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The Medical Implications of Nuclear War (1986)

Chapter: 18 The Consequences of Nuclear War: An Economic and Social Perspective

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Suggested Citation:"18 The Consequences of Nuclear War: An Economic and Social Perspective." Institute of Medicine. 1986. The Medical Implications of Nuclear War. Washington, DC: The National Academies Press. doi: 10.17226/940.
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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. The Consequences of Nuclear War: An Economic and Social Perspective HAL COCHRANE, PH.D., and DENNIS MILETI, PH.D. Colorado State University, Fort Collins, Colorado INTRODUCTION The original purpose of this paper was to assess the systemic effects of a limited nuclear war and offer some thoughts regarding the potential health care complications that might result. As work progressed, it became increasingly apparent that research into the direct and immediate impact of war has been, and continues to be, the subject of considerable effort. However, a review of the literature on the consequences of nuclear war revealed few references to social science research. The citations that were uncovered appeared to be confined almost entirely to the application of economic theory to problems of reconstruction. Much of the work was performed in the mid-1960s to mid-1970s and is therefore dated. To our knowledge, little has been done on such subjects as social response to a warning of nuclear attack; willingness of health care organizations to administer aid under postattack conditions; ability of a moneyless economy to rebuild without the aid of other nations and without a heavy reliance on fuel oils. There is, on the other hand, no shortage of assumptions regarding the nation's institutions, individual behavior, and the likelihood of social change, none of which have been seriously questioned. As a result, published projections that implicitly adopt current economic and social arrangements should be questioned as well. In such a short paper, we cannot pretend to cover the subject of socio- economic consequences in any depth. However, we do not apologize for raising a wide variety of issues that may frustrate even the most patient 381

382 MEDICAL RESOURCE NEEDS AND AVAILABILITY reader. We view this as an opportunity to question, speculate, and entertain possibilities that may not have been previously considered. WARNINGS OF WAR Mutual assured destruction (MAD) is founded on the condition that each side's offensive weaponry surpasses the defensive capability of the other. Deterrence is thought by some to be stable so long as populations and industry remain vulnerable to the destructive capacity of the other side. If one subscribes to MAD, then it must follow that any movement to reduce vulnerability or enhance offensive capacity heightens the risk of war. Accordingly civil defense could play a dual role. Under ideal circumstances it might reduce casualties, but if thought to be too effective it could also destabilize the arms race, and under certain conditions heighten the potential for misinterpreting intentions. It is well known that the Soviet Union has invested considerable effort to develop an effective civil defense system. The Central Intelligence Agency (CIA) notes that there is sufficient blast-resistant shelter space for the Soviet leadership at all levels (Weinstein, 19811. The Federal Emer- gency Management Agency (FEMA) assumes that the Soviet Union would not launch a preemptive strike without first protecting its own citizens (or at least reducing the number of anticipated casualties to tolerable levels), by evacuating the larger cities and population centers proximate to major industrial plants. It is estimated that it would take from 3 to 5 days to complete the process. Such large-scale population movements would be readily detected by U.S. intelligence sources interpreted as a warning of an impending nuclear strike. One response to this message, albeit an unlikely one, would be for the U.S. to launch a first strike directed at the highly vulnerable evacuees. A second, which was favored for some time by FEMA, would take advantage of the lead time afforded by the observed movements to relocate 145 million of our own citizens. This so-called crisis relocation strategy has been roundly criticized for its lack of realism and the fact that only meager resources were devoted to its preplanning. Despite the apparent lack of support at the federal level for crisis relocation, unplanned evacuations may still be an important factor in determining the number and types of casualties that might be sustained as a direct result of war or indirectly as a product of the evacuation itself. It is interesting to note that the debate over crisis relocation presumes that evacuations are orchestrated primarily by FEMA. However, a spontaneous flight from areas thought to be targeted cannot be precluded, in the event of a sudden escalation in tension between the world's superpowers. It is

AN ECONOMIC AND SOCIAL PERSPECTIVE 383 highly unlikely, for example, that Soviet population movements, of the scale indicated above, would escape the attention of the news media. The question which then must be answered is how will U.S. citizens react? This is an area where lessons learned as a result of studying societal response to natural hazards and warnings, particularly earthquake predic- tion, may provide insights. How people in general and people with disaster response roles respond to information about impending catastrophe has been the target of research for three decades. The findings have been summarized (cf. Mileti, 1975; Williams, 1964) and suggest several principles that would affect the vul- nerability of medical and health care systems to nuclear war. People respond to situations of impending danger on the basis of their situationally defined perceptions of risk, and what they then believe to be appropriate response to those perceptions. Even without official govern- ment evacuation plans or sanctioned warnings of an impending nuclear exchange, news regarding related events could lead some people to per- ceive risk and evacuate to areas thought to be safe. Persons who are responsible for providing postimpact aid, such as health care professionals, might be motivated to evacuate personnel and supporting materiel in order to preserve their ability to provide assistance after the attack (cf. Mileti et al., 1981~. Given Abrams' (1984) estimates of medical requirements, it is doubtful whether such behavior would alter the outcome. THE DIRECT AND IMMEDIATE IMPACT OF WAR The immediate effects of nuclear war, the completeness of the devas- tation it brings, and the detailed accounting of the expected human suf- fering have all been the subject of numerous studies. We begin with a war scenario which provides the basis for estimating the demands placed on the medical system, and sets the parameters for determining the direct and indirect economic impacts. The results are then reexamined in the context of what is known about organizational behavior and transforma- tion. Damage to Cities Other papers in this volume have touched on many of the direct effects of a limited nuclear war. In order to avoid repetition we will briefly describe the scenario which is used as a point of departure for the issues raised in this paper. The following calculations are based on the Federal Emergency Management Agency's CRP-2B scenario which assumes that

