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The Medical Implications of Nuclear War, Institute of Medicine. ~ 1986 by the National Academy of Sciences. National Academy Press, Washington, D.C. Psychological Consequences of Disaster: Analogies for the Nuclear Case JAMES THOMPSON, PH.D. M'ddlesex Hospital, London, England INTRODUCTION No disaster experienced in recorded history resembles the potential destruction of major nuclear war. Nonetheless, past disasters can give us pointers to the likely responses of those who survive the immediate effects, though it will always be necessary to interpret the findings carefully with due allowance for the differences that restrict the applicability of the comparison. Localized disasters such as explosions and fires give a partial view of likely reactions, which, in the case of nuclear war, would be repeated across whole continents. Earthquakes and floods give a better understand- ing of large-scale and generalized destruction, though it is correspondingly more difficult to comprehensively evaluate how everyone reacted. All these disasters differ from the nuclear case in that there is always an undamaged outside world able to offer some help and assistance. Fur- thermore, the imponderable effects of radiation will impose a delay on rescue attempts, since most people will be unable to establish when it is safe to come out from what remains of their shelters. The electromagnetic pulse is likely to have severely damaged the communication networks on which all effective relief operations depend. Most of all, the probable extent of the physical destruction to civilization would be so extensive as to make unlikely any concerted rescue operation, even if it could be mounted. Most people would be concerned with their own survival, and 290

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PSYCHOLOGICAL CONSEQUENCES OF DISASTER 291 the illusion of centrality that is held by disaster victims would, for many, be more of a reality than an illusion. Classification of Disasters as Analogies for the Nuclear Case It is a matter of considerable relief that, as yet, there are no references to how people have reacted to a major nuclear war. Therefore, in order to provide some illustrative guidance, data about other catastrophes have had to be used as analogies for the nuclear case. Disaster Agents A descriptive system first put forward by Hewitt and Burton (1971), and later adapted by Leivesley (1979), can be used to divide disaster agents into five categories: Atmospheric: cyclone and hurricane, tornado, drought, snow, fire Hydrologic: flood, storm surge, Tsunami Geologic: earthquake, landslide, volcano Biologic: epidemics, crop diseases, and biological warfare Technologic: Accident (engineered structures, transport, chemicals, nu- clear reactors, nuclear weapons, nuclear weapons testing, radioactive ma- terials, fired, war (conventional bombing, nuclear weapons) Disasters can also be categorized by the extent of energy release, fre- quency of occurrence, and period of duration. An earthquake can last for a few seconds, an avalanche for a few minutes, a blizzard for several hours, a flood for days or even weeks, and a drought for months or even years. In general, the disasters that cause most casualties, earthquakes, floods, and cyclones, occur with the lowest frequencies. This means that such terrible events tend to be rare in most people's experience, and thus it is hard to learn how to predict them and protect people against their worst effects. The power of these natural events may also make it seem futile to take many protective steps. In a more general sense, there are a wide variety of hazards which may lead to disaster. The perception of these hazards has an important impact on whether precautionary steps are taken. Hazards can be classified into the following categories: Natural tornado, earthquake, flood Quasinatural air and water pollution

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292 Social-epidemic and riot Man-made building collapse, fire, car accident, boat accident HEALTH CONSEQUENCES OF NUCLEI We People's perceptions of hazard have been studied by factor analytic methods (Kales, et al., 1976), and it has been found that they can be organized into two factors. The first factor, which accounts for most of the variation in perceptions, is orderly, relaxed, and peaceful versus cha- otic, tense, and ferocious. The second factor is natural, uncontrollable, and fair versus artificial, controllable, and unfair. From this it will be evident that wars are seen as chaotic, tense, and ferocious and also arti- ficial, controllable, and unfair. Turning now from the disasters themselves to the impact that they have on humans, differences exist between the levels at which the response of victims to the disaster can be studied. Individuals can be studied, or the level of analysis could be raised to that of the family, the community, and society as a whole. Appropriateness of Analogies The problem with the approach by analogy is that no single disaster approximates all the features of a nuclear war. Although Hiroshima and Nagasaki represent the only examples of nuclear bombing, the weapons used there were very much smaller in their explosive power than those that are available today. The bombings occurred without any warning, the construction of housing was very different from that of modern European cities, and the population had no knowledge of nuclear explosions or radioactivity. In terms of psychological reactions, Japanese culture was very different from that of present-day Europe, with there being a high degree of group identification and respect for authority. Most of all, the surrounding areas were not under nuclear attack and were able and willing to give some assistance. Communications were maintained at a national level, so that radio and telegraph, roads, and railways in the surrounding countryside were all functioning. Despite this, the basic effect of the blast was the same. A modern nuclear war could involve the detonation of large numbers of far more powerful weapons, with or without any warning, over large sections of the Northern Hemisphere. Such a nuclear war might last hours, weeks, or months and the electromagnetic pulse could serve to disable most electronic communications. In terms of sheer physical destruction, earthquakes give an indication of the effects of massive blast damage, but not even these physical effects are really comparable. Depending on the intensity and waveform of the

