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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. Medical Supply and Demand in a Post-Nuclear-War Worlds HERBERT L. ABRAMS, M.D. Stanford University, Stanford, California Any analysis of our capacity to survive a nuclear war must view the medical problems that survivors will confronts in the context of the health care system's capacity to provide a meaningful response. A system has been defined as a group of diverse units combined to form an integral whole and to function in unison, usually under some form of control. The health care system is surely one of the most complex aggregations of people and things that characterize modern society. Its annual cost of greater than $300 billion is equivalent to that of the entire U.S. Defense Department. In England, it is the largest single employer of labor. The problems of medical supply and demand in the post-nuclear-war world are too numerous and too complex to be dealt with fully here. Instead, this analysis will focus on the most acute needs of the injured population and the most obvious tools of the medical profession those without which it could not begin to handle the casualties that will follow a massive exchange. Only the most obvious elements of a system with many points of vulnerability will be considered. Even within the hospital sector less than half the system at best the beds, doctors, nurses, blood products, and drugs required for the injured may represent less severe constraints than the fuel, power, transportation, communication, food, *From the Center for International Security and Arms Control, Stanford University, and the Departments of Radiology, Stanford University School of Medicine and Harvard Med- ical School. 349

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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. Medical Supply and Demand in a Post-Nuclear-War Worlds HERBERT L. ABRAMS, M.D. Stanford University, Stanford, California Any analysis of our capacity to survive a nuclear war must view the medical problems that survivors will confront) in the context of the health care system's capacity to provide a meaningful response. A system has been defined as a group of diverse units combined to form an integral whole and to function in unison, usually under some form of control. The health care system is surely one of the most complex aggregations of people and things that characterize modern society. Its annual cost of greater than $300 billion is equivalent to that of the entire U.S. Defense Department. In England, it is the largest single employer of labor. The problems of medical supply and demand in the post-nuclear-war world are too numerous and too complex to be dealt with fully here. Instead, this analysis will focus on the most acute needs of the injured population and the most obvious tools of the medical profession those without which it could not begin to handle the casualties that will follow a massive exchange. Only the most obvious elements of a system with many points of vulnerability will be considered. Even within the hospital sector less than half the system at best the beds, doctors, nurses, blood products, and drugs required for the injured may represent less severe constraints than the fuel, power, transportation, communication, food, *From the Center for International Security and Arms Control, Stanford University, and the Departments of Radiology, Stanford University School of Medicine and Harvard Med- ical School. 349

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MEDICAL SUPPLY AND DEMAND IN A POST-NUCLEAR-WAR WORLD 351 PE RSON N E L Physicians Nurses COMMUNICATION Lab Technicians SUPPLIES Outside Support Personnel, etc. Surgical Inside Medical ER's Housekeeping, etc. Disasters, etc. ~ TRANSPORTATION \ Inside Outside For Patients For Hospital Personnel For Supplies, etc. FUEL Oil Gas POW E R Lights Refrigeration Communication Air Conditioning, etc. / WASTE DISPOSAL EQUI PMENT ECG X-Ray / ICU, etc. - HOSPITAL \ \ /1 BLOOD PRODUCTS Blood Plasma Packed Cells Platelets l.V. Fluids WATE R Clean Sterile FOOD Staples Fresh Foods Special Foods, etc. DRUGS Antibiotics Analgesics Anti- Inflammatory Anesthetic Cardiotropic, etc. FIGURE 1 Factors on which the proper functioning of a hospital depend. The numbers and types of injuries in the surviving population were derived from FEMA estimates of casualties.6* Accounts of the nuclear attacks on Hiroshima and Nagasaki7 ~ provided additional data, as did those of the Texas City disaster (a dockside explosion of a ship carrying ammonium nitrate fertilizer, which caused more than 3,000 casualties, most of them trauma related).9 ~0 Estimates based on these sources suggest that there will be 93 million survivors, of whom approximately 32 million will have been injured (Table 1~. A total of 23 million Americans will have varying degrees of radiation sickness, while 14 million will have suffered trauma, burns, or both. The percentage of moderate and severe injuries in the three major categories was derived from the tables of Oughterson and Warren.8 The breakdown . *The casualties estimated by FEMA used conventional assumptions about nuclear weap- ons' effects. These do not take into account the "superf~res" and the conflagration model described elsewhere in this volume (see Postol; B rode and Small; Daugherty, Levi, and von Hippel).

