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The Medical Implitations of NUtIEAR WAR INSTITUTE OF MEDICINE NATIONAL ACADEMY OF SCIENCES Fredric Solomon, M.D., and Robert Q. Marston, M.D. Editors With a Foreword by Lewis Thomas, M.D. NATIONAL ACADEMY PRESS Washington, D.C. 1986

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NATIONAL ACADEMY PRESS 2101 CONSTITUTION AVENUE, NW WASHINGTON, DC 20418 NOTICE: The symposium reported in these proceedings was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the symposium were chosen for their special competences and with regard for appropriate balance. These proceedings have been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. Conclusions and views expressed by the authors of papers are their own and do not necessarily represent those of the program sponsor, the Institute of Medicine. The Institute of Medicine was chartered by the National Academy of Sciences to enlist distinguished members of appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. The National Academy of Sciences was established in 1863 by Act of Congress as a private nonprofit, self-governing membership corporation for the furtherance of science and technology required to advise the federal government upon request within its fields of competence. Under its corporate charter the Academy established the National Research Council in 1916, the National Academy of Engineering in 1964, and the Institute of Medicine in 1970. Library of Congress Cataloging-in-Publication Data The medical implications of nuclear war. Based on papers presented at a symposium held at the National Academy of Sciences, Washington, D.C., Sept. 20-22, 1985 and organized under the auspices of the Institute of Medicine. Includes index. 1. Nuclear warfare-Hygienic aspects-Congresses. 2. Emergency medical services Congresses. 3. Nuclear warfare Environmental aspects Congresses. 4. Nuclear warfare-Psychological aspects Congresses. 5. Nuclear warfare Social aspects Congresses. I. Solomon, Fredric. II. Marston, Robert Q., 1923- . III. Institute of Medicine (U.S.) [DNLM: 1. Nuclear Warfare congresses. 2. Radiation Injuries congresses. 3. Radioactive Fallout-adverse effects congresses. WN 610 M4865 1985] RA648.3.M445 1986 363.3'498 86-18134 ISBN 0-309-03692-5 ISBN 0-309-03636-4 (pbk.) Copyright @) 1986 by the National Academy of Sciences No part of this book may be reproduced by any mechanical, photographic, or electronic process or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted or otherwise copied for public or private use, without written permission from the publisher, except for the purposes of official use by the United States government. Cover photo: Nagasaki, 10 August 1945, 11 A.M. The heavy overcast of smoke from fires cut of the sunlight. The narrow path, along which the wounded are being carried on stretchers, leads to Nagasaki Railway Station. (Photograph by Yosuke Yamahata.) Copyright @) 1981 by Hiroshima City and Nagasaki City. Reprinted by permission of Basic Books, Inc., Publishers. A videotape digest of symposium highlights is available. For information, write the Institute of Medicine, Office of Information, at 2101 Constitution Avenue, NW, Washington, DC 20418. Printed in the United States of America First Printing, September 1986 Second Printing, September 1988

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INSTITUTE OF MEDICINE Steering Committee for the Symposium on the Medical Implications of Nuclear War ROBERT Q. MARSTON, M.D. (IOM), Chairman, President Emeritus, University of Florida, Gainesville HERBERT L. ABRAMS, M.D. ATOMS, Visiting Professor, Department of Diagnostic Radiology, Stanford University School of Medicine, and Stanford Center for International Security and Anns Control WILLIAM R. BEARDSLEE, M.D., Clinical Director, Department of Psychiatry, Children's Hospital Medical Center, and Assistant Professor, Harvard Medical School K. SUNK D. BERGSTROM, M.D., Ph.D. (IOM, NAS), Professor of Chemistry, Karolinska Institute THOMAS C. CHALMERS, M.D. (IOM), Distinguished Service Professor of Medicine, President and Dean Emeritus, The Mount Sinai Medical Center, New York City DAVID S. GREER, M.D. ATOMS, Dean of Medicine and Professor of Community Health, Brown University ALEXANDER LEAF, M.D. (IOM, NAS), Ridley Watts Professor of Preventive Medicine, Harvard Medical School, and Chairman, Department of Preventive Medicine and Epidemiology, Massachusetts General Hospital JENNIFER LEANING, M.D., Chief of Emergency Services, Harvard Community Health Plan GILBERT S. OMENN, M.D., Ph.D. (lOM), Dean, School of Public Health and Community Health, and Professor of Medicine and Environmental Health, University of Washington JEANNE PETERSON, United Nations Office of Population CHESTER M. PIERCE, M.D. ATOMS, Professor of Education and Psychiatry in the Faculty of Medicine, the Graduate School of Education, and the Faculty of Public Health, Harvard University THEODORE A. POSTOL, Ph.D., Science Fellow, Stanford Center for International Security and Anns Control lOM, Member of He Institute of Medicine NAS, Member of the National Academy of Sciences . . . lZZ