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PSYCHOLOGICAL CONSEQUENCES OF DISASTER 293 quake, different types and degrees of damage occur, but they are different in form from blast damage. In some cases the tremors preceding the major event serve as a warning, particularly in areas where earthquakes have already been experienced by the population. Although earthquake damage can be widespread, radio communications are generally still possible and there is no fear of immediate contamination, as would be the case with radioactivity. Massive fires resemble the effects of postnuclear firestorms, but, once again, present data are based on the fact that there is an undamaged outside world to come to the assistance of those in the fire zone. Hurricanes and tornadoes replicate many features of blast damage, but they generally come with some warning and do not leave immediately contaminated ground. Floods cause widespread damage, generally come with some warning, and often lead to fears of health risks. Major epidemics leave the physical world undamaged, but they replicate the immense depletion of population that would follow a major nuclear war and come closest to revealing attitudes to radioactive contamination. Table 1 summarizes the major features of disasters as analogies for a major nuclear war and gives very rough, and highly debatable, estimates of impact for illustrative purposes only. It serves not so much to tie down each disaster into a rigid system of measurement, but simply to summarize some of their major features to make comparisons possible. ANALYSIS OF HUMAN REACTIONS TO DISASTERS Although past disasters are imperfect guides to the future, they must be studied if likely future reactions are to be understood. Leivesley (1979), in a study on disasters and welfare planning, gives over 400 references and Kinston and Rosser (1974) give 117. Quarantelli (1980) has worked extensively in this area, and Churcher et al. (1981) have reviewed the literature with reference to nuclear war. Kinston and Rosser (1974) re- viewed the psychological effects of disasters, which they define as situ- ations of massive, collective stress, in an attempt to draw some conclusions from the extensive but unsystematized literature on human reactions to catastrophes. They note that there has often been a reluctance to fully investigate these reactions, as if researchers were averting their eyes from what they found. It was 17 years before any attempt was made to study the psychological consequences of the bombings of Hiroshima and Na- gasaki. Even civil defense exercises set up to deal with simulated disasters fail to meet the pressing psychological needs of the supposed victims, and reveal an apparent unwillingness to confront the misery of personal trag- edy.

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PSYCHOLOGICAL CONSEQUENCES OF DISASTER 295 Even when prompt and effective treatment is available, as in the burns victims described by Cobb and Lindemann (1944), and despite excellent planning and precautions to minimize psychological stress, 43 percent of the survivors showed evidence of psychiatric illness. This indicates the pressing need to investigate as fully as possible how people react to disasters and to be aware of the psychological impairment which usually results. Despite a measure of reluctance to investigate the consequences of catastrophes, some features have been identified. Kinston and Rosser (1974) use a classification system based on the work of Tyhurst (1951) and Glass (1959), who categorize the phases of disaster as threat, warning, impact, recoil, and postimpact. Although these categories merely represent points along a continuum and describe average reactions which may not occur in all people, they help us understand the course of events. Threat All life is subject to potential hazards, but some hazards are more evident and dangerous than others. Earthquake belts, volcanic slopes, war zones, and floodplains all carry particular risks. In terms of the risk of nuclear war, countries that themselves deploy nuclear weapons are especially at risk, and within those countries missile bases and possibly urban centers are likely targets. The evaluation of risk is a problematic subject, involving subjective estimates and attempts at calculated probabilities. Slovic and Fischoff (1980) have looked at public perceptions of a variety of hazards and have shown that perceived risks are often at variance with actual risks. These differences may be partly accounted for by the prom- inence that the media gives to dramatic events, thus increasing their sa- lience over less newsworthy occurrences. But Slovic et al. (1982) have shown that when both experts and members of the public are asked to rate hazards by other perceived characteristics such as whether the risk is voluntary and what the extent of catastrophic potential might be, much of the difference between the two groups disappears. Threat is the condition under which we live at present. It is evident that a pressing danger exists, but the perceived salience of the threat varies from person to person and from time to time. Chivian (1983) has reviewed children's sense of nuclear threat, and argues that this is more widespread and substantial than generally realized. Escalona (1963, 1965, 1982) has extensively studied children's and adolescents' fears about nuclear war, which she feels threatens their belief in the future and the trustworthiness of their parents. Schwebel (1982) suggests that the nuclear threat is a contributing factor in anxiety and other disorders noted among teenagers.

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296 HEALTH CONSEQUENCES OF NUCLEAR WAR Beardslee and Mack (1982) conclude that children are deeply disturbed by the threat of nuclear war and have doubts about their own survival. In the United Kingdom, 52 percent of teenagers feel that nuclear war will occur in their lifetime, and 70 percent feel that it is inevitable one day (Business Decisions, 19831. Tizard (1984) reviewed the literature on chil- dren's fears about nuclear war. She found that many of the studies were unsystematic, but that methodologically sound studies, which had asked large representative samples of graduating high school students in the United States neutral questions about the future, found increasing levels of alarm about the nuclear threat. Bachman (1984), in a study of the sort described above, found that the proportion of adolescents who often wor- ried about the nuclear threat rose from 7 percent in 1976 to 31 percent in 1982, and the feeling that nuclear or biological annihilation would occur in their lifetimes rose from 23 percent in 1976 to 35 percent in 1982. Solantous et al. (1984), in a survey of 5,000 Finnish 12- to 18-year- olds, found that even in this nonnuclear, neutral country, 79 percent of the 12-year-olds and 48 percent of the 18-year-olds named a probable future war as their major fear. Adults share this concern and show a general perception that they are at risk because of nuclear weapons, though this is rarely stated as the most pressing worry people face. A 1982 Gallup Poll found that 72 percent of an adult sample was worried about nuclear war, and 38 percent thought that nuclear war would occur. In general, there is no consistent relationship between such anxieties and attitudes to nuclear weapons policies. Despite evidence of anxiety in many people, the most consistent reaction appears to be some form of denial, which Lifton (1967) describes as "consistent human adaptation." Some people avoid the subject totally. Other reactions are resignation, helplessness (Seligman, 1975), fatalism, and unquestioning trust. The myth of personal invulnerability, that necessary fiction of everyday life, holds strong and allows people to continue the necessary tasks of living. All authority tends to be displaced onto leaders and authorities, and people tend to feel helpless and unable to influence events through their actions. Warnings To understand the way that people respond to warnings of impending catastrophes, it is necessary to review the accounts that have been given of those disasters in which warnings were possible. A few points must be considered about the relationships among warnings, stress, and behavior. For a warning to be effective it must have a reliable association with the threat, and there must be a credible action to take in response to it.