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352 MEDICAL RESOURCE NEEDS AND AVAILABILITY of FEMA's estimate of 14 million survivors with trauma, burn injures, or both was extrapolated from Glasstone's table of distribution of injures among survivors in Japan (70 percent blast and 65 percent burns).7 A 35 percent overlap of injures can be estimated by summing the blast and burn injures. Thus, there would be a total of 9.1 million burn injures (65 percent of 14 million) and 9.8 million blast injures (70 percent), of which 4.9 million (35 percent of 14 million) would be combined trauma and burn. Among the 9.8 million blast victims, it is probable that 6 million will have open wounds. There will be hundreds of thousands of head, thorax, abdomen, and extremity injures (Table 21.9,~0 Compounding the problem of multiple and combination injures (e.g., trauma and burns) will be that of nonfatal radiation exposure, which extends the healing time while it increases susceptibility to infection and mortality. (A study of combined burn and radiation injuries in dogs showed that animals with 100-rad exposure alone had a 0 percent mortality rate; with a 20 percent burn, the mortality rate was 12 percent. When the animals were exposed both to a 100-rad exposure and a 20 percent burn, the mortality rate was 75 percenti21. Burns and burn-related needs will pose an acute dilemma during the immediate postattack penod. Hospital care is most critical for those with burns over 20 percent of the body surface; all of the 5.3 million classified TABLE 1 Casualty Estimates (in millions)a Radiation sickness (total) Only With trauma, burns, or both Severe Moderate Trauma (total) Only With burns Severe Moderate Burns (total) Only With trauma Severe Moderate 23 5 18 13 10 9.8 4.9 4.9 s 4.8 9.1 4.2 4.9 5.3 3.8 aEstimates indicate that there would be 93 million survivors, 32 million of whom would be injured. There would be a total of 41.9 million single and combined injuries. SOURCE: Notes 4 and 6-9.

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MEDICO SUPPLY kD DEMAND IN A POST-NUCLE~-W~ WORLD 353 TABLE 2 Breakdow ~ oF 11~:~ 1~:= Injury Number Open wounds Head Thoracic Abdominal Pelvic and genitourinary Extremities Upper extremity fractures Hand Upper leg Lower leg and foot Maxillofacial Eye Vertebral or spinal cord Ruptured eardrums Total 791,800 823,200 s3s,000 392,000 147,000 70s,600 264,600 78,400 78,000 284,200 ss,soo 400,800 ss,soo 891,800 800,000 SOURCE: Notes 9 and 10. as severely burned would most likely be hospitalized in peacetime. A civil defense estimates is that 60 percent of the patients hospitalized in a mass disaster would have lesser burns, leaving 40 percent or, in this case 2.12 million survivors with burns in the critical category.* Trauma will pose a problem of similar dimensions. In 1978, 20.8 million operations were performed in the United States.5 Nearly a quarter of that number would have to be performed within the first few days after the attack if the 5 million survivors with severe trauma injuries received surgical treatment at least once. Furthermore, most x-ray film would have been exposed to radiation and thus made useless, so that it would be difficult to identify the precise anatomy of fractures, ruptured viscera, and penetrating wounds before surgery. The amount of time that elapses before treatment is an important factor in burn and trauma injuries. In one study of severe burn patients (burns over 25 to 64 percent of the body), the mortality rate rose from 63 percent *One 60-bed burn ward in a military hospital requires 8,200 square feet of space (about 762 square meters). i3 Thus, a facility for the 2.12 million most acutely burned survivors of CRP-2B would require 290 million square feet (about 27 million square meters) of space, or 10.4 square miles (about 27 square kilometers) an area approximately the size of Berkeley, California. 14

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354 MEDICAL RESOURCE NEEDS AND AVAILABILITY for those admitted to the hospital 2 hours postburn to 88 percent for patients who had treatment delayed from 6 to 23 hours. In addition, use of available resources requires some sort of effective transport: of supplies to the injured and of the injured to an appropriate site for therapy. This may be unlikely or impossible after the attack, when transportation will be disrupted, radiation levels will be high, and the critically injured will be in need of immediate care. Approximately 33 percent of the population of the United States will receive initial fallout levels of 3,000-10,000 reds (R)/hour, 23 percent will receive 1,000-3,000 it/hour, and 22 percent will receive 300-1,000 R/hour.4 In large cities, the radiation may be more intense; initial fallout in New York City may be at a rate of 32,000 R1hour.4 Radiation intensity will decrease by a factor of 10 after 7 hours, of 100 after 49 hours, and of 1,000 after 2 weeks.2 Initially, however, prohibitively high radiation levels would prevent outside help from en- tering areas where most of the injured would be. For this reason, an individual in an area that initially received 3,000 it/hour may have to wait weeks before outdoor activity is tolerable "up to a few hours per day."4 Large numbers of injured survivors will be unable to reach care of any kind. Current Versus Posta~ack Resources and Requirements Medical Personnel Physicians Physicians, nurses, and allied health personnel are more concentrated in urban areas than is the general population. While 73 percent of U. S . inhabitants live in urban areas, the percentage of physicians in cities is 87 percent. i4 Most city dwellers will become casualties, since cities are high-priority targets. In 1979 there were 371,000 active phy- sicians in the United States. is The death or incapacitation of 87 percent of these would leave only 48,000 to treat the 32 million injured estimated by FEMA one doctor for every 663 patients (Table 21. (Viewed in a different perspective, 1.3 million physicians would be required to see each of the 32 million patients for a half hour on the first day, provided that all of the former were able to work a 12-hour shift. If each patient were seen once during the first two days, only 666,667 physicians would be required-still more than 15 times the number available.) Specialties Certain specialists would be more in demand than others. Most of the population with severe blast injuries (5 million) would pre- sumably require surgery; less than one-third of professionally active phy- sicians are in surgical specialties. is If 87 percent became casualties, there would therefore be one surgeon for every 410 patients with serious blast