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IV STEERING COMMITTEE FREDERICK C. ROBBlNS, M.D. (IOM, NAS), ex officio President, institute of Medicine ~ 1980- 1985), University Professor, Department of Epidemiology and Biostatistics, Case Western Reserve School of Medicine ARTHUR C. UPTON, M.D. STOMP, Professor and Chairman, Department of Environmental Medicine, New York University School of Medicine FRANK VON HIPPEL, Ph.D., Professor, Woodrow Wilson School of Public and International Affairs, and Center for Energy and Environmental Studies, Princeton University Institute of Medicine President SAMUEL O. TH1ER, M.D. Project Staff FREDRIC SOLOMON, M.D. (Project Director), Director, Division of Mental Health and Behavioral Medicine, Institute of Medicine MARC MESSING (Deputy Project Director), Staff Consultant, institute of Medicine NANCY WINCHESTER, Editor, National Academy Press

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Contents Foreword . e ~ Lewis Thomas, M.D. Preface e x Robert Q. Marston, M.D., and Fredric Solomon, M.D Understanding and Preventing Nuclear War: The Expanding Role of the Scientific Connnnunity ................................ David A. Hamburg, M.D. Part ~ Nuclear War with Modern Weapons: Physical Effects and Environmental Consequences Possible Fatalities from Superf~res Following Nuclear Attacks in or near Urban Areas ............................................. Theodore A. Postol, Ph.D. A Review of the Physics of Large Urban Fires H.~. Brode, Ph.D., and R.D. Small, Ph.D v . . . 1 15 73

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Vl Recent Assessments of the Environmental Consequences of Nuclear War ........................................... Richard P. Turco, Ph.D. Nuclear Famine: The Indirect Effects of Nuclear War ....... Mark A. HarweR, Ph.D., and Christine C. Harwell, ].D Nuclear Winter: The State of the Science George F. Carrier, Ph.D. . Atmosphenc Perturbations of Large-Scale Nuclear War Robert C. Malone, Ph.D. Possible Toxic Environments Following a Nuclear War John W. Birks, Ph.D., and Sherry L. Stephens Radioactive Fallout ......................... Charles S. Shapiro, Ph.D., Ted F. Harvey, Ph.D., and Kendall R. Peterson, M.S. Part I} Health Consequences of Nuclear War Casualties Due to the Blast, Heat, and Radioactive Fallout from Various Hypothetical Nuclear Attacks on the United States CONTENTS ............. 96 .. 117 136 ....... 141 ....... 155 167 ................. 207 William Daugherty, Barbara Levi, Ph.D., and Frank von Hippel, Ph.D. Acute Radiation Mortality in a Nuclear War Joseph Rotblat, Ph.D. 233 Burn and Blast Casualties: Tnage in Nuclear War - 251 Jennifer l caning, M.D. Food and Nutrition in the Aftermath of Nuclear War Alexander Leaf, M.D. .......... 284