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PSYCHOLOGICAL CONSEQUENCES OF DISASTER 297 However, humans have considerable shortcomings as estimators of the probabilities of future hazards (Slovic et al., 1974; Kahneman et al., 1982~. Even when a hazard is acknowledged, people may perceive it in many different ways, seeing it as improbable or, on the other hand, so inevitable as to vitiate any human actions. Research on responses to stressors indicates that appraisal of threat is a psychological process, and knowledge about a stressor tends to improve coping responses in any situation in which coping responses are possible. In general, having something to do that reduces the threat, or even simply appears to do so, reduces the impact of stressors. In studies of experimental stress on animals, the least affected groups are those that receive warnings of impending shocks and can reduce the probability of receiving them by carrying out avoidance behaviors, however onerous. The groups that suffer most stress, as measured by the rate of stomach ulceration, are those that suffer an equal number of shocks without benefit of warning and cannot reduce their frequency by any instrumental means (Weiss, 1973~. Without a warning these animals can never relax, since they have no safety signal and could experience a shock at any time. A reliable warning, on the other hand, does cause temporary high levels of anxiety, but once the danger is over, safety can be assumed by the absence of danger warnings. Such helpless animals suffer considerably, and their helpless behavior has many similarities to human depression (Seligman, 1975), which is char- acterized by a failure to initiate responses, even when these might lead to the avoidance of further stresses. The safety signal hypothesis should explain why the conventional bombing attacks on London appeared to cause less psychological stress than those of the V-bombs later in the war. In the first case the air raid sirens and the eventual all clear provided reasonably reliable signals of safety, but with the rockets no such indication was possible. Studies of Disaster Warnings Simply because a warning has been given does not mean that it will be heeded. Denial can continue in some individuals up to the moment of impact itself. During the Hawaiian tidal wave of May 1960, evacuation was minimal (Lachman et al., 19611; and on the banks of the Rio Grande, festive crowds watched and cheered the rising floodwaters (Wolfenstein, 1957~. These active denials of danger have their place in everyday life, but when they are carried over in the face of a real threat, they constitute a danger in themselves, since they obstruct preventative action. The myth of personal invulnerability still holds. A measure of this delusion can be gauged by the finding that the majority of people believe that they are

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298 HEALTH CONSEQUENCES OF NUCLEAR WAR more likely than average to live past 80 years of age (Britten, 19831. Once the danger is admitted, people who are very trusting may overrely on official pronouncements. Those who lack faith in parental establishment figures may be susceptible to rumor. Precautionary activity depends on the adequacy of information as to what needs to be done and whether a group effect begins to take place once people take the warning seriously. Conflicting advice is usual (Churcher et al., 1981), and many people may be unable to decide on a consistent response. Some studies have looked at the warning process in detail, and these will be considered as analogies for likely reactions to warnings of an attack with nuclear weapons. Short Warning Times Drabek and Stephenson (1971) have given a detailed account of the behavior of 278 families randomly selected from approximately 3,700 families who had been evacuated from their homes prior to a flood in Denver, Colorado. At 5:30 p.m. one cloudy afternoon, in which there had been occasional showers throughout much of the day, police cars cruised past suburban houses with the following announcement: "A 20- foot wall of water is approaching this area. You have 5 to 15 minutes to evacuate. Leave for high ground immediately." The events leading to this announcement need a brief summary. After a tornado earlier in the day, a wall of water was seen sweeping down one of the tributaries of the South Platte River, which flows through Denver. The local sheriff raised the alarm at 3 p.m., and this was received with some incredulity, since a major flood had not occurred on the river for 100 years. By 4 p.m. police began evacuating those closest to the river, and by 5 p.m. they broadened the area of evacuation. Throughout the warning period radio and television responded in a sporadic fashion. Some stations carried on with normal programs, while others gradually shifted to increased flood coverage. This led many people to switch from one station to another in an attempt to confirm conflicting stories which seemed impossible to believe. The wide area of television coverage meant that people in safe areas converged on the danger zone to contact friends and relatives or, in the largest number of cases, simply because of curiosity. From the viewpoint of the families in the danger area, their many attempts to confirm the warnings frequently yielded contradictory information, and of those who evacuated immediately, as many as one-third returned home, often infiltrating through police lines which had been set up to prevent looting. At 8:15 p.m. the floodwaters arrived, causing considerable dam- age but no loss of life because of the evacuation.