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MEDICAL SUPPLY AND DEMAND IN A POST-NUCLEAR-WAR WORLD 355 injures. For the 800,000 head injures (Table 2), only 399 qualified brain surgeons would be available to treat them. There are only 2,610 plastic surgeons in the country; 339 would remain to treat the 5.3 million severely burned patients that is, one plastic surgeon for every 15,634 patients. Nurses The same critical shortages would occur among nurses and allied health personnel, since they are generally located in the same areas as physicians (Table 31. In 1979 there were 1,223,000 registered nurses and 376,000 practical nurses in the United States. is Casualty losses would leave a total of 207,870 nurses, or one for every 154 patients. In 1976, the average ratio of hospital nurses to patients was about 1 to 3;~6 in intensive care or bunt units it is 1 to 1. For the Postattack penod, data from Hiroshima can be used to estimate a group of 6.7 million patients that will need intensive care that portion of the most severely injured who would be likely to die between the days 2 and 20 following the attack. ~ Only one registered nurse would be available for every 42 patients in this group. If the nurse-patient ratio is modified to one nurse for every three of the 6.7 million patients needing intensive care and one nurse for every seven of the 10.9 million regularly hospitalized patients; and if a nurse visits the 14.4 million ambulatory patients at a rate of 10 patients per hour, or 120 patients in a 12-hour shift; and if we assume that ambulatory patients are all seen the first day, 7.7 million nurses would be required on the first day after the attack. Allied Health Personnel The work of physicians and nurses would be seriously hampered, if not impossible, without the help of a varied and TABLE 3 Number of Hospital Beds and Medical Personnel ResourcePreattackPostattackPostattack Needs Hospital Bedsa1,350,000273,00017,600,000 Burn beds1,34602,100,000 Intensive care beds62,00014,8806,700,000 Physicians371,34348,275666,667 Registered nurses1,200,000158,9907,700,000 Licensed practical nurses387,00048,8802,464,000 Medical technologists129,60016,770231,594 Pharmacists121,50030,375419,479 Radiologic technologists96,79012,583173,771 aNumber of hospital beds minus psychiatric beds. SOURCE: Notes 15 and 23.

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356 MEDICAL RESOURCE NEEDS AND AVAILABILITY complex group of associated personnel. Medical technologists, phar- macists, and radiological technologists would play an important role. There were 129,000 medical technologists and 97,000 radiological tech- nologists in 1976.16 Even if the equipment were still available to perform the necessary tests, it would take the 17,000 surviving medical technol- ogists 30 16-hour days to perform one 15-minute test on each patient. A normal type and cross match under peacetime hospital conditions takes 45 minutes. If each medical technologist worked only on typing and cross matching for 16 hours a day, it would take them 49 days to cross match blood for the 17.6 million hospitalized injured. Similarly, the 9.8 million survivors with blast injuries would need x- rays performed by the 12,600 radiologic technicians who would survive uninjured. Apart from the staggering deficiency of numbers, radiation exposure, as noted above, would render much of the x-ray film unusable and equipment would be largely unavailable. In 1975, there were 121,500 active pharmacists in the United Statesmen Pharmacists are more widely dispersed than other medical personnel. Most of them work in community pharmacies, not hospitals. Their casualty rate has been figured from the percentage of retail pharmacies located in urban centers with a population over 50,000. * Seventy-five percent work in such areas, so that 30,375 pharmacists will remain uninjured. In 1979, there was a daily average of 379 full-time employees per 100 patients in community hospitals a ratio of nearly 4 to 1. If this ratio were to be preserved, 66 million hospital workers would be required after the attack in order to treat the 17.6 million injured at preattack levels of hospital care. This represents a number greater than the 61 million un . . . nJurec . survivors. There would also be a vast number of ambulatory and chronically ill patients in need of medical attention following the attack. Burns of less than 20 percent of the body surface are more easily managed, i7 and burns of 15 percent or less may be treated in an ambulatory setting. On the basis of our casualty estimates and FEMA's breakdown of injuries, this group would number about 7 million. The area of the body burned is of great importance, however. Smaller burns involving the face, hands, feet, or genitalia are more serious because they affect airway, vision, excretion, locomotion, or the patient's ability to care for himself.~9 In an exposed population, a large number of facial and hand burns must be anticipated. One military burn unit reported that 66 percent of their patient population had facial burns, even under ordinary conditions. ~3 *Data from Pharmaceutical Data Services, Division of Pharmaceutical Care Systems, Subsidiary of Foremost-McKesson, Phoenix, Arizona.