384 MEDICAL RESOURCE NEEDS AND AVAILABILITY the United States is exposed to 6,559 megatons (Mt) of nuclear explosives targeted primarily at military installations and 250 centers of population exceeding 50,000. In the absence of warning and any subsequent evacuation, about 125 million people would be caught within the 2-psi circles (geographic areas which sustain a blast overpressure of 2 pounds per square inch); nearly 58 million would be inside the 15-psi region (Haaland et al., 1976; p. 201. In preparing the scenario, defense planners anticipated the delivery of 843 1-Mt warheads. It is estimated that each ground burst would leave a crater 1,000 feet (about 305 m) in diameter and 200 feet (about 61 m) deep. All structures from the point of detonation to a distance of 0.6 miles (about 1 km) would be leveled. Within the band between 1.7 and 2.7 miles (about 2.7 and 4.3 km) (5 psi) only skeletal remains of commercial and residential multistory structures would be observed. The 2-psi circle, characterized by moderately damaged structures (cracked load-bearing walls, windowless, contents blown into the streets), would reach 4.7 miles (about 7.6 km) (Office of Technology Assessment, 1979; pp. 27-31~. Damage to Electronic Systems: Effects of Electromagnetic Pulse In contrast to the effects of blast and fire, the electromagnetic pulses (EMP), generated as a result of airbursts, leave no visible signs. None- theless, in theory such pulses could be highly damaging to microcircuitry. Because of the partial test ban treaty (1963) and the highly sensitive nature of EMP to national security, there is little hard evidence to conclude just how much damage might be incurred. However, recent military interest in new communications technology, such as the $10 billion MILSTAR project, to protect against the effects of EMP suggests how serious the problem may prove to be. Although much of what is known about EMP either is classified as secret information or is highly speculative, the danger the phenomenon poses is very real. Telecommunications networks, in- formation processing equipment, and highly sophisticated medical tech- nology would be vulnerable and could be irreparably harmed by such a blast. ~ The problems this pulse poses for electronic equipment are twofold. Electrical power grids would pick up the EMP and transmit a transient spike in voltage to equipment drawing power at the time of the detonation. The rapid rise in voltage would damage microprocessors in a way similar to that resulting from lightning strikes. However, the rise in voltage would be typically 100 times faster, thereby rendering common surge protectors ineffective. Second, the electronic component itself could pick up the 1

AN ECONOMIC AND SOCIAL PERSPECTIVE , ~, _ _ ~ 385 pulse and generate internally induced currents. The result could produce nhv~ical damage to the equipment. High-altitude bursts (above 21 km) produce EMP, which could blanket hundreds of thousands of square kilometers (Office of Technology As- sessment, 1979; p. 22~. A high-yield weapon detonated 200 miles (about 322 km) above Kansas would generate a pulse which would affect the entire country plus parts of Canada and Mexico. Furthermore, the entire region would be blacked out simultaneously, since the radiation produced by the explosion travels at the speed of light (p. 5194. The economic and social ramifications of disrupting a highly developed electronic network would be staggering. Not a single facet of the economy would escape the effects of an interruption to the normal flow of communications, data retrieval, and the accompanying capacity to process vast amounts of in- formation. Concern about the potential effects of EMP is new, and as a result little is yet known about the social and economic consequences which might be triggered. Most large corporations have taken at least minimal steps to prepare disaster plans permitting them to carry on data processing functions in the event of sabotage or fire. Such plans normally involve securing the rights to utilize an alternative facility (e.g., sharing systems) and duplicating records on magnetic tape. Of course, this strategy will succeed only if the backup system is spared, an assumption which may be appropriate in the event of fire but less so given a nuclear exchange. Few corporations and governmental agencies, however, have actually taken steps to protect sensitive data processing equipment. These exceptions appear to be con- centrated primarily in the financial sector and are prompted by consid- erations of liability as much as concern about social and economic impacts.2 Such protection is likely to fail, however, even in cases where an extreme amount of caution is exercised. For example, the Federal Reserve System, charged with the important task of tracking and controlling the nation's money supply, maintains a bombproof backup facility. However, this is the strongest link in the network. Few other banks or their corporate clients can boast of such a capability. Hence, despite the fact that the Federal Reserve's computers would most likely survive the war, little data would be available for them to process. The viability of the nation's electronic funds transfer and recordkeeping system turns on the degree of protection afforded by all its participants. The sensitivity of the nation's credit system to computer failure was demonstrated recently when Paul Volcker, Federal Reserve Board Chair- man, revealed that "something in the nature of a computer glitch" left the Bank of New York $30 billion overdrawn (November 20, 1985~. To

386 MEDICAL RESOURCE NEEDS AND AVAILABILITY quell fears, the Fed was forced to make an unprecedented loan of $22.6 billion to the New York bank, the interest on which amounted to more than $5 million per day. The loan, according to Volcker, was made amid "increasing evidence of potential problems at other institutions around the country," all part of the computer network involved in the purchase and sales of government securities. This is, of course, a rather mild event in contrast to the prospects of disruption due to a nuclear exchange. It does, however, underscore the sensitivity of these financial systems, in- viting speculation as to how economic recovery might proceed in the event of a total collapse. Direct Consequences for Medical Care Abrams (1984), in pulling together a plausible set of projections re- garding the direct effects of such an attack, provides a sobering view of the situation. Abrams' calculations are based on the assumption that the attack is sudden, leaving the victims no time to take protective actions. Furthermore, the need for health care assistance is based on preattack medical procedures. Beginning with the fact that 73 percent of the nation's populace resides in areas assumed to be attacked, along with 80 percent of the country's medical supplies, it quickly becomes evident that the need for care would far outpace the medical resources which survive the attack. However, it is the extent of the imbalance which is so startling. He concludes that of the 93 million survivors, 32 million would require medical care.3 It is difficult to imagine how the estimated 48,000 physicians surviving the attack could cope with a workload which would tax 1.3 million (Abrams, 1984; p. 6571. How long medical care organizations could continue to function effectively under such conditions is open to question. There is, however, a body of research regarding the sociology of organizations which suggests that cohesiveness and the will to carry on in such an overwhelmingly stressful environment would be a limiting factor in de- livering care. This perspective is developed more fully below. THE LINGERING EFFECTS OF NUCLEAR WAR The longer-term effects of war would pose an altogether different set of challenges for the medical care system. Maintenance of a reasonable standard of health may be impossible without the rapid recovery of the economy's critical industries: petroleum, petrochemicals, electronics, ag- riculture, and pharmaceuticals. Without these it is difficult to imagine how the potential for the transmission of disease could be controlled.