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PSYCHOLOGY CONSEQUENCES OF DISASTER 299 Drabek and Stephenson argue that five analytical characteristics are especially important. In contrast to more typical slowly developing floods this one was (1) sudden, (2) unexpected, (3) unfamiliar to the populace, and (4) highly localized in its danger area; and (5) warnings were received in quite varied social contexts. Response to warnings suggests that individual responses are affected greatly by group memberships, with the most important being the family unit. Most people responded to the flood as family members, not as isolated individuals; and of those families that were together at the time of warning, 92 percent evacuated together. When family members were separated at the time of the initial warnings, which happened for 41 percent of the total sample, their immediate concerns were making contact with each other. Although 52 percent received their warnings from mass media (as op- posed to 28 percent from peers and relatives and 19 percent directly from the authorities) these people were far more likely to ignore the message or spend time attempting to confirm it than those who got more direct warnings. For example, see the results in Table 2. Although mass media sources often urged evacuation of very specific areas, these warnings tended to be viewed as background information, while a direct request from the authorities was far more likely to get people moving. Mass media seemed to generate the behavior of further infor- mation seeking-people stayed "glued" to their sets rather than leave as advised. Mass media and peer recommendations to evacuate were received with skepticism by 60 percent of respondents, but when the authorities were the source, such skepticism occulted in only 22 percent of cases. Even in this case one police officer recounted an experience in which a woman casually approached the car from which he was broadcasting the evacuation TABLE 2 Response of Denver Residents to Flood Warnings Attempted Continued Routine Confirmation Evacuated Message Content Activity (percent) (percent) (percent) "Some areas flooding or evacuating" 36 38 26 "River rising" 38 33 29 "Flood water coming down River Platte" 29 25 46 "Evacuate" 22 18 60 SOURCE: Drabek and Stephenson (1971:Table 2).

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300 HEALTH CONSEQUENCES OF NUCLEAR WAR warning over a loudspeaker and calmly asked "What theater is it at?" Several exchanges were required before the woman was willing to accept that it was not a publicity stunt. The overwhelming bias was to interpret the warnings as nonthreatening and then search for other clues with which to discount or confirm them. Rather than being sterile receptacles of news, people actively worked on what they had been told, and even when they came to accept that a flood was imminent, they still maintained a feeling of personal invulnerability and thought that their own house would not be hit. Another study of short warning times, in this case of about 1.5 hours, was conducted by Hodler (1982), who surveyed residents in the path of a tornado which had passed through Kalamazoo, Michigan, killing 5 people, injuring 79, and leaving 1,200 homeless. The storm had first been spotted and tracked at 2:30 p.m. and was routinely handled by the mass media, which at 3:45 issued a severe thunderstorm warning. A tornado was seen 15 miles to the west of the city, and the civil defense sirens sounded at 3:56, with the mass media by that time making near continuous emergency broadcasts. By 4:10 the tornado struck. A random sample led to 263 personal half-hour interviews. Two-thirds of the subjects had heard the warning sirens, but 17 percent of those did not know what they meant. Safety was sought by 48 percent, the warnings were disregarded by 18 percent, and 22 percent tried to confirm the warning by looking outside or turning on their radios and televisions. This means that in total 40 percent did not try to evacuate. Michigan had experienced 306 tornados between 1953 and 1975, so this lethargic response was not based on Ignorance. Longer Warning Times Perry et al. ~ 1982) investigated the level of perceived risk, the warnings received, and the extent to which these were believed by residents near the Mount St. Helens volcano about 16 days after moderate earthquakes indicated that it had come to the end of a 123-year dormant period. At the time when the telephone survey started on a sample of 173 respondents, a state of emergency had been declared for the surrounding area, and when data collection was completed two days later, the news media re- ported that the immediate crisis was over. The study thus affords a quick look at a crucial phase in the disaster warning process. Residents monitored news media avidly, with a majority of 55 percent even hearing four or more volcano reports per day, while only 10 percent heard only one per day. Television was the most common source of news at 98 percent, with newspapers at 91 percent and radios at 87 percent following close behind. Interpersonal contact was a somewhat less frequent source, though 70

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306 HEaLTH CONSEQUENCES OF NUCLEAR WAR need to work through the events in order to give them some meaning. The need for explanation is part of dependency and leads to rumor and absurd gullibility. People will be anxious to obtain reliable news, and will expect their own experiences to be news. The monitoring of the news serves as an attempt to reconstruct a comprehensible set of explanations and to reduce the uncertainty brought about by uncontrollability. For example, following the assassination of President Kennedy the average U.S. adult spent ~ hours per day for the next 4 days listening to the radio or watching television, behavior which Janis (1971) interpreted as an attempt to work through the cultural damage. In this dependent and vul- nerable state, chance factors can have a disproportionate effect on the interpretation of the event and the view as to what must be done in the future. Scapegoats may need to be found, and chance may provide them. Scientists, militarists, and politicians may escape initial attention, while those involved in bringing relief may be the target of frustration and feelings of betrayal (Lacey, 1972~. Once the immediate danger is past, some survivors will begin to take steps to cope with the consequences. Even as the warning of danger is announced people will find themselves in conflicting roles. They will have to decide whether they should continue with their jobs, take up civic and emergency duties, or return to look after their families. Killian (1952) found that conflicting group loyalties and contradictory roles were sig- nificant factors affecting individual behavior in critical situations. Typi- cally, it is the person without family ties who leads rescue work, while the others generally run to their homes to discover if their families are in danger. Even so, Killian reported that some who were searching for their families, after a tornado had struck, were capable of helping others they found on the way. Those whose occupational roles bore little relationship to the needs created by the disaster, such as shopkeepers, disregarded their jobs more easily and came to the assistance of the community. Faced with an overwhelming catastrophe, family bonds are likely to predominate over civic duties, because everyday tasks and responsibilities will be seen as irrelevant and futile by most people. It should be noted that natural disasters generally come without warning, and rarely require emergency workers to leave their families unprotected while moving them- seIves to places of relative safety, as would apparently be required of them in the event of nuclear war. Postimpact Gradually, individual reactions become coordinated into an organized social response. The form this will take depends very much on cultural