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MEDICO SUPPLY ED DEMAND IN A POST-NUCLE0-W~ WORLD 357 Finally, there are well over 20 million people with diabetes, hyperten- sion, or heart disease in the United States.20 Without appropriate drugs, many who survive will require health care and hospital beds. Hospital Beds In 1978, the United States had 1,137,666 short- and long-stay hospital beds, excluding those set aside for psychiatric patients. Seventy-six percent of all hospital beds are located in urban areas. ~4 It is assumed that all of these hospitals would be destroyed or rendered useless, leaving 273,000 beds available following the attack (Table 3~. With an average community hospital occupancy rate of 73 percent,i many of these beds will already be occupied by seriously ill patients. During a tense war situation, it is possible that all but the most seriously ill would be removed from hospitals. Hence, a preattack occupancy rate of 20 percent has been assumed. About 55 percent of the injured with trauma and burns would require hospitalization.4 The FEMA figures fail to grapple with radiation injury. Those receiving large doses of radiation will require hospitalization, par- ticularly since the exposure level will be uncertain. In patients who have been exposed to 300-1,000 reds, hospital care with antibiotic therapy, blood transfusions, fluid replacement, or bone marrow transplants will frequently make the difference between death and survival.7 ~0 2~ If 55 percent of the total 32 million injured require hospitalization, there would be 17.6 million patients-64 for each available hospital bed. A 20 percent preattack occupancy rate would leave one bed for every 81 patients. Burn Beds A high proportion of the injured will have suffered severe or extensive burns and will require special care. These injuries are the most difficult to treat, since they require a specialized environment as well as more medical supplies and personnel than any other injury category. One estimate, based on the known effects of the bomb in Japan, is that 5.3 million survivors will be classified as severely burned that is, in- dividuals who would most likely be hospitalized in peacetime. About 60 percent of this group would have burns over less than 20 percent of the body surface.* Even if these patients were excluded, the number requiring burn beds will be 2.12 million-almost eight times the total number of remaining hospital beds (Table 31. *The breakdown is as follows: after a mass disaster 60 percent of hospitalized patients would have burns of less than 20 percent; 30 percent would have burns of 20-40 percent; and 10 percent would have burns of over 40 percent. A study of burn patients at Massa- chusetts General Hospital over a 19-year period reported a similar distribution of burns.22

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358 MEDICAL RESOURCE NEEDS AND AVAILABILITY Burn care is prolonged. In the burn unit of one military hospital, in which the average patient had a 30 percent body burn, the average length of hospitalization was 60.8 days 73.5 days for survivors. Each patient had an average of 4.3 operations. 13 After the initial hospitalization, years of skin grafting operations were needed. A severe burn may require as many as 30-50 operations, both immediate and delayed. i7 Burn care facilities are scarce even in peacetime. In the United States, there are 135 such units, with a total of 1,346 beds.23 Their availability is especially crucial for children and for those burned over 60 percent of their bodies. Burn units tend to be in the largest, most centrally located hospitals; Massachusetts has three, all of which are in Boston.24 All burn beds will probably be destroyed in an attack targeted at urban areas. intensive Care Beds There are 62,000 intensive care beds in the United States (including pediatric and cardiac beds and excluding neonatal beds).23 The same percentage of intensive care beds as general hospital beds is likely to be destroyed (76 percent), since they are more evenly distributed among hospitals than burn units. This leaves about lS,OOO remaining intensive care beds. If the 2.12 million survivors with burns of over 20 percent of the body surface are moved to intensive care beds, there will be a ratio of 142 burn patients for every one intensive care bed. In Hiroshima, 21 percent of the injured died between days 2 and 20 after the attack.7 In the attack under consideration, 4 these most severely injured survivors would number 6.7 million 450 patients for every re- maining bed. Assuming a 20 percent preattack occupancy rate, there would be one bed for every 563 patients. Blood and Blood Products In 1979 11.1 million units of blood were collected in the United States.25 Nearly all the blood used directly for transfusion is collected from vol- untary donors in community blood centers and hospital blood banks; the 213 community and regional centers collect 88 percent of the nation's blood supplies.25 These centers are generally near the hospitals they ser- vice; the same percentage (76 percent) of the national blood supply as of hospitals would therefore be destroyed. In the last decade, there has been increasing use of blood components, such as red cells and platelets, rather than of whole blood. In 1979, for example, of the 13.4 million units transfused, 54.6 percent were transfused as red blood cells, 16.6 percent as platelet concentrate, 16.2 percent as whole blood, 9.6 percent as plasma, and 3.1 percent as cryoprecipitated antThemophilic factor.26