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CONTENTS Psychological Consequences of Disaster: Analogies for the Nuclear Case ........................................... James Thompson, Ph.D. . . V11 ....... 290 The Immunological Impact of Nuclear Warfare 317 David S. Greer, M.D., and Lawrence S. Riflcin Expected Incidence of Cancer Following Nuclear War Nikolai P. Bochkov, M.D., and Per Oftedal, Ph.D. Genetic Consequences of Nuclear War Per Oftedal, Ph.D. ........ 329 .......................... 337 Part III Medical Resource Needs and Availability Following Nuclear War Medical Supply and Demand in a Post-Nuclear-War World Herbert L. Abrams, M.D. The Consequences of Nuclear War: An Economic and Social Perspective ....................................... Hal Cochrane, Ph.D., and Dennis Mileti, Ph.D Part IV hnages and Risks of Nuclear War: Psychosocial Perspectives . Children's and Adolescents' Perceptions of the Threat of Nuclear War: Implications of Recent Studies ...................... William R. Beardslee, M.D. Scandinavian Youth View the Future: A Preliminary Report of a Large Questionnaire Survey ............ Magne Raundaten, Ph.D., and Ole Johan Finnoy .. 349 ........... 381 ....... 413 ..................... 435 Adult Beliefs, Feelings, and Actions Regarding Nuclear War: Evidence from Surveys and Experiments 444 Susan T. Fiske, Ph.D.

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~ Vlll Hope and the Denial of Stress in the Nuclear Age Shiomo Breznitz, Ph.D. The Nuclear Arms Race and the Psychology of Power Jerome D. Frank, M.D., Ph.D. Managerial Demands of Modern Weapons Systems John D. Steinbruner, Ph.D. Sources of Human Instability in the Handling of Nuclear Weapons .. Herbert L. Abrams, M.D CONTENTS ............. 467 ........ 474 485 490 The Impact of Crisis-Induced Stress on Decision Making 529 Alexander L. George, Ph.D. Part V Long-Term Consequences of and Prospects for Recovery from Nuclear War: Two Views View I Car! Sagan, Ph.D. View II Lynn R. Anspaugh, Ph.D. Conclutl~ng Remarks Summary and Perspective: With Some Observations on Informed Consent .................................................. Herbert J. Abrams, M.D. 566 583 Glossary 589 Biographies of Contnbutors Index 607

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Foreword I was in Europe at the time of the Institute of Medicine's symposium, and I read the accounts of the meeting in the headlines of the French, German, and British newspapers. Banner headlines, lead stories, front pages every- where. The announcement was that a nuclear war would cause AIDS. No matter that the real AIDS is caused by a virus. The concept of immune deficiency as a consequence for the survivors of radiation, malnutrition, burns, grief, and other assaults of nuclear bombardment was compelling. It was as though the problem of hydrogen bombs had suddenly turned into something the writers could lay hands on. Something to sit down and think about, and compose a front page story about; something different from all those unthinkable matters. To be sure, there were some lines at the bottom of the stories, continued on inside pages, giving some new estimates of the numbers of people to be killed outright by blast and burns, the utter impos- sibility of any health care system doing anything even marginally useful, and some mention of the "nuclear winter" scenario. But it was AIDS that caught the attention of the press, AIDS that made the story. When I got back to New York a few days later, the whole story had vanished from the papers, but I found clippings from most of the earlier reports that had appeared in the national papers and news magazines. Same story: AIDS. And then that was the end of the matter. No more stories in the days and weeks that followed, not about the medical consequences of nuclear war. Back to normal: the stuck inconclusive Geneva talks, the harangues by states- men hungry for television, the talk of new talks, arms control talks, treaty violation talks, editorials saying that neither side can trust the other or ever IX