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PSYCHOLOGICAL CONSEQUENCES OF DISASTER 307 norms. Many of the victims will be coping with the consequences of loss and bereavement. This will diminish their capacity to interact socially in a productive manner. Victims need some form of acknowledgment of their suffering, but social norms may deny them the right to express their grief and hopelessness. Fear and apprehension persist, and many may feel that the catastrophe will recur. Aftershocks of an earthquake commonly cause more fear than the initial shock itself. People develop a conditioned fear response, and their capacity to maintain control of their emotions is di- minished. Disaster persists as a tormenting memory, and is relived again and again. CONVENTIONAL BOMBING Although conventional bombing campaigns involve far less explosive power and far longer time courses than would be likely to be the case in a nuclear war, they should be given some attention for two main reasons. First, the mass raids on cities in some instances approach the extent of destruction caused by small nuclear weapons. Second, facts and fictions about the Blitz influence both popular and official perceptions of the way Londoners would react to a future bombing campaign. Many accounts have been given of World War II bombing raids (Titmus, 1950; Ilke, 1958; Janis, 1951; Harrison, 1978), and in this instance, it would be most informative to collate data from many different sources to highlight the common features that have emerged. Preparations The Blitz raids were preceded by a long period of international tension, which gave the public and the authorities time to make practical and psychological preparations. The previous data on urban bombing were sparse, and the predictions were that there would be massive casualties and considerable panic, and that if deep shelters were provided this would lead to a shelter mentality in which people would refuse to come out to work. As a projection of the reports from Guernica, Spain, this was an understandable view, as was the overriding fear of a gas attack. The very long conditioning period of the phony war served to give the population time to develop coping responses. Duties were allocated which served to give key community members an important role in air raid preparations, thus providing them with something to do and setting a coping example for others to follow.

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308 HEALTH CONSEQUENCES OF NUCr;FAR WAR Effects When the bombing began, however, social cohesion and morale broke down very quickly in the worst-affected areas, though censorship ensured that this was not widely known at the time. Badly damaged zones had to be cordoned off by the police, and emergency services were unable to cope. All this occurred despite the fact that there was warning of attack and pauses between attacks and that 1.5 million women and children had been evacuated. The fact that the bombing could not be maintained without pause gave the population time to make some adjustments, and the for- tuitous fact that a bomb fell near Buckingham Palace while the East End was receiving the brunt of the attack defused an explosive social divide and made Londoners fee} that they were all in it together. The shelter policy resulted in fewer casualties than had been calculated, but the extent of damage to housing and infrastructure had been severely underestimated, as had been the problems of dealing with large numbers of displaced homeless people. Nearly a quarter of a million homes were damaged beyond repair, while 3.5 million suffered repairable damage, though these losses could not be made good during the war period. Emergency services adapted to the new demands, but in many areas of London fires raged uncontrollably. The authorities had prepared for massive casualties and panic. Instead they got a dazed but functioning population that required food, clean water, shelter, and new forms of social organization. Titmus (1950) observed: "The authorities knew little about the homeless who in turn knew less about the authorities." The speed with which the large number of people in a dazed and bewildered condition could be organized and rehabilitated determined the rate at which the damage could be repaired, production returned to full capacity, and further demoralization in surrounding areas avoided. What was needed, the observers of that time agreed, was a "much more powerful and imaginative organization" to deal with "the purely psychological and social effects of violent air attack" (mass observation of 1940, cited in Harrison, 1978~. This organization should have brought a wave of social help, hot tea, and sympathy to snatch people out of their introversion and to link them up again with the outside world. The impact of World War II bombing on the United Kingdom population was twofold. First, there were the direct casualties (about 60,000 deaths plus injuries); but second, and more numerous, were those who suffered disruption and loss because of damage to the structure of society itself. Children and old people suffered disproportionately through neglect, such that their wartime mortality figures were elevated and accounted for an- other 6,000 deaths through indirect effects.

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PSYCHOLOGICAL CONSEQUENCES OF DISASTER 309 The raid on Coventry on the night of November 14-15, 1940, caused such damage to the infrastructure of that city that in the aftermath there was close to being a breakdown of social organization. Food had to be brought in from Birmingham and Stoke on Trent, and entry into the damaged areas was prevented by armed troops. In the Southampton raids, large sectors of the population ignored official instructions and began "recking, moving out into the country and sleeping in hedges during the night, and then some of them trecked back in to work the next day. The stresses of long periods of deprivation and un- certainty caused deep rifts in society that were also noted in Japan and Germany during the air war. Toward the end of the war the V-bomb campaign imposed new stresses on London's population, and this was particularly the case for the V2 rocket, which fell without warning. Stress levels were very high, and a new evacuation began again. No all clear was ever possible until the launch bases themselves were destroyed. The raids on Hamburg in 1943 caused heavy casualties and mass evac- uation. Only because of the evacuation were there sufficient undamaged houses (only about 50 percent of the housing stock remained) for the very much smaller population that returned to the city to live in cramped quarters. Summary The findings from conventional bombing offer only a very partial view of reactions to nuclear war. The power of nuclear weapons is so great that massive destruction can be caused virtually without warning on a society which is now even more interdependent and tightly coupled as an industrial system. It is thus more fragile and will have to absorb more damage without time to recover. However, conventional bombing does provide an analogy. The aftermath of a major nuclear war would be like Coventry trying to get help from Hamburg, while Dresden seeks help from both. NUCLEAR BOMBING: HIROSHIMA AND NAGASAKI The bombings of Hiroshima and Nagasaki offer a partial view of the effects of a potential future nuclear war. The weapons were very small by present-day standards, the culture and the era were different, and there was neither warning nor any knowledge of radiation. The Hiroshima bomb, at about He equivalent of 12,500 tons of TNT, would now be regarded as a small battlefield weapon or merely as the detonator of a 1-megaton