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MEDICO SUPPLY kD DEMAND IN A POST-NUCLE0-W~ WORLD 359 Similarly, whole plasma is now largely transfused into patients for its coagulation factors26 and collected chiefly for its derivatives albumin, antihemophilic factor concentrate, and immune serum globulin.27 Volume expansion is achieved either with balanced electrolyte solutions such as Ringer's lactate or with plasma proteins, such as albumin, which draw several times their weight of fluid into the circulation.28 The blood and blood components that are relevant to burn, blast, and radiation injures are whole blood, red blood cells, platelets, plasma, albumin, and white blood cells. Synthetic volume expanders such as Ring- er's lactate and venous intravenous fluids must be considered as well. The following formula was used to estimate the daily inventory of blood and blood components: [(amount produced daily)-(amount transfused daily)] x (shelf life of product) + (amount produced daily) = daily inventory.* Throughout most of the country, the shelf life of whole blood is now 35 days25 with a few exceptions, such as Massachusetts, where it is still 21 days. Following the above formula, 57,895 units would be available on any given day. This is a 10-day supply under normal rates of usage. If 76 percent of it is destroyed, 13,895 units will remain (Table 4~. This estimate is substantiated by the fact that on a random day in January 1981, the American Red Cross- which collects approximately half the blood collected in the United States had an 8.7-day supply of blood on hand in its New England Region. White Blood Cells Since antibiotics are widely available, there is little need to transfuse white blood cells except in patients who are not producing them and who are threatened with infection despite the use of antibiotics. This would include those exposed to whole body radiation as well as patients on immunosuppression or cytotoxic drugs. In peacetime, the use *The amount produced daily was derived from the fact that, on average, there was a yield of approximately 150 percent of blood products from the 11.1 million units of whole blood collected in 1979.25 Thus, there were actually 16.7 million units of blood products produced, although only 13.4 million units were transfused. Daily production and trans- fusion were estimated by dividing 16.7 and 13.4 million units by 365 days in a year (45,753 units produced and 36,712 units transfused per day). For example, the daily inventory figure for whole blood was determined as follows: 16.2 percent of the blood supply is transfused as whole blood; 16.2 percent of daily production (45,753) is 7,412; 16.2 percent of daily transfusion (36,712) is 5,947.

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370 MEDICAL RESOURCE NEEDS AND AVAILABlL17rY of pump and power failure and pipe rupture. A significant electromagnetic pulse could be generated by a one-megaton weapon and would disrupt power sources and electronic equipment over a wide area.45 In the absence of power, no life support instruments would be operative. As noted above, the medical response will be influenced by a host of factors that go well beyond beds, personnel, and supplies. SUPPLY VERSUS DEMAND: THE DEVELOPING WORLD Need Versus Avaitabili~ The two most important sources of illness in the developing world are malnutrition and infection. In analyzing the impact of nuclear war on the health care of this huge segment of the world's population, it will be assumed that North America, Europe, and the Soviet Union are no longer able to export food, drugs, medical equipment, and supplies to their former markets. A brief analysis of three areas of central importance to health care" pharmaceuticals, medical equipment, and grain supplies-may help es- tablish the dimensions of the problem. TABLE 9 Blood, Fluids, Drugs, and Supply Inventory (Case 2: Michigan Resources 7 ~ ~ TypePreattackPostattackPostattack Need Whole blood (U)2,3151,7591,280,000 Red blood cells (U)7,8025,9291,280,000 Platelets (U)48036515,620,000 Plasma (U)4,2293,2141,700,000 Albumin (U)136,000103,3601,700,000 Ringer's lactate (liters)256,000194,5601,920,000 Intravenous solutions (dextrose and saline) (liters)4,040,0003,070,4007,580,000 Antibiotics (tetracyclines) (kg)1,7001,2906,280 Anesthetics (lb)b27,50020,500300,000 (12,474)(9,299)(136,080) Bandages (sq yd)C1,200,000912,0003,860,000 (1,003,344)(762,542)(3,227,425) Needles (no.)1,280,000973,0001,520,000 Intravenous injection sets (no.)91,60069,616720,000 aAssuming a one-megaton airburst. bValues in parentheses are metric equivalents, in kilograms. CValues in parentheses are metric equivalents, in square meters.

