, and there would be no way of getting the drug to the majority of those needing it.

Perhaps *next in urgency* should be listed: finding food; monitoring food for radioactivity; discipline and rationing; sanitation; locating and avoiding intense radiation; detecting and avoiding use of spoiled food (no refrigeration). Food supply would not be assured, and this fact alone could precipitate a complete breakdown of law and order.

To initiate professional health care even on the smallest scale it would be necessary to locate uninjured doctors and nurses; to locate drugs and medical supplies; to secure food and rest, assistance, and support for these professionals. The lack of hospital utilities, laboratories and X-rays would greatly hamper any service they might render.

*Lethal effects of radiation* can be summarized briefly: a very high dose (5000 rads +) causes death in hours; a smaller but lethal dose (400 rads +): death in weeks. In the latter case, sickness starts with diarrhoea and vomiting, followed by temporary improvement, and then the same symptoms recur with the addition of haemorrhage, anaemia, infections, and a slow death. Those who receive 100 - 400 rads would also suffer nausea and vomiting, as would many people who have been shocked or injured without significant irradiation. It would be difficult to distinguish those who had received a lethal dose from those who had not: all would be subject to the same fear of impending death. Fear would be a major feature of life after a nuclear war.

There is little experience on which to base estimates of *psychiatric problems*. In all probability they would be widespread and severe. Depression, causing apathy, despair, sluggish thinking, difficulty in making decisions, emotional numbing and emotional instability, would probably affect almost all survivors. Hysteria might be a common response to the unprecedented stresses. I would anticipate a high incidence of outright insanity. There would no doubt be suicides, as well as failed attempts at suicide that would add to the load of injured people.

*Multiplication of pests* could be expected. Flies and other insects are more resistant to radiation than mammals, and would have abundant food supply in the many human and animal corpses. Their rate of reproduction is rapid. Rats, mice, domestic and other small mammals might be less exposed to blast and radiation, and would have the same abundant food supply.

Conditions would predispose to the *spread of infection*. Overcrowding would contribute to spread of respiratory and intestinal infections, hepatitis and wound infections. Insects and small mammals would spread infection from human and animal corpses and excreta. Enemy-introduced infections are also possible.

The *irradiation of pregnant women* would cause stillbirths, birth defects, and mental retardation {19}. (A dose sufficient to cause immediate abortion would be lethal to both mother and fetus.) There would be increased risks of all kinds throughout pregnancy, delivery and in the puerperium. Fear of all these effects would add to psychological stress.

The predicted "Nuclear Winter" comprising darkness, cold, and atmospheric pyrotoxins, would compound the many problems. Darkness would hamper all movement and activity, and add to depression, fear and panic. Cold might reduce the problem of flies, but would add to misery, and cause exposure and hypothermia (with merciful anaesthesia and death to some of the injured and infirm). Cases of frostbite would be expected. In severely cold conditions wounds do not heal well unless sutured very promptly, because the exudates freeze {17}. The disorganisation of medical services would mean no prompt attention for most injuries, and therefore poor healing.

No quantitative estimates are available for the effects of *pyrotoxins* {18}. These are the toxic products of combustion on a massive scale: carbon monoxide, oxides of nitrogen, dioxins, furans, etc. They would be deleterious to all life, and might be a serious cause of morbidity and mortality.

During the months of continued survival, many adverse factors can be identified, which would include medium-term radiation problems: sub-lethal doses of radiation predispose to infections because of lack of both the immune response and the leucocyte response to infecting bacteria. Radiation also causes defects of blood coagulation, with anemia from bleeding and from marrow depression. All of these effects tend to increase mortality from burns and injuries, and from infections that the normal human body combats easily. Fear of this invisible threat would also be widespread.

Many diseases controlled by antibiotics in modern civilized life could become serious again, with no antibiotics and many people suffering from impaired immunity; examples are: scarlet fever, quinsy, meningitis, pneumonia, infections from small wounds, septicaemia. Similarly, a number of diseases now routinely controlled by immunization could become common again: poliomyelitis, diphtheria, whooping cough, measles, tetanus. Influenza is common already, but without immunization and without supportive treatment of those who get complications, it could become a major cause of death.

Infectious diseases now regarded as rare or exotic could re-appear in epidemic form, natural immunity having been lost by a population rarely exposed, and acquired immunity being impaired by irradiation. They include tuberculosis, typhoid, typhus, cholera, amoebic dysentery, yellow fever, malaria and plague. Plague is carried by rats and other small mammals, and is transmitted to humans by fleas. The disease is still endemic in the western states of America, and a few human deaths are reported each year. Epidemics of plague decimated Europe several times in the Middle Ages, and in the absence of preventive medicine and rodent control could do the same in North America.

Dangers from rodents, dog packs, and their parasites, would include spread of infections such as rabies and tetanus as well as plague and typhus. There would also be the risk of attack from such animals, and fear of the animals themselves.