AN ECONOMIC AND SOCIAL PERSPECTIVE 387 Leaning (1983; p. 424) has forcefully argued that some of the greatest risks to health lie in the postattack period. The prolonged period of crowd- ing in makeshift fallout shelters, which are likely to be poorly ventilated and ill equipped to treat or dispose of wastes, would create the conditions for the rapid spread of disease. Providing that the survivors endure this period, they would face similar difficulties outside. The lack of sanitary systems, the absence of power for refrigeration, the presence of millions of unburied dead, and a disturbed ecological balance fostering the rapid growth in insect populations would combine to produce an environment fertile for the contraction and transmission of disease. The complex in- teractive effects of stress, malnutrition, and an immune system damaged by radiation would tend to weaken the physiological defenses to a point where people may succumb to diseases presently considered to be only moderately virulent.4 It might not be unreasonable to anticipate postwar pandemics similar to those just described. Survivors weakened by malnutrition could not expect to be vaccinated nor would antibiotics be available in sufficient quantities to prevent complications. The focus of health care therefore shifts from the immediate problems of administering postattack aid to the longer-term issues surrounding re- construction. The number of casualties produced by hunger and exposure would not be significantly altered by the availability of trained medical personnel and pharmaceuticals. Access to food and energy would prove to be the key to survival. The prospects for avoiding catastrophe are tied inextricably to the prospects for reconstruction. Prospects for a General Economic Recovery The economic infrastructure which is left intact after the attack would play a key role in determining the length of time during which such life- threatening conditions might persist. The survivors would face the critical task of rebuilding a viable economy capable of rapidly reallocating un- damaged capital and distributing uncontaminated foodstuffs. The few stud- ies which have dealt with the issue of economic recovery are sobering. Potential Vulnerability Affecting National Survival (PVANS), a study prepared in 1970 for the Office of Civil Defense by the Stanford Research Institute (SRI) (Goen et al., 1970), estimated the fewest number of nuclear detonations required to "prevent economic recovery." The attack which SRI found to be most effective in achieving this end combined the de- struction of the industrial capacity located in 71 of the nation's largest standard metropolitan statistical areas, 5 and SRI concluded that a crippling blow could be delivered by a combination of 500 1-Mt and 200 to 300

388 MEDICAL RESOURCE NEEDS AND AVAILABIlll~Y additional 100-kiloton (kt) weapons. This number is only 10 percent of that posed by the formulators of the FEMA CRP-2B scenario. The direct effects of the PVANS attack, in terms of health care delivery, would not differ significantly from the projections sketched above. However, the economic dislocations resulting from the attack may create a whole new set of health issues. The SRI results have been subjected to refinements by Katz (1982; p. 115) and others (Sassen and Willis, 19741. These studies suggest that an even lower exchange threshold (100 to 300 Mt) would result in unac- ceptable economic disruptions and bottlenecks. Reasons for Doubting Economic Projections The picture, grim as it is, may understate the impacts. The tools avail- able to researchers are based on historic patterns of production and insti- tutional arrangements. However, these are likely to change during the period of reconstruction. It is highly unlikely that the social order, for example, would remain static. There are a number of other reasons for doubting the economic projections. The methodology should be ques- tioned. There may be insufficient reserves of domestic oil and gas to meet the needs of both reconstruction and production of essential consumer items. Trading patterns may not return to their prewar state. The destruc- tion of data processing and retrieval facilities would make it difficult to conduct monetary reform or reestablish property rights, both of which have, in past wars, been instrumental preconditions for a rapid recovery. Naturally, there are a large number of other issues which could have been addressed. The few we have chosen to include offer a perspective which is somewhat different from that of previously published works. They also reflect some highly speculative thoughts regarding the extent to which recent trends in the economy might affect the speed and nature of recovery. Methodological Concerns Input-output models, which are the foundation for many of the economic recovery studies, utilize a static matrix of technical coefficients.6 The fact that these coefficients are computed based on statistics collected while the economy is in a balanced state leads one to wonder about the reliability of the approach when applied to the analysis of catastrophic shocks. As an alternative to this static model, Cochrane (1984) simulated a market economy which permitted industries to substitute labor for capital