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x FOREWORD will, endless bewildering columns on the SDI and the talk about SDI. Wretched, dishonest, evasive talk, political talk, with no mention anywhere of burnt blasted vaporized human beings in the billions and half the planet frozen and irradiated. The same turning away from real life and real death danger that we have all been tolerating, some of us even encouraging, since we and the Russians began building our "arsenals," as we like to call the things to make it seem like old times, same old clash of arms, same excitements. The British and the French with theirs, and the Chinese and Indians and God only knows who else with theirs, all of humanity caught up in the craziness like lemmings running headlong toward the cliff, everyone muttering unthinkable. We behave as if we really believe these are weapons even, burn our tongues, weapons of "defense." We brandish them, display them like the spears and banners of primitive tribes shouting insults across a river boundary, getting ready to fight, to defend, to burn up the earth for the honor. Maybe holding back, but only for the moment, at the thought of catching AIDS. And then, next day, that thought gone. When I complain, as I bitterly do, to my journalist friends about all this, they say what on earth do you expect us to do? We can't run front page stories every day about the world coming to an end, they say. People won't read things like this, they say. I raise my voice, yell sometimes, what the hell are newspapers for? You're supposed to provide information, real news, and this is the news of the world, the news of the end of the world, print more of it for God's sake before it's too late, I say. Put the nuclear winter up there on the front page every day, give it the biggest blackest headlines you've got, make it the main story, run it and run it. I say all that, and things like that, and they look at me with embarrassment. But AIDS ! And then nothing. And in that one day of stories, down at the bottom, winding things up, a short paragraph saying 56 million Americans would be killed outright in a 100-megaton attack on cities; not much better in an attack on military targets (our "assets," we call them), 38 million if they do that. That's from 100 megatons, the equivalent of a warning shot over the heads of a crowd considering that we and the Soviets have between us 20,000 megatons or whatever the number now is. I complain to my journalist friends in a voice as reasonable as I can make it, even good-natured, can't you at least do more to get the public thinking hard about nuclear winter? Too much uncertainty, they say, you can't be sure about the weather, can't predict it until it really happens. Anyway, people don't want to read about it, be told about it. Not a good thing to think about. And anyway, what can be worse than 2.2 billion sudden human deaths? They ask me that, then say, that's the closest estimate available for the deaths in a really full-scale nuclear war, when everything is let fly. How can you get

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FOREWORD Xl i people (the "reading public," they say) to think about a lot of clouds, even the extinction of some other kinds of life on the planet, when you've got a number that is at least half the human species? Then they use the word that has become the cliche of late twentieth century statecraft: unthinkable. That is the center of the trouble, I see that. Nuclear war is for sure, beyond question, dead certainly, literally, figuratively, any way you don't want to think about it: unthinkable. If we go on this way, unthinking, putting it out of our minds, leaving it to statecraft of the kind we've got all over the world, or leaving it to the editorial writers, the columnists, the TV newsmen, or the military people, first thing you know some crafty statesman or some other crafty unbalanced military personage, one side or the other, is going to do something wrong, say something wrong, drop something, misread some printout, and there will go 30,000 years of trying ever since Lascaux right up to Bach and beyond into this benighted century all civilization, gone without a trace. Not even a thin layer of fossils left of us, no trace, no memory. Pay attention to George Kennan and Solly Zuckerman and their books along with this one. They have thought longer and more clearly than most people close to the complexities. Solly Zuckerman, with years of experience as science adviser to the British cabinet, says we're in trouble because of the weapons-scientists ("technicians," he calls them, with austere and adult con- tempt), and the lack of anyone with the authority and power and real brains (brains, not easy cleverness or clever craziness) to tell them what to do, or more importantly what not to do. Tell them: that's enough now, don't improve the technology, don't make anything technically sweeter or smarter, go home and we'll pay you to stay there. Unthinkable is the word for whatever is in front of our eyes but too big to figure out, too frightening. Pay attention, in this book, to the doctors and the scientists here assembled. Everything needed for thinking clearly, wincing all the way but thinking anyway, is written down in these chapters. Anyone, any age, can read what's here and understand what we could be in for if we stay on this road. What to do is another matter, but at least the facts of the matter are laid out here. You'd better bet your life it's thinkable. Lewis Thomas, M.D. President Emeritus Memorial Sloan-Kettering Cancer Center