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MEDICO SUPPLY ED DEMAND IN A POST-NUC~-W~ WORM 371 TABLE 10 World Pharmaceutical Production, 1980 Countries Production Million U.S. Dollars Percent Developed countries Market economies North America 18,600 22.1 Western Europe 27,440 33.0 Others 11,970 14.3 Centrally planned economies Eastern Europe 15,960 Total, developed countries 73,970 19.1 88.5 Developing countries Africa470 0.6 Asiaa4,690 5.6 Latin America4,400 5.3 Total, developing countries9,560 11.5 Total, world market83,530 100.0 aExcluding China. SOURCE: Denved from note 46. Drugs The value of worldwide drug production amounted to US$84 billion in 1980. Developed market economies accounted for 70 percent of total output. Centrally planned economies (Soviet Union, China, and Eastern Europe) followed with 19 percent, while the share for developing countries was just over 11 percent (Asia produced 5.6 percent; Latin America, 5.3 percent; and Africa, 0.6 percent) (Table 101.46 A few nations control the bulb of pharmaceutical production. The United States, Japan, and West Germany together represent half of the world's total output. In the developing world, more than two-thirds of the drugs manufactured come from a half dozen countries: India, Brazil, Mexico, Argentina, Egypt, and South Korea. In the other countries, there are few indigenous sources.47 Consumption is uneven. Developing countries, with nearly two-thirds of the world's population, consume only 14 percent of the pharmaceuticals produced. * Furthermore, they depend heavily on imports to satisfy their *Developed market economies accounted for 70 percent of world consumption, and the centrally planned economies accounted for the remaining 14 percent.

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372 MEDICAL RESOURCE NEEDS AND AVAILABILITY needs. The international pharmaceutical trade approximates US$14 billion. Of this, developing nations imported 32 percent and exported only 4 percent, whereas developed countries as a whole exported 96 percent and imported 68 percent.46 Most developing nations do not have a strong chemical industry. They import finished or semifinished drugs rather than basic or intermediate chemicals that require extensive local processing. The imports come largely from transnational pharmaceutical firms based in the developed market economy countries.46 An analysis of a sample of 10 developing countries confirms their reliance on foreign fins for maintenance of their health care systems (Table 11~.48 On average, foreign firms held 75 percent of the market share of pharmaceutical products of the sampled developing nations, with the vast bulk coming from the United States and Europe. Of the top 50 firms, U.S. companies are responsible for almost 50 percent of sales; and together the United States, West Germany, and Switzerland house 33 of the 50 largest drug firms. These account for almost 80 percent of the pharmaceutical sales of the top 50 companies. A major nuclear exchange would cut off this critical source of pharmaceuticals for the developing world. Medical Equipment Like the pharmaceutical industry, the medical equipment market in developing countries is dominated in large part by foreign suppliers, no TABLE 11 Pharmaceutical Market Shares Held by Domestic and Foreign Firms in 10 Selected Countries (percent) Country Domestic Share Foreign Share Saudi Arabia 0 100 Nigeria 3 97 Venezuela 12 88 Brazil 15 85 Indonesia 15 85 Mexico 18 82 India 25 75 Iran 25 75 Argentina 30 70 Philippines 35 65 Average of 10 countries 25 75 SOURCE: Note 48. Reprinted with permission from the author.