AN ECONOMIC AND SOCIAL PERSPECTIVE 389 and consumers to substitute more abundant commodities for those in limited supply. It was found that the destruction of a portion of an econ- omy's capital stock results in a new matrix of trade flows and hence in a new set of input-output coefficients which adjust throughout the recon- struction period. In addition the model produced 1. new price ratios: 2. new mix of consumer and producer goods; 3. new import-export balance; 4. a pattern of recovery which depends on the elasticity of substitution (labor for capital), the competitiveness of producers in other regions, and the amount of external aid flowing to the victims; 5. new government budget deficit. Most noteworthy for the issue of postwar reconstruction, the model shows that under certain conditions7 the economy would never reattain its prewar prominence. It appears that the conditions which led the Japanese and German economies to rapidly rebound from World War II bombing raids are not likely to be repeated. Systems models (Pugh-Roberts Associates, Inc., 1981) have been con- ceived as a means of assessing the combined effects of environmental and climatic change on the survivor's health and material well-being. How- ever, here too, the functions (in this case differential equations) are drawn from past experiences which reflect a unique pattern of prices, capital and labor productivity, health, and legal and political institutions. Once again, the accuracy of these dynamic models in portraying the consequences of an event, which is likely to alter the very foundation of man's relationship to nature as well as to his fellow man, should be seriously questioned. Perhaps the most serious shortcoming we have found in the works cited above is the lack of social science input. Except for Katz (1982), economic projections are made without even a passing reference to behavioral and institutional considerations. One thing is clear. A nuclear exchange of the magnitude reported in these studies would cause a rapid collapse of the nation's social and economic infrastructure. The speed with which a new system could be erected is an open question, and one which may never be answered. However, there are a number of issues worth noting that have been skirted thus far and to which we now turn our attention. The Social Aspects of Recovery The results of sociological research suggest that a CRP-2B level of nuclear weapon exchange would alter the social order and, consequently,

390 MEDICAL RESOURCE NEEDS AND AVAILABILITY human behavior in ways which may not have been captured by the analyses just cited. What might the postwar social order look like and what would contribute to its formation? Conceptual Framework The social "glue" that holds complex in- dustrialized societies together is efficient but impersonal. In the course of a typical day, an individual is expected to play a variety of highly seg- mented roles. Adherence to these roles creates an image which often masks the underlying personality. It is only rarely that the true persona, the whole person, is revealed to others. When this happens it is normally to a close intimate. Most human interaction in complex industrialized nations is impersonal and limited role playing. This impersonal social glue serves an important function in that differentiation and objectification are essential to efficiently carrying out the task of provisioning society and caring for unmet needs. For example, once the role of customer is learned, a person can buy almost anything in almost any store in the nation without going through the more personal but time-consuming task of getting to know the salesclerk. Role playing is of lesser importance to small rural com- munities, agrarian societies, and tradition-bound cultures which are bonded instead by personal relationships. In such a setting, individuals are more apt to get to know each other and interact personally (cf. Tonnies, 1957; pp. 31-102~. The impersonal social glue dissolves quickly under the stress of national or community emergency. Disasters that result in significant loss of life and property will serve to transform the order which bonds social life (cf. Mileti et al., 1975; Dynes, 1970; Barton, 1969), eliciting an intense identification with the community (Barton, 1969), guilt over being a sur- vivor (Lifton, 1967), an energetic response to provide help to those who need it (Dynes, 1970), and the development of an emergency consensus (Barton, 1969) which focuses human attention on the few acts directed toward the sole values of preserving life and helping others. A disaster- induced shift in social order and behavior triggers a temporary suspension of providing aid and comfort to the disaster victims. This pattern has been observed time and again (cf. Mileti et al., 1975; Dynes, 19701. However, these findings are drawn from experiences where communities were ca- pable of rebuilding both their physical capital and social relationships in a form which reflect their predisaster states. In almost every instance. ample resources, information, and relief personnel were funneled from unaffected regions to the disaster-stricken community (cf. Fritz, 1961), making it possible for it to return to the predisaster form of social orga- nization. Localized, community-wide disasters, therefore, would undoubt- edly see the social order change, albeit temporarily, to enhance the ability

AN ECONOMIC AND SOCIAL PERSPECTIVE 391 and stamina of medical and health care system personnel to perform their work. The first order of routine social life is thus impersonal but efficient. The second order of social life is personal and typifies life and behavior in both communities impacted by localized disasters and life in agrarian and traditional societies; it, too, is efficient for it focuses attention on disaster relief goals, temporarily abandoning less-important priorities. The second order soon reverts back to the first as immediate emergency needs are met. Application to CRP-2B The finding that disasters experienced see the first order of social life replaced temporarily with a second order that reverts back to the first order when emergency needs are met and after outside assistance converges on the stricken area is not likely to hold given the magnitude of disruption and depravation accompanying a nuclear ex- change. In this case the second order would give rise to a new third order rather than revert back to the first order; in other words, nuclear exchange would produce changes leading to a permanent social reorganization rather than a temporary change as characterizes most other disasters. - Sociological research has documented the emergence of second orders replacing first orders in hundreds of studied disasters (cf. Mileti et al., 1975; Dynes, 1970; Barton, 1969~. These second orders contain the seeds of new third social orders including new group leadership (e.g., Dynes, 1970), new bases for the distribution and use of power (e.g., Quarantelli, 1970), less complex systems of social stratification and status (e.g., Bar- ton, 1969), and the abandonment of traditional societal priorities (cf. Mileti et al., 1975~. These changes have been detected in cataclysms of all types ranging from snow storms (Frtiz et al., 1958) and mine disasters (Lucas, 1969) to natural and technological emergencies in general (cf., Mileti et al., 1975; Quarantelli, 1970; Form and Loomis, 19561. These seeds and the second order are only abandoned when the inevitable demise of the second order is triggered by the convergence of outside help and when the goals of meeting emergency impact needs and the restoration of that which was destroyed are met. It is unlikely that the two factors that trigger the demise of second orders would occur after nuclear exchange; the seeds of a new social order contained in second orders would not be blocked from emerging into a new and permanent third order. The first of these factors is the convergence of nonvictims on the affected area. It is unlikely that outside assistance would reach the surviving victims of destroyed cities in the CRP-2B scenario for months, if at all. The second of these factors is meeting impact needs and the restoration of that which was destroyed. It is also