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Preface On August 6, 1945, a 15-kiloton atomic bomb ignited the center of the Japanese city of Hiroshima, flattening it and killing more than 100,000 people. Just three days later, a second bomb was exploded over the city of Nagasaki, resulting in the deaths of another 70,000. For months after the attack, many survivors developed symptoms that puzzled doctors: blood cell abnormalities, high fevers, chronic fatigue, diarrhea, vomiting, and depression. Physicians began to term these symptoms "radiation sickness." It would eventually be revealed that survivors were experiencing an increased incidence of certain forms of cancer. Now, forty-one years later, the destructive power of a 15-kiloton bomb (equivalent to 15,000 tons of TNT) is dwarfed by weapons of megaton force (1 million tons of TNT). Although development of ever more destructive weapons continues, scientific examination of the effects of nuclear weapons upon the short- and long-term health of survivors, as well as upon the en- vironment, has lagged until very recently. In 1981, Paul Crutzen and John Birks calculated the effects on the Earth's atmosphere of large-scale fires that would result from a major nuclear ex- change. A subsequent series of analyses expanded on the concept of a mid- day twilight or "nuclear winter" that might follow in the weeks and months after a nuclear war. This led to a fundamental reassessment of postwar en- vironmental conditions, especially those affecting food production. The early 1980s also saw Me beginning of new efforts by physicians and by scientists from many disciplines and many nations to examine the indirect health-related . x'''

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XIV PREFACE effects of nuclear war, including intermediate-term consequences for survivors and effects on persons living far away from anticipated war zones. More comprehensive appraisals were produced of the catastrophic social, economic, and psychological sequelae of nuclear war. Scholars began anew to examine the psychosocial dimensions of nuclear arms competition, international con- flict, and the threat of nuclear war. The time seemed propitious, therefore, to convene an international group of scholars in the autumn of 1985 to review the medical implications of these and other new studies. In addition to considering the direct and indirect health effects of nuclear attack, these physicians and scientists were asked to examine the availability of medical resources and the psychological issues surrounding nuclear weapons and war. It was fitting that this conference was organized under the auspices of the Institute of Medicine in Washington, D.C. Since being chartered by the National Academy of Sciences in 1970, the Institute has devoted itself to examining developments in science, health care, and public policy that affect the health of the public. Indeed, it has asserted that nothing can have greater potential impact on health than a nuclear war. A statement adopted by the IOM membership in 1982 reflects that concern: "Nuclear war is the single event that could terminate all our efforts to improve the human condition. That possibility seems particularly ironic at a time when great strides are being made in alleviating human ills, and even greater ad- vances are in prospect.... The only preventive medicine we know that can avoid the medical consequences of nuclear war is to prevent nuclear war itself. " It is also fitting that this symposium occurred during Frederick Robbins's tenure as president of the Institute of Medicine. Dr. Robbins has long been concerned with the threat of nuclear war, and this symposium last fall was an appropriate tribute to his five years of leadership. In fact, the symposium has had the support and guidance of three Institute presidents. David Hamburg, who was Fred Robbins's predecessor, contributed in several ways to the success of the symposium-through the support of the Carnegie Corporation of New York, which he now heads, through his advice on the program as it was being developed, and through the extraordinary chapter that opens this book. Finally, Samuel Thier, the current president of the Institute, has directed the review and dissemination of the results of the symposium, including this volume. In his opening remarks to the conferees, Frank Press, president of the National Academy of Sciences and chairman of the National Research Coun- cil, emphasized the value of vigorous scientific debate on this topic: "The profundity of the consequences of nuclear war are such that symposia of this type-building up momentum for these issues and for public concern and disseminating the kind of information and knowledge that is generated at a conference like this are a most valuable public service."