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310 HEALTH CONSEQUENCES OF NUCLEAR WAR strategic bomb. However, these bombings are still the closest examples of what would occur in a contemporary nuclear war, with larger explosions occurring on a potential 18,500 strategic targets (SIPRI, 19841. Considering the importance of these events for our era, the bombings of Hiroshima and Nagasaki have been underreported. Some accounts have been repeated often, but much of the film material collected at the time has only recently been released, and the work done with the survivors was incomplete and often exaggeratedly technical, avoiding personal ac- counts and bypassing a mass readership. The account here is taken from Thompson (1985~. Lifton (1967) picked 33 survivors at random from lists kept by local Hiroshima research institutes, plus 42 survivors who were particularly articulate or prominent with regard to the atom bomb. A structured in- terview explored the individual's recollection of the original experience and its meaning in the present, as well as residual concerns and fears, and the meaning of his or her identity as a survivor. No account can hope to capture what the survivors experienced. They were submitted without warning to an explosion so vast that it seemed that the world itself was coming to an end. At 8:15 a.m. on August 6, 1945, most people in Hiroshima were in a relaxed state, since the all clear had just sounded. Few people could recall their initial perceptions. Some saw the pika a flash of light or felt a wave of heat, and some heard the don-the thunder of the explosion depending on where they were at the moment of impact. Everyone assumed that a bomb had fallen out of a clear sky directly on them, and they were suddenly and absolutely shifted from normal existence to an overwhelming encounter with death, a theme which stayed with each survivor indefinitely (Lifton, 1963~. Those far from the city were shocked to see that Hiroshima had ceased to exist. A young university professor, 2,500 meters from the hypocenter at the time, summed up those feelings of weird, awesome unreality in a fre- quently expressed image of hell: Everything I saw made a deep impression-a park nearby covered with dead bodies waiting to be cremated . . . very badly injured people evacuated in my direction . . . Perhaps the most impressive thing I saw were girls, very young girls, not only with their clothes torn off but their skin peeled off as well . . . My immediate thought was that this was like the hell I had always read about. . . . I had never seen anything which resembled it before, but I thought that should there be a hell, this was it. In Nagasaki a young doctor Akizuki (1981) was preparing to treat a patient when the atom bomb exploded. After pulling himself from the debris of his Urakami hospital consulting room, he was eventually able to look out of where the window had been to the world outside.

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PSYCHOLOGICAL CONSEQUENCES OF DISASTER 311 The sky was dark as pitch, covered with dense clouds of smoke; under that blackness, over the earth, hung a yellow-brown fog. Gradually the veiled ground became visible, and the view beyond rooted me to the spot with horror. All the buildings I could see were on fire.... Electricity poles were wrapped in flame like so many pieces of kindling. Trees on the near-by hills were smoking, as were the leaves of sweet potatoes in the fields. To say that everything burned is not enough. The sky was dark, the ground was scarlet, and in between hung clouds of yellowish smoke. Three kinds of color black, yellow and scarlet- loomed ominously over the people, who ran about like so many ants seeking to escape. What had happened? Urakami hospital had not been bombed I understood that much. But that ocean of fire, that sky of smoke! It seemed like the end of the world (Akizuki, 1981~. After encountering so much horror, survivors found that they were incapable of emotion. They behaved mechanically, felt emotionally numb, and at the same time knew they were partly trying to pretend to be unaffected in a vain attempt to protect themselves from the trauma of what they were witnessing. I went to look for my family. Somehow I became a pitiless person, because if I had pity I would not have been able to walk through the city, to walk over those dead bodies. The most impressive thing was the expression in people's eyes bodies badly injured which had turned black their eyes looking for someone to come and help them. They looked at me and knew I was stronger than they.... I was looking for my family and looking carefully at everyone I met to see if he or she was a family member but the eyes the emptiness the helpless expres- sion-were something I will never forget (Lifton, 19631. A businessman who had hastily semirepaired his son's shoe before he went to work in the city center was overcome with guilt that this same shoe had- prevented his child from fleeing the fire. The man fruitlessly searched for his child's body and was left in a state of perpetual self- accusation. Most survivors focused on one ultimate horror which had left them with a profound sense of pity, guilt, or shame. A baby still half-alive on his dead mother's breast, loved ones abandoned in the fire, pathetic requests for help which had to be ignored- each survivor earned a burning mem- ory. In Nagasaki, Akizuki was swamped by burnt survivors clamoring for water and medical attention. Half naked or stark naked, they walked with strange, slow steps, groaning from deep inside themselves as if they had travailed from the depths of hell. They looked whitish; their faces were like masks. I felt as if I were dreaming, watching pallid ghosts processing slowly in one direction as in a dream I had once dreamt in my childhood.