392 MEDICAL RESOURCE NEEDS AND AVAILABILITY not likely that survivors could, on their own, restore the destroyed physical environment and meet impact needs. The CRP-2B scenario surpasses the threshold needed for a permanent social reorganization into a new third order: surviving human collectives would be isolated from the others, no outside aid could be expected, and survivors could not meet all the needs required to restore their community to its preattack states. It is not likely that the temporary disaster-response norms that char- acterize a typical second order would prevail for long. They would produce a permanent social reorganization a third order-with new leadership, values, systems of stratification and status, power relationships, and so- cietal priorities to guide behavior. The actual shape that the third order takes would be determined by personalities and a mix of individual char- acteristics (e.g., knowledge of survival skills, emergent leadership qual- ities, and so on), as well as the ownership of scarce resources that survive the disaster. These are difficult to predict; consequently it is difficult to predict the character of the third order that would emerge. It is not unlikely, however, that new, localized, small, nonnational and self-contained emerging societies would replace the national state and that these would vie for uncontaminated food, fuel, and other resources deemed to have survival value. It is not likely, therefore, that medical resources would be shared between these community-like "societies." Medical and health care sys- tems would be constrained to function within emerging neighborhood societies until international aid is received and equitably distributed. Critical Industries: Prospects for Recovery Detailed studies of how quickly critical industries might rebound are clearly lacking. What does exist is either outdated or based on questionable assumptions. No one is likely to question the inclusion of pharmaceuticals, agriculture, and energy in a list of industries crucial to the direct delivery of care or to the maintenance of health over the longer term. However, technological advancements, occurring over the past two decades, have increased the economy's sensitivity to the effects of war. Banking, data processing, telecommunications, and international trade have taken on increased importance. The brief discussion which follows is designed to highlight the potential effects these industries may have on the pace of reconstruction . Pharmaceutical Industry The highly concentrated production of phar- maceuticals in the Philadelphia area contributes in no small way to the problem of vulnerability. Programs of cost containment have forced hos- pitals to cut inventories to the point where, if not resupplied within 3

AN ECONOMIC AND SOCIAL PERSPECTIVE 393 days, they would be forced to implement rationing. It appears that no significant stocks of critical drugs exist anywhere within the public or private sector. The nation's current state of drug dependence speaks to the importance of this single industry. It is surprising, therefore, that it is the least-studied component of the medical care system. Reports iden- tifying the vulnerability of its production processes, the location of man- ufacturing plants, and the nature of its distribution networks are out-of- date or classified (Anderson, 1982), or the data have yet to be collected. The sensitivity of this industry to disruption is changing as a result of the combined effects of technology and international competition. The pharmaceutical industry in the United States, although still a significant contributor to worldwide production, has lost ground in recent years to its foreign competitors. Nearly 150 firms currently conduct research and produce patented drugs in the United States. Only 20 percent of these, however, represent significant U.S.-based multinational operations. An equal number are foreign-owned firms which have chosen to locate fa- cilities in the United States. The following quote from a National Academy of Sciences study (1983, p. 34) of the pharmaceutical industry aptly describes the complicated ties that have evolved within this highly inter- nationalized industry. The extensive and increasing multi national diffusion of individual pharmaceutical firms has rendered "U.S. pharmaceutical industry" a term of unclear meaning. The larger pharmaceutical houses found in America have long since developed extensive facilities in dozens of foreign markets. Conversely, foreign based firms have established operations in the United States; in fact, the largest U.S. firm in the mid-1970's in terms of pharmaceutical sales to American consumers was Roche Laboratories, a subsidiary of the Swiss based firm Hoffman LaRoche. The widespread practices of licensing innovations, marketing agreements, and joint ventures among fines of many nationalities further complicates the assignment of specific products to individual nations. It is clear from the statistics that U.S. dominance in pharmaceutical production and research and development (R&D) has declined over the past two decades. The U.S. share of world R&D expenditures has fallen from greater than 60 percent during the 1950s to less than 30 percent in 1982. The percentage of world pharmaceutical production occurring in the United States has declined from 50 percent in 1962 to 38 percent in 1978.8 It is still too early to tell exactly what these statistics portend for the U.S. producers. However, if the number of new drugs9 entering U.S. clinical trials continues to decline, one might expect the profit position of U.S. producers to follow suit and the U.S. position in the world market- place to further erode. One must conclude, therefore, that world depend

394 MEDICAL RESOURCE NEEDS AND AVAILABILITY ence on an undisrupted flow of pharmaceuticals from U.S. firms has been exaggerated. In recent years, generic drug producers have posed a growing threat to the industry's profit position since technological advances have made it possible to imitate patented drugs by slightly altering a compound's mo- lecular structure. These so-called multisource drugs accounted for 45 per- cent of licit drug sales within the United States in 1979, 7 percent of which (or 3 percent of all sales) were achieved by smaller firms. Most of the 600 generic producers distribute their product almost exclusively to the domestic market, oftentimes restricting their efforts to a particular region. The scale of operation is typically $10 million or less in annual sales (Egan et al., 1982; p. 371. How quickly might the pharmaceutical industry be rebuilt and sufficient production of pharmaceuticals and biologicals be resumed? There is, of course, no definitive answer to such a question; however, some indicators are worth noting. Most industry analysts would agree that a nuclear attack on the Northeast would devastate pharmaceutical research and develop- ment. The high concentration of skilled lab technicians and scientists in the region would be difficult to replace, given that many of the nation's prestigious institutions of higher learning would perish in the same attack. Such losses would have an incalculable impact on the nation's ability to advance pharmacological research, one which may take decades to re- cover. The impact such a loss would have on a global scale may, however, be less significant since the Swiss and Japanese have made great strides to advance their own capacity to carry on independent research. It is clear from Abrams' (1984) work that drug shortages would ma- terialize quickly after the attack and might continue for years as a result of the potential immunological impacts reported by Greer and Rifkin (this volume). However, there are several factors which could work to boost supply in the months after the exchange. Offshore production could be expanded, providing, of course, that the effects of the war are limited to the United States and the Soviet Union. How climatic change may alter production and distribution from these facilities is not at all clear. Second, the technical challenge of producing critical drugs varies widely. The fact that the manufacturers of generic drugs tend to be small suggests that sophisticated training and equipment may not be necessary in all instances. How quickly an onshore drug industry might be reconstructed is open to debate, since to our knowledge the resilience of this important health care sector has never been subjected to careful scrutiny. However, it is quite possible that production of certain antibiotics, volume expanders, and technically less challenging pharmaceuticals might rebound rapidly.