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MEDICAL SUPPLY AND DEMAND IN ~ POST-NUCLE0-W~ WORLD 373 TABLE 12 Imports of Medical Equipment in Developing Countries Percent Imported From the From Europe and Country Year Total United States From Europe the United States Algeria 1985 100 4 85 89 Argentina 1981 75 41 35 76 Brazil 1985 34 36 50 86 Chile 1983 100 40 45 85 Colombia 1983 72 36 48 84 Ecuador 1978 100 25 60 85 Guatemala 1978 100 58 27 85 Honduras 1978 100 38 18 56 Korea 1983 90 43 16 59 Mexico 1980 80 56 39 95 Philippines 1980 99 56 20 76 Singapore 1980 100 37 50 87 Thailand 1981 90 23 45 68 Venezuela 1980 100 50 25 75 SOURCE: Notes 49-62. tably those in the United States and Western Europe. A random sample of developing countries* showed that they imported 89 percent of their medical equipment, 79 percent of it from the United States and Western Europe (Tables 12 and 13~.49-62 Reliance of these developing countries on outside sources has remained constant over the past 7 years. In 1980, Mexico imported 56 percent of its medical equipment from the United States and 39 percent from Western Europe a combined total of 95 percent. Singapore received 87 percent of its health supplies and in- strumentation from the Western developed nations,60 while Venezuela and the Philippines imported 75 and 76 percent, respectively.5962 In 1983 Chile and Colombia acquired 85 percent of their medical equipment from American and European suppliers.52 53 In 1985, Algeria is projected to import 89 percent and Brazil 86 percent.49 As in the drug industry, the United States and Western Europe assume roughly three-quarters of the foreign market share in medical equipment. The destruction of the industrial apparatus of these two areas would cripple *Fourteen countries were selected for this sample: Algeria, Argentina, Brazil, Chili, Colombia, Ecuador, Guatemala, Honduras, Korea, Mexico, the Philippines, Singapore, Thailand, and Venezuela.49~62 These countries varied markedly in their level of development and the per capita income. The sample is not fully satisfactory because of the difficulty of obtaining data on some of the African countries, whose level of dependence is even higher.

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374 MEDlCaL RESOURCE NEEDS AND AVAILABILITY TABLE 13 Imports of Medical Equipment in Developing Countriesa Imports From the Average of From the United States 14 Countries Total United States From Europe and Europe Percent 89 39 40 79 Millions of U.S. dollars 42.9 38.3 16.8 17.2 34.0 aTotals are from a sample of 14 developing countries, including Algeria, Argentina, Brazil, Chile, Colombia, Ecuador, Guatemala, Honduras, Korea, Mexico, Philippines, Singapore, Tha~- land, and Venezuela. SOURCE: Notes 49-62. the health care systems of the developing world and deprive them of much of the equipment essential for acute and chronic health care. Food Food production is powerfully connected to the international economy. While there have been major studies of the effects of a nuclear war on plants, animals, and ecosystems, only a few have addressed the problems of international subsistence from a macrolevel. Some authors have focused on the rebuilding of the U.S. economy without adequate recognition of our dependence on foreign markets for goods, imported raw materials, and sources of energy.63 Regions that trade with the developed countries are reciprocally dependent on them and would be profoundly affected by their collapse. The effects of a massive nuclear exchange between the United States and Soviet Union, therefore, would spread far beyond the borders of the countries directly involved. Atmospheric changes might limit the agricultural growth of smaller economies, which could no longer depend on the developed nations for either money or materials. The total gross domestic product (GDP) for the world's market econ- omies in 1977, in millions of U.S. dollars, was 6,161,000. Including estimates for centrally planned economies, that figure was roughly US$7,977,500 million in 1977. (Market economies do not include the centrally planned economies of the USSR, China, Bulgaria, Romania, Poland, Hungary, Czechoslovakia, German Democratic Republic, and Cuba.) To the figure for world market GDP, the United States contributed 31 percent, and the countries of Europe contributed 33 percent. Together with Canada, the United States and Europe account for over one-half (51 percent) of the GDP of the world economy.64 Estimates indicate that the

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MEDICAL SUPPLY AND DEMAND IN A POST-NUCLEAR-WAR WORLD 375 Soviet Union generated 13 percent of the total in 1977.65 Thus, if the economies of North America, the USSR, and Europe were destroyed, almost two-thirds (64 percent) of the world's economic strength would vanish. By contrast, the combined economies of Africa in 1977 produced only 3 percent of the world total. Caribbean and Latin American nations contnbuted 6 percent. Asian nations, including Japan and the Middle East, added another 20 percent. These figures contrast sharply with population statistics. The 1979 pop- ulation of Norm Amenca and Europe was 17.7 percent of the world total, while that of Africa, Asia, and Latin Amenca amounted to 76.6 percent. The population for India and China alone totals roughly 1.6 billion, over a third of the world's people.66 Disparities between world population and production of the basic ag- ncultural staples are equally striking. In 1980 the world production of wheat totaled 444,534 thousand metric tons. North Amenca produced 86,319 thousand tons, or 19 percent, a figure 3.5 times greater than its proportion of the world population. In contrast, Africa produced 8,634 thousand metric tons (2 percent) but had 10 percent of the world popu- lation. With nearly 58 percent of the world's inhabitants, Asian counties produced only 29 percent. The Soviet Union produces 9S,000 metric tons, yet it must import substantial amounts each year from We United States, Argentina, Canada, Australia, and Western Europe. Europe produces 22 percent of the world's wheat which, as with North America, far exceeds its consumption (Table 141. Other coarse grains also show an imbalance between level of production and population. The United States produces 43 percent of the world's TABLE 14 Percentage of World Population and Agriculture Production United States Europe USSR Total Percent of world population 5 11 6 22 Percent of agriculture production Oats 16 35 33 84 Barley 5 45 27 77 Soybeans 59 1 1 61 Potatoes 6 41 30 77 Corn 43 14 2 59 Wheat 15 22 22 59 Tractors 21 40 10 71 Harvesters-threshers 18 24 20 62 SOURCE: Note 66.