Deformities and disabilities would result from lack of surgical treatment of non-fatal injuries: infected wounds with delayed healing and excessive scarring, mal-united fractures, non-united fractures, osteomyelitis, keloids from burns, facial disfigurements (causing severe social and emotional stresses).

After the dust and soot clouds settled and the sun's rays again reached the surface of the earth, destruction of ozone in the stratosphere would allow excess ultraviolet light to penetrate the atmosphere, causing blindness in many animals and in humans (unless they could protect their eyes), causing burns and cancers of the skin, and reducing the food supply by its effects on plant growth and on pollinating insects.

Long-term radiation problems would include increased incidence of leukemia, thyroid abnormalities and tumours, cancers of many organs, sterility and infertility, mutations causing abortions, still-births and genetically determined diseases, as well as shortening the average life-span. In absolute numbers the increased incidence of leukemia and other cancers would have limited importance. Rather few of the survivors would live long enough to develop solid cancers, which have a long latent period; leukemia has a short latent period, but is a fairly rare disease. The Japanese survivors had only 60 cases of leukemia per 100,000 people exposed, about 15 times the usual incidence {1}. Fear of cancer might add more trauma than the cancers themselves.

Many medical disorders need continuing treatment which would not be available after a nuclear war, with hospitals out of action or overcrowded with injured, and pharmaceutical stores and factories destroyed. Some common examples are listed in Table 1. Many other problems could be cited. For example, some renal patients require periodic dialysis, which would not be available. Cardiac pacemakers could be put out of action by the "Electro-Magnetic Pulse". Patients with all these conditions would suffer deteriorating health or death when their supportive treatment was withdrawn.

Quotations from the official statements of learned medical societies support my conclusion that the medical problems resulting from nuclear war would have no solutions, and no conceivable preparations could be of significant value.

From the British Medical Association report on The Medical Effects of Nuclear War:

"It is difficult to see how more than a small fraction of the initial survivors of a nuclear war in the middle and high latitude regions of the Northern Hemisphere could escape famine and disease during the following years." {12}

"We believe that such a weight of nuclear attack [200 Megatons on the British Isles] would cause the medical services in the country to collapse. The provision of individual medical or nursing attention for victims of a nuclear attack would become remote. At some point it would disappear completely and only the most primitive first aid services might be available from a fellow survivor." {13}

"There is no doubt that the experience of conventional warfare is * irrelevant* [emphasis in original report] to the scene that would confront whatever survivors remained after a major nuclear attack." {9} "Survivors would be preoccupied exclusively with the search for food and shelter. They would be unlikely to devote attention to the care of the sick and dying." {10}

"We do not doubt that doctors would wish to give help even in the midst of such devastation, nor do we doubt that they would be looked upon by survivors as natural leaders; but their impact on the situation would be minimal." {11}

From the Ontario Medical Association: "That the O.M.A. place on record its view that there is no effective medical response to the sequelae of nuclear war." (Resolution passed 6 June, 1983.)

From the Report of the Board of Trustees of the American Medical Association:

"Available data reveal that there is no adequate medical response to a nuclear holocaust. In targeted areas, millions would perish outright, including medical and health care personnel. Additional millions would suffer severe injury, including massive burns and exposure to toxic levels of radiation, without benefit of even minimal medical care." {14}

From the Health Policy Committee of the American College of Physicians:

"These facts argue that medical disaster planning for nuclear war, unlike that for radiation accidents, is futile." {15}

"There is no possible adequate medical response to a situation where hundreds of thousands of people would be injured or ill, most hospitals destroyed, most medical personnel killed, and most medical supplies unavailable." {15}

"The College believes that education is a key to prevention of nuclear war, and endorses increased professional and public education on the medical consequences of nuclear war." {15}

"Finally, the College, in keeping with its stance on the value of prevention in health promotion, urges the Federal Government to continue and emphasize international dialogues on mutual nuclear disarmament." {15}

We may note that the American College of Physicians is sufficiently concerned to step outside its strictly professional field, and urges the U.S. government to act to reduce the risk of nuclear war. Observation of the nuclear arms race over the last 40 years, and its recent acceleration with preparation for war-fighting "if deterrence fails", show that the governments of U.S.A. and Russia are little influenced by thoughtful descriptions of the expected effects of nuclear war, which have been presented by Albert Einstein and many scientists and scientific bodies after him. It may be that popular pressure, by protests and demonstrations like those that have followed recent deployments of new weapons in Europe, as well as a clear stand by the majority of voters in the democratic countries, are more effective ways to influence the super-power governments and reduce the risk of the terrible health catastrophe that has been outlined in this paper. The very presence of enormous numbers of nuclear weapons constitutes a grave risk, even if it is claimed that there is no intention to use them.