AN ECONOMIC AND SOCIAL PERSPECTIVE 395 This possibility was confirmed by a reconnaissance study of a repre- sentative pharmaceutical firm conducted in preparation for the symposium on which this paper is based. When faced with the questions regarding communications, supplies, or personnel, the managers revealed that au- tomation would play a key role, permitting the firm to continue production. It was agreed that the most threatening aspect of the problem would be the availability of supplies in the desired quantity and quality required by U.S. Food and Drug Administration (FDA) standards. The high cost of carrying raw material inventories (in terms of both product and warehouse space) has induced manufacturers to rely heavily on their suppliers. This has placed firms in a vulnerable position with regard to disruptions of the distribution network. The required ingredients are furnished by suppliers that have either been approved directly by the FDA or indirectly as a result of having a U.S. Pharmaceutical Standards designation. It should be pointed out that in the absence of the FDA, the purity of supplies might deteriorate rapidly. Furthermore, it is unclear how these small producers would seek out new sources of raw ingredients or adjust production to account for the expected variability in raw ingredients. These two factors, more than almost any other, could act to restrict the speed with which pharmaceutical production might rebound. The production process, in contrast to quality assurance, is dependent upon durable electromechanical equipment. Providing that power is avail- able, production could be carried on with as few as 20 percent of the workforce reporting. Surprisingly, it was suggested that producing units could continue for at least short periods of time without the involvement of upper-level management. Microprocessors and communications equip- ment are currently more heavily utilized in the testing laboratory and the marketing and sales departments than in production. It is, therefore, un- likely that EMP-induced damage to electronic testing equipment would force production to be terminated, since mixtures and processes are well established. Operations could continue so long as electrical power and raw ingredients of sufficient quality and quantity are available. Energy Industry A secure supply of energy is, without question, one of the two most important ingredients determining the speed with which a viable economy could be reconstituted. Katz (1982) and Sassen and Willis (1974), among others, have pointed out the extent to which the nation's capacity to provide food and shelter is tied to the various facets of energy production, processing, and distribution. It is well known that the nation's largest petroleum refineries are concentrated along the Gulf coast. inviting speculation as to how few warheads would be required in

396 MEDICAL RESOURCE NEEDS AND AVAILABILITY order to deliver the economy a crippling blow. Katz (1982; p. 115) con- cludes that as few as 100 to 300 Mt could produce unacceptable economic disruption and bottlenecks. In our opinion, it is doubtful whether such a limited exchange would create hardships which would last more than several years. Furthermore, we believe that it is unlikely that significant longer-term health effects would result. The nation's agricultural heartland would be spared, as would be a sizable proportion of the nation's housing stock and productive capital. In contrast, the CRP-2B scenario poses a level of destruction from which the economy might never recover and which could produce a state of chronic malnutrition and health problems similar to those observed in the Third World. It is questionable whether the nation's stock of liquid fossil fuels would be sufficient to replace the vast investment in housing, plant, equipment, and the supporting public infrastructure lost due to such a large-scale nuclear exchange. The im- portance of energy to the economy has already been noted; however, one must also ask whether rebuilding would so deplete the nation's proven oil, gas, and coal reserves that economic recovery would be a painful process drawn out over several decades. It is noteworthy, however, that both Japan and Germany were able to reestablish viable economies within 5 years after the armistice ending World War II. How were they, especially Japan, able to overcome a heavy dependence on external suppliers of energy and raw materials? If, in the process of rebuilding, the United States is forced to exhaust its liquid fossil fuel reserves, might it still count on repeating the Japanese experience? Capital as Embodied Energy The complexity of modern production techniques belies the simple fact that energy, predominantly in the form of fossil fuels, is an essential ingredient. It is easy to conceive of man- ufacturing processes which are fully automated and therefore require little or no labor. Such methods may even appear to economize on the use of energy. However, robotic machines are little more than common tools controlled by microprocessors. They are fashioned primarily from mate- rials such as steel forgings and wire harnesses which involve the use of furnaces, drop hammers, and similar energy-intensive processes. It is, therefore, misleading to focus solely on the direct energy used in projecting fossil fuel requirements to rebuild a war-shattered economy. Barring the obvious exceptions of transportation and space heating, most energy is consumed by the intermediate goods and primary metals industries. Sorting out what might appear to be an infinite number of interactions continuously taking place in a sophisticated economy is less of a problem than one would first anticipate. Economists have learned that by normal- izing the shipment of goods and resources from one industry to another,