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PREFACE XV Moreover, Dr. Press reminded the audience that, despite the level of internal government activities, many of the best ideas for the control of nuclear weap- ons and the best estimates of the consequences of nuclear war have come from scientists and scholars working outside official circles. Indeed, during that September weekend, more than 80 scientists from nine countries were joined by concerned members of the general public. Thirty papers were pre- sented which, after subsequent refinement, have become the contents of this volume. The authors come not only from government laboratories but also from private consulting firms, hospitals, and academia. In the months that have passed since the symposium, the failures of U.S. and European space launch vehicles and the accident at the Soviet nuclear power plant have dramatized an important point: there are difficulties inherent in the design, maintenance, and operation of complex fail-safe systems. The tragedies at Cape Canaveral and Chernobyl seem to underscore certain con- clusions in David Hamburg's opening chapter and in Part IV of this volume: namely, we cannot depend indefinitely upon technology, prudence, or good luck to safeguard mankind from the risk of nuclear war. In fact, it is argued, the hazards of nuclear weapons and modern strategic systems are so complex and permit so little margin for human error or misunderstanding in a time of crisis, that even the most sophisticated efforts of crisis management might fail us in a nuclear confrontation. In the long run, strategic military crises must be prevented from developing among the nuclear powers of the world, because neither human judgment nor technology can be relied upon to avoid nuclear war in the event of a prolonged and complex confrontation. This volume is divided into five parts. The first provides an overview of the physical and environmental effects of nuclear war, setting the stage for later sections that address the medical impact of various types of nuclear attack. Among the papers in Part I is a disturbing report by Theodore Postol from the Stanford Center for International Security and Anns Control. Based on the properties of modern nuclear weapons, he estimates that firestorms triggered by nuclear explosions would kill two to four times as many people in or near cities than have been predicted by standard government studies. Unlike Hiroshima and Nagasaki, where many of the survivors were able to walk out of the blast zones and seek help, contemporary weapons would produce vast "hurricanes of fire," making escape impossible over wide areas. Other contributors to Part I review the physics of large urban fires and update projections of nuclear winter. "Nuclear famine" is also described, drawing on the very recent work of SCOPE (The Scientific Committee on Problems of the Environment of the International Council of Scientific Unions). Because of the dependence of third-world countries on rice, wheat, and corn harvests, as well as on agricultural support from the world's superpowers, a nuclear attack that destroyed crop harvests and stockpiles and interrupted

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XVI PREFACE distribution systems might kill more people in noncombatant nations than in combatant ones. And new ecological concerns are raised for example, the toxicity of an environment laden with the by-products of burning plastics and other man-made materials. In Part II, the consequences of nuclear war are considered from a standpoint of deaths, injuries, and, especially, the health of survivors. In preparation for this symposium, a Princeton University research team developed the first detailed computer model outside the classified literature for calculating U.S. casualties from a nuclear war. This model was then used to examine the sensitivity of casualty estimates to various assumptions about nuclear weapons effects. The work indicates that if some heretofore standard assumptions are revised as proposed in several of the other papers in this volume (e.g., greater lethality of firestorms or of radiation exposure) a "limited" attack solely on strategic nuclear targets would kill tens of millions, a figure much greater than earlier government estimates. The Princeton group also dem- onstrates that it is virtually meaningless for military analysts to distinguish between attacks in which nuclear weapons are used on military-related in- dustries but not on civilian targets and attacks in which cities are targeted per se: the toll is nearly as great in either case because such industries are so frequently located within or adjacent to major population centers. Also in this section, physicians and scientists describe problems of triage and care of the injured survivors of nuclear war. They provide new estimates of the lethality of radiation exposure under wartime conditions, consider the effects of food shortages and malnutrition on the prospects for survival, and discuss the psychological consequences of surviving major disasters. Scien- tists from Norway and the Soviet Union offer estimates of the long-term genetic and carcinogenic effects of nuclear weapons use. In a provocative new synthesis, the combined effects of high levels of ionizing and ultraviolet radiation, burns and physical trauma, malnutrition, and psychological stress upon human immunology are examined; investigators from Brown University argue Mat these multiple insults would impair the cell-mediated immune capability of a great many survivors, making them likely to succumb to diseases such as pneumonia, tuberculosis, and cancer diseases that are prev- alent among today's victims of the virus-caused immune deficiency known as AIDS. Part III reviews the demand for medical resources after a nuclear attack and estimates the actual supply likely to be available. If a single one-megaton bomb were exploded over the city of Detroit, for example, it is calculated that survivors would need about forty times the number of burn beds currently available throughout the entire United States. They would also need twice the number of intensive care beds currently available, and the need for blood transfusions would exceed the existing supply many times over. A more