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376 MEDICAL RESOURCE NEEDS AND AVAILABILITY maize (corn); Canada produces 48 percent (18S,077 of 392,249 thousand metric tons in 1980~; and Europe produces over 60 percent. Asia produces only 83,139 thousand metric tons (21 percent), yet it has 10 times the population of North America. Corn is a staple not necessarily for the human diet but for animal feed. Similar considerations apply to barley and oats. North America produces 23 percent, Europe produces 35 percent, and the USSR produces 33 percent of oats (Table 14~. Africa produces only 0.6 percent and Asia, 3.5 percent. Europe produces 45 percent of the barley, the USSR produces 27 percent, and North America produces 12 percent. Africa grows only 3 percent.67 Different countries have varied demands for such agricultural staples. For example, the Soviet Union, despite its relatively high production figures, in 1979-1980 imported 16 percent of the world's wheat and coarse grain exports.68 Yet for every major crop, the same pattern is evident: North America, the Soviet Union, and Europe harvest the vast majority of the world's produce for their relatively small societies. Together, their people make up 22 percent of the world's population (Table 14), yet they produce 63 percent of the wheat, 65 percent of the corn, 91 percent of the oats, and 84 percent of the barley. Three-quarters of all tractors and two-thirds of all harvester-threshers are currently in inventories throughout North America, Europe, and the Soviet Union (Table 14~. A total of 68 percent of nitrogenous fertilizers in 1979-1980 were produced in the same three regions, along with 97 percent of potash fertilizers and 75 percent of phosphate fertilizers. Con- sumption figures are revealing here. The major economies all produce fertilizer in excess of their consumption, but Asia and particularly Africa consume far more than they can produce. Elimination of the supplier nations would not only diminish food supplies but would also strip the world of resources necessary to produce new crops over the long term. One group of manufactured chemicals that would be lost are herbicides. In 1980 the world's developed market economies were responsible for 98.1 percent of all herbicide exports. North America exported 25 percent and Western Europe exported 70 percent, with West Germany being the largest supplier. Compounding this problem is the fact that a similar situation exists for insecticides. Developed world market economies export almost all the chemicals that noncentrally planned societies require. In 1980 the figure was 96 percent. The United States exported 21 percent, while Europe's share was almost 69 percent.69 In the wake of a massive nuclear war, farming methods may well revert to a primitive level, with the lack of access to modern machinery, fertil- izers, and insecticides. The impact on the developing world will be pro

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MEDICO SUPPLY ED DEMAND IN A POST-NUCLE0-W~ WORLD 377 A"SUBSISTENCE LOOP" Malnutrition ~ Decreased Economic and Agricultural Production - , Disease Death FIGURE 2 Impact of food deprivation. Weakness and increased susceptibility to infection and disease impede the capacity to work, further decreasing agricul- tural production with a worsening of malnutrition in a theoretical subsistence loop. 63 found. While it will augment the disparity between food supplies and population need that now exists, it will surely limit the capacity to handle many of the problems of disease and medical care. Like the Northern Hemisphere, the Southern Hemisphere may find itself constrained by a subsistence loop, in which malnutrition begets disease, disease impairs the ability to produce, and decreased production impedes the cycle of recovery (Figure 21.63 ACKNOWLEDGMENT The research presented herein was supported by grants from the Car- negie Corporation, the John D. and Catherine T. MacArthur Foundation, the W. Alton Jones Foundation, and the New Prospect Foundation. Ruth Chasek played a major role in organizing much of the data on which this article was based. Margaret Sullivan was involved and helpful in the research on the second and third sections. Mrs. Jeffery Stoia con- tributed importantly in reviewing and shaping the manuscript. Margaret Mariscal typed the manuscript with skill and grace. To all, I am deeply indebted. NOTES iAbrams, H. L., and W. E. Von Kaenel. 1981. Medical problems of survivors of nuclear war: Infection and the spread of communicable disease. N. Engl. J. Med. 305:1226-1332. 2U.S. Office of Technology Assessment. 1979. The effects of nuclear war. Washington, D.C.: Office of Technology Assessment.

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