AN ECONOMIC AND SOCIAL PERSPECTIVE 397 the direct and indirect effects of any change in product demand can be forecast. The resultant multipliers are readily modified to determine the amount of energy, measured in Watt years (a unit of energy equivalent to the energy expended in one year by one watt of power), for example, that would be required per dollars worth of shelter produced. Table 1 shows a range of energy intensiveness for a sample of industries. As of 1977, the average energy intensiveness of the U.S. economy was 2 Watt years; radio and telecommunications required only 0.46, while buildings, public utilities, and highways absorb 1.61, 1.99, and 3.32, respectively (Krenz, 1977; p. 1221. The shift from a predominantly service-based economy characteristic of the prenuclear war U.S. pattern of production to one designed to emphasize construction would result in a potential doubling of direct and indirect energy demand per dollar worth of product. TABLE 1 Energy Intensiveness by Selected Sectors of the National Economy Sector of the Economy Watt year/$ GNPa (1967) Products Food and kindred products Apparel Transportation and warehousing Communications and radio Wholesale and retail trade Finance and insurance Medical and educational New construction Residential Nonresidential buildings Public utilities Highways Average of all sectors (approximate) 1.57 1.17 2.64 0.46 0.95 0.61 1.05 0.93 1.61 1.99 3.32 2.00 aGross national product. Do We Have Enough Oil and Gas to Rebuild? Since plant, equipment, shelter, and public facilities are to some extent the embodiment of fossil fuels, nuclear war would not only destroy cities and communities but the process of rebuilding would deplete the nation's stock of natural resources. Estimates of how much are open to heated debate. However, given certain simplifying assumptions regarding the magnitude of losses and the postwar availability of fuel from abroad, a reasonably accurate picture can be developed.

398 MEDICAL RESOURCE NEEDS AND AVAILABILITY The U.S. stock of capital is currently worth nearly $9 trillion (1985 dollars). A Assuming that 60 percent of this stock is destroyed in the wake of the CRP-2B 6,559-Mt exchange, and given the simplifying conditions shown in Table 2, a total of 3.7 x 10~3 Watt years would have to be expended to restore the capital stock to its prewar state. At present, how- ever, the nation's demand for fossil fuels far outpaces domestic supply. Hence, energy required for reconstruction can only be obtained by cutting into the prewar pattern of use or by boosting imports significantly. For reasons discussed under the topic of trade relationships and underscored in Table 2, the process of rebuilding may have to rely on domestic reserves alone. TABLE 2 Assumptions Used to Compute Energy Requirements Energy Requirements 2 Watt years of direct and indirect energy is needed to recreate the lost capital (measured in 1967 dollars). Unchanging Composition of Fossil Fuel Supplies The composition of fossil fuels consumed during the period of reconstruction, i.e., the percentage provided by oil, gas, and coal, would remain unchanged. As of 1985, oil, gas, and coal comprised a respective 45, 22, and 25 percent of the nation's annual energy needs. The combination of hydropower, nuclear thermal plants, and other minor sources made up the remaining 8 percent. Proven Reserves The ultimate postwar supply of recoverable oil, gas, and coal are assumed to be equivalent to the current proven reserves, which are 29.5 billion barrels, 5.9 trillion cubic meters, and 292 billion metric tons, respectively. It is assumed that nuclear detonations would not significantly diminish these reserves, but no additions could be anticipated. Termination of Energy Imports The decimated U.S. economy would not produce sufficient foreign exchange in order to import energy supplies. Energy Refining Transportation and Distribution Unaffected All facets of the energy industry would be spared. This is, of course, an overly optimistic assumption since most defense strategists believe that the nation's refineries would be a high priority target. Capital Goods Industry Could Meet Demands Sufficient capacity exists to produce replacement housing, plant, equipment, and necessary public facilities. This too may exaggerate the speed with which rebuilding might proceed. As in the case of the energy sector, it is unlikely that domestic manufacturers would be able to meet such demands. Primary industries, which have comprised a declining proportion of national production over the past two decades, would certainly be targeted. Energy Production Is Limited to 10 Percent of Remaining Reserves-As a rule of thumb, the volume of oil extracted from a pool is maximized so long as the ratio of production to reserves is less than 10 percent. Since a more rapid rate of depletion results in larger volume of oil left unrecovered, petroleum engineers ensure that production is managed accordingly. The Destroyed Capital Is Not Salvageable The Production of Oil, Coal, and Gas Is Dictated by the Ability to Produce from Reserves Economic factors are assumed to play a secondary role.

AN ECONOMIC AND SOCIAL PERSPECTIVE 0.45 0.40 0.35 0.30 0.25 0.20 0.152 0.10 0.05 o 399 ~ . 4C MA ,^~1 _ ~ 9CC ~ -; I I I -·~_~l 1 0 20 40 60 YEAR o 50 + 65 o 75 ~ 85 X 95 v 100 PERCENT REDUCTION FROM PREWAR LEVELS OF CONSUMPTION FIGURE 1 Oil for consumption. Provided that these assumptions hold, one might expect a pattern of production and exhaustion such as that shown in Figures 1 through 4. The results indicate that the nation's stock of shelter and productive facilities can only be reestablished if other energy uses are drastically curtailed. For example, the reconstruction process would take 8 years to complete if the annual supply of petroleum allocated to activities other than re- building was cut to 15 percent of that observed prior to the war. In the event that these petroleum demands can only be reduced to 25 percent of the prewar level, total reconstruction would never occur; slightly more than 40 percent of the capital stock could be replaced. These results are dependent on a rather restrictive set of assumptions which, if anything, exaggerate the speed with which rebuilding might occur. The only factors which hold the potential to brighten the picture is a dramatic jump in the level of energy imports or a rapid growth in U.S. coal production. Both would be subject to a variety of bottlenecks

400 l.o of 0.8 0.7 0.6 0.5 IL c: 0.4 UJ MEDICAL RESOURCE NEEDS AND AVAILABILITY - /! ~ / ~ 0.3 0.2 0.1 o ~or _ , o ~r T 4 6 2 YEAR -:. 1. ~. ~i: 8 10 o 50 + 65 O 75 ~ 85 x 95 v 100 PERCENT REDUCTION FROM PREWAR LEVELS OF CONSUMPTION FIGURE 2 Percent of capital stock rebuilt as a percentage of prewar oil con- sumption. anct economic considerations, reducing the likelihood that such simplifying assumptions would significantly alter the conclusions. Agriculture A point which seems self-evident but has not been the subject of systematic research is the effect of the postattack weather on the economy. Without question, the combination of colder temperatures, envisioned by Sagan (Ehrlich et al., 1985), and radiation would reduce agricultural yields. One might also expect that increased variance in rainfall accompanying the new environmental conditions would induce surviving farmers to abandon specialized crops. Diversification might be the only option available for coping with fluctuating temperature and moisture. It is clear that abandoning specialization would depress production. Lastly, the effects of nuclear winter on soil losses have yet to be addressed. It is not implausible to expect significant amounts of wind erosion for several years after the war. The magnitude of such losses and their subsequent impact on agriculture have not yet been established.