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PREFACE . ~ XV11 extensive nuclear exchange involving the United States, Europe, and the Soviet Union and its allies would wipe out most of the world's supply of pharmaceuticals, medical equipment, and food. Also in Part III, two social scientists offer an economic and social perspective on the consequences of nuclear war. Contributors to Part IV address the nuclear arms race from a psychosocial point of view: How does the threat of nuclear war affect the attitudes and behavior of adults and children? Studies provide evidence that many young children are worried about the possibility of nuclear war; most learn about nuclear war from television or the media and rarely discuss it with their parents. One study indicates that people in their late teens are somewhat less concerned than younger children; and surveys of adult attitudes consistently indicate that although most people believe a nuclear war has a moderate chance of occurring within their lifetime (and also believe they will not survive it), they take no action toward preventing it. The maintenance of hope and the denial of responsibility in the nuclear age are also discussed in Part IV. Furthermore, a review of the demands on managers of nuclear weapons systems leads to serious concern that there might be a breakdown of leadership in the case of a nuclear attack. The attitudes of world leaders toward war and power are examined, as is the history of decision-makers' behavior under the stress of international crises. Finally in this section is a call for improving the screening system used to select nuclear weapons handlers. Although psychological problems are sup- posedly discerned before candidates are chosen, a psychiatric interview for weapons handlers is not required, and more than 3,000 previously screened armed forces personnel are removed each year from weapons handling because of alcohol or drug abuse, mental disorders, and other psychosocial problems. Rounding out the book are remarks by Carl Sagan and Lynn Anspaugh, who offer contrasting viewpoints on the prospects for recovery from nuclear war and on the use of scientific information in policy-oriented discussions in this area. Many scientists, like Sagan, emphasize the importance of assuming "worst-case" analyses as the basis for policy discussions much as military planners assume worst-case scenarios in projecting defense needs while others agree with Anspaugh that the uncertainties in any discussions of the consequences of nuclear war are so numerous, and so fundamental, that they preclude the application of these studies to policy debates. There seems to be wide agreement that the biological and environmental effects of nuclear war are not fully understood and that our knowledge of these issues will continue to grow as research continues; however, compared with research expenditures on the physical aspects of nuclear weapons effects, biological, psychosocial, and ecological studies appear to be underfunded and late in starting.

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. . . XV111 PREFACE Herbert Abrams, a member of the symposium's steering committee, closes the volume with a powerful, personal summary of lessons to be learned from the Institute of Medicine's conference. The value of this symposium is, in large part, a credit to the steering committee, which worked many long, hard hours despite ongoing responsi- bilities at universities, hospitals, and research facilities. All the members of the committee, along with the authors of these chapters, share a deep com- mitment to the importance of this work and made many extraordinary efforts to make the symposium successful. Special recognition is due Marc Messing, who served as symposium coordinator, and the staff of the National Academy Press, which transformed the symposium papers into this attractive volume. It was our pleasure to work with them. The symposium could not have taken place nor could this volume have been published without the generous support of the Carnegie Corporation of New York. We also want to thank the National Research Council for its financial assistance. We believe that the papers presented here constitute the most comprehensive and authoritative review to date of health-related issues associated with modern nuclear weapons and the threat of nuclear war. Moreover, as a result of preparation for the symposium and interaction at the conference itself, new calculations and hypotheses emerged that are potentially of far-reaching im- portance. It is our hope that this volume will increase public understanding of the risks and consequences of nuclear war and will inspire scientific efforts and government actions designed to avoid such a catastrophe. Robert Q. Marston, M.D. Chairman Fredric Solomon, M.D. Project Director

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The Medical ImpIkellons of "V([~' -'

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