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312 HEALTH CONSEQUENCES OF NUCLEAR WAR Severely injured people cried out for help. Parents refused to leave dead children, still requesting that they be attended by the doctor. Passing planes caused panic, and victims tried to hide till they passed. Most survivors had witnessed terrible scenes, piles of dead bodies heaped up in streams, mothers and children locked in each other's arms, a mother and her fetus still connected by its umbilical cord, all dead (Akizuki, 1981~. These survivors were so profoundly affected by what they had expe- rienced that all aspects of their subsequent lives were marked by it, and they felt that they had come into contact with death but remained alive. Survivors attempt to make sense of the fact that they have survived while others have perished. Unable to accept that this was a chance occurrence, survivors are convinced that their survival was made possible by the deaths of others, and this conviction caused them terrible guilt. Guilt and shame developed very quickly in Hiroshima survivors, as it did in those who escaped concentration camps, and in both cases it has been intense and persistent. Lifton set out the train of thought of Hiroshima survivors thus: I was almost dead . . . I should have died . . . I did die or at least am not alive . . . or if I am alive it is impure of me to be so . . . anything which I do which affirms life is also impure and an insult to the dead who alone are pure . . . and by living as if dead, I take the place of the dead and give them life. This is the painful accommodation that the Holocaust survivor makes to the joyless fact of having survived. It is grief made the more keen by there being no bodies to be buried and mourned, nor any familiar land- marks to show that life continues, and thus aid the adjustment to loss. Person, body, house, street, city, and even nature itself have been con- sumed. Summary Although proper follow-up studies of psychological effects do not ap- pear to have been done, psychotic disorder is uncommon; but depression and anxiety about cancer; fears of death and dying; and generalized com- plaints of fatigue, dizziness, irritability, and difficulty in coping are usual. This pattern is similar to that found after major civil disturbances and can be conceptualized as an understandable concentration of the attention on possible danger signals to the exclusion of long-term plans. The absence of proper follow-up studies is itself a psychological phenomenon worthy of note, since it suggests that the scientific community itself averted its eyes from the long-term consequences of the disaster. In Lifton's view the experience of the atomic bombings differed from other disasters in that it plunged the survivors into an interminable and

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PSYCHOLOGICAL CONSEQUENCES OF DISASTER 313 unresolvable encounter win death. The immediate horrifying carnage was followed by long-term delayed effects, thus breaking He myth of personal invulnerability in a permanent way. In experiential terms, every victim saw his secure sunlit world destroyed in an instant. It felt like the end of the world, not just the end of one city. It is not hard to understand why they should disgust the apparent "all clear." REFERENCES AND BIBLIOGRAPHY Akizuki, T. 1981. Nagasaki 1945. London: Quartet. Anderson, C. R. 1977. Locus of control, coping behaviours, and performance in a stress setting: A longitudinal study. J. Appl. Psychol. 62(4):446-451. Anderson, E. W. 1942. Psychiatric syndrome following blast. J. Mental Sci. 88:328. Anderson, W. A. 1969. Disaster warning and communication processes in two commu- nities. J. Comm. 19(2):92-104. Bachman, G. G. 1984. How American high school seniors view the military: 1976-1982. Armed Forces and Society 10(1):86-94. Baker, E. J., J. C. Brigham, J. A. Paredes, and D. D. Smith. 1976. The Social Impact of Hurricane Eloise on Panama City. Tallahassee, Florida: The Florida State University. Baum, A., R. Fleming, and J. E. Singer. 1983. Coping with victimization by technological disaster. J. Social Issues 39(2):117-138. Beardslee, W., and J. Mack. 1982. The impact on children and adolescents of nuclear developments. American Psychiatric Association Task Force Report No. 20. Pp. 64-93 in Psychosocial Aspects of Nuclear Developments. Washington, D.C.: American Psy- chiatric Association. Britten, S. 1983. The Invisible Event: An Assessment of the Risk of Accidental or Un- authorized Detonation of Nuclear Weapons and of War by Miscalculation. London: Menard Press. Business Decisions. 1983. Nuclear Weapons Study Summary Report, Survey conducted for the TV Times. Chivian, E. 1983. Adverse effects on children. Pp. 105-118 in S. Farrow, and A. Chown, eds., The Human Cost of Nuclear War. Medical Campaign against Nuclear War. Cardiff, England: Titan Press. Churcher, J., J. Gleisner, E. Lieven, and R. Pushkin. 1981. Nuclear war and civil defence: some psychological and social implications. Paper presented at British Psychological Society Annual Conference. Churcher, J., and E. Lieven. 1983. Images of nuclear war and the public in British civil defence. J. Social Issues 39:117. Cobb, S., and E. Lindemann. 1944. Neuropsychiatric observations during the Cocoanut Grove fire. Ann. Surg. 117:814. Cutter, S., and K. Barnes. 1982. Evacuation behaviour and Three-Mile Island. Disasters 6(2): 116-124. Dawes, R. M. 1980. Social dilemmas. Annul Rev. Psychol. 31:169-193. Drabek, T., and J. Stephenson. 1971. When disaster strikes. J. Appl. Social Psychol. 1(2): 187-203. Drabek, T. E., W. H. Key, P. E. Erikson, and J. L. Crowe. 1975. The impact of disaster on kin relationships. J. Marriage & The Family 37(3):481-494. Escalona, S. K. 1963. Children's responses to the nuclear war threat. Children 10:137- 142.

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314 HEALTH CONSEQUENCES OF NUCLEAR WAR Escalona, S. K. 1965. Children and the threat of nuclear war. In M. Schwebe, ea., Be- havioural Science and Human Survival. California: Behavioral Science Press. Escalona, S. K. 1982. Growing up with the threat of nuclear war: Some indirect effects on personality development. Am. J. Orthopsych. 52:600-607. Fischoff, B., P. Slovic, and S. Lichtenstein. 1978. Fault trees: Sensitivity of estimated failure probabilities to problem representation. J. Exp. Psychol. Human Percep. Perform. 4:342-355. Glass, A. J. 1959. Psychological aspects of disaster. J. Am. Med. Assoc. 171:222. Greene, M. R., R. W. Perry, and M. K. Lindell. 1981. The March 1980 eruptions of Mt. St. Helens: Citizen perceptions of volcano threat. Disasters 5(1):49-66. Greenson, R., and T. Mintz. 1972. California Earthquake 1971: Some psychoanalytic observations. Int. J. Psychoanalyt. Psychother. 1(2):7-23. Gunter, B., and M. Wober. 1982. Television viewing and public perceptions of hazards to life. Report of the Independent Broadcasting Authority. Haas, J. E. 1978. The Philippine earthquake and tsunami disaster: A reexamination of behavioural propositions. Disasters 2(1):3- 11. Halpern, E., and H. Schleifer. 1978. Volunteer deployment during community crisis: A view within Caplan's concept of support systems. Crisis Intervention 9(1):2-11. Hansson, R. O., D. Noulles, and S. J. Bellovich. 1982. Knowledge, warning and stress: A study of comparative roles in an urban floodplain. Environ. Behav. 14(2):171-185. Harrison, T. 1978. Living Through the Blitz. London: Penguin. Hewitt, K., and I. Burton. 1971. The Hazardousness of a Place: A Regional Ecolo~v of Damaging Events. Toronto: University of Toronto Press. ~ ~11__ ~Car ~ Ins ~ . ~,! _- Boater, -I. w. CYST. Residents' preparedness and response to the Kalamazoo tornado. Disasters 6(1):44-49. Ilke, F. C. 1958. The Social Impact of Bomb Destruction. Norman, Okla.: University of Oklahoma Press. Jackson, E. L. 1981. Response to earthquake hazard: The west coast of North America. Environ. Behav. 13(4):387-416. Janis, I. 1951. Air War and Emotional Stress. New York: McGraw-Hill. Janis, I., and L. Mann. 1977. Emergency decision making: A theoretical analysis of responses to disaster warnings. J. Human Stress 3(2):35-48. Janis, I. L. 1971. Stress and Frustration. New York: Harcourt Brace. Kahneman, D., P. Slovic, and A. Tversky. 1982. Judgement under Uncertainty: Heuristics and Biases. Cambridge: Cambridge University Press. Kates, R. W. 1976. Experiencing the Environment, S. Wapner, S. B. Cohen, and B. Kaplan, eds. New York: Plenum Press. Killian, L. M. 1952. The .cismi~tonn~.~. of m''ltinlP arn''n mPmhPr`:hin in ~iCOci^- Am Sociol. 57(4):310. Do ^r-- sir ^ ~ ~ At. ~111. J. Kinston, W., and R. Rosser. 1974. Disaster: Effects on mental and physical state. J. Psychosomat. Res. 18:437-456. Lacey, G. N. 1972. Observations on Abervan. J. Psychosomat. Res.` 16:257. Lachman, R., M. Tatsuoka, and W. J. Bank. 1961. Human behaviour during the tsunami of May 1960. Science 133: 1405. Laube, J. 1973. Psychological reactions of nurses in disaster. Nursing Research 22(4):343- 347. Leivesley, S. 1977. Toowoomba: Victims and helpers in an Australian hailstorm disaster. Disasters 1(3):205-216. Leivesley, S. 1979. A study of disasters and the welfare planning response in Australia and the UK. Unpublished Ph.D. thesis, University of London.

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316 HEALTH CONSEQUENCES OF NUCLEAR WAR Thompson, J. 1985. Psychological Aspects of Nuclear War. Chichester, England: British Psychological Society and John Wiley and Sons. Tichener, J., and F. Kapp. 1976. Family and character change at Buffalo Creek. Am. J. Psych. 133(3):295-299. Titmus, R. M. 1950. Problems of Social Policy. London: Longmans Green. Tizard, B. 1984. The impact of the nuclear threat on child development: Problematic issues. Harvard Ed. Rev. 54(3):271-281. Tversky, A., and D. Kahneman. 1974. Judgement under uncertainty: Heuristics and biases. Science 185:1124-1131. Tyhurst, J. S. 1951. Individual reactions to community disaster. Am. J. Psych. 107:764. Wallace, A. F. 1956. Tornado in Worcester. National Academy of Sciences Disaster Study No. 3, Washington, D.C. Weiss, J. 1973. Effects of coping behavior in different warning signal conditions on stress pathology in rats. J. Compar. Physiol. Psychol. 77(1):1-13. Wolfenstein, M. 1957. Disaster: A Psychological Essay. London: Routledge and Kegan Paul.