AN ECONOMIC AND SOCIAL PERSPECTIVE 401 Money, Credit, and Banking The wholesale destruction of physical capital envisioned by the formulators of the CRP-2B scenario would result in a sudden and dramatic flight from money to real assets. To the extent that a postwar voluntary exchange economy is permitted to function, a rapid acceleration in the price of essential goods could be anticipated. Based on the experience of German monetary reform after World War II, it may be possible to quickly reissue currency in amounts which are tied to the reduced scale of economic activity (Stanford Research Institute, 19691. However, the fact that modern banking is highly dependent on electronic funds transfer systems, which have been pointed out above to be highly vulnerable to EMP, may complicate matters. Money is no longer a tangible commodity but is a complex combination of bits stored in electronic memory banks. Who will step forward to conduct monetary reform, and how it would be accomplished in an equitable fashion, is without question one of the most important aspects of economic recovery. Without a means of exchange, the survivors would be forced to resort to barter or simply implement a command economy where production and o.e 0.7 0.6 0.1 o ~100 +tt _ XX how ' I 1 ~-_ i ~5 - _~__ 0 20 40 60 YEAR lo 50 + 65 O 75 ~85 x 95 v 1 Do PERCENT REDUCTION FROM PREWAR LEVELS OF CONSUMPTION FIGURE 3 Gas for consumption.

402 1.0 0.9 0.8 0.7 0.6 us 0.5 CC LU CL MEDICAL RESOURCE NEEDS AND AVAILABILITY /~' 0.4 0.3, 0.2 0.1 - //// ~ 0 2 4 6 YEAR lo 50 + 65 ~75 O 85 8 10 x 95 v 100 PERCENT REDUCTION FROM PREWAR LEVELS OF CONSUMPTION FIGURE 4 Percent of capital stock rebuilt as a percentage of prewar gas con- sumption. resource allocation is dictated. In any case, it is clear that the projected period of economic recovery reported in the literature takes no account of this important consideration, and we believe, therefore, that the resultant estimates are overly optimistic. The postwar economy would be more inefficient and grow slower than might appear to be the case given current statistics. Trade Relationships International trade would suffer for similar rea- sons. It is unlikely that our current trading partners would be willing to sustain the balance of payments deficits which have been recorded in recent years. Such has been made possible by the fact that many other areas of the world are politically less stable than the United States. As a result the U.S. dollar has served as a hedge against a sudden reevaluation of other currencies (due to revolutions or monetary mismanagement). Nuclear war would not only wipe out foreign claims on U.S. assets but would eliminate the very reason for the dollar's prominence as an inter

AN ECONOMIC AND SOCIAL PERSPECTIVE 403 national medium of exchange. Postwar international trading would most likely be conducted on a quid pro quo basis. Both U.S. and foreign economic recovery would suffer as a result. Treatment of Surviving Capital One can only wonder how the own- ership of property will be settled and what ingenious mechanisms survivors might invent to distribute that which is still economically viable. Records would be difficult to retrieve. In some cases capital would be rendered useless as a result of raw material shortages. At the other extreme, the owners of uncontaminated land located in more favorable climatic zones could reap substantial gains, providing of course that property rights are respected. An unprecedented reduction and transfer of wealth could take place within a relatively short time period. How would the legal and political systems respond? Why Would the U.S. Experience Differ from that of Germany arid Japan? A recovery period lasting a decade or more contrasts sharply with the recorded postwar economic performance of both Germany and Japan. Each sustained heavy losses but were able to reestablish viable economies within 5 years after the cessation of hostilities. What forces led both of these nations to their current economic prominence? Could such factors be repeated to produce a rapid economic recovery in the United States? The factors which coalesced to create a favorable climate for both the Japanese and German economies are unlikely to reoccur. Fossil fuels during the postwar period were both plentiful and inexpensive. Contrary to popular belief, Germany sustained relatively minor damage to its pro- ductive capital. "It must be emphasized that bomb damage to industry, as opposed to transport and housing, was relatively negligible. Germany's . . . post-war industrial potential was roughly equivalent to that which had existed in 1938." (Owen-Smith, 1983; p. 13~. Reconstruction during the war with technically more advanced equipment meant that Germany emerged from fighting with a superior industrial base. Bomber raids simply obliterated housing and commercial establishments in the cities' centers, leaving the industrial plants situated in the outskirts virtually untouched. It has been estimated that industrial losses amounted to between 10 and 20 percent for metallurgical, chemical, engineering, and textile firms. Japan's losses were more telling. Its index of industrial production dropped from a prewar high 149 (in 1940) to 31 in 1946 (Allen, 1963, pp. 200-2091. The previous high was not reachieved until 1953, although it grew steadily throughout the intervening period.

404 MEDICAL RESOURCE NEEDS AND AVAILABILITY Both Japan and Germany benefited greatly from external aid, primarily from the United States. Assistance to Germany alone amounted to $3.6 billion between 1946 and 1953, a sizable amount, especially when mea- sured in current dollars. Approximately half the aid was in the form of Government and Relief in Occupied Areas (GARIOA), an emergency program to alleviate starvation (Owen-Smith, 1983; p. 29~. The foodstuffs provided by both the GARIOA and the Marshall Plan, which succeeded it, permitted Germany to economize on scarce foreign exchange so it could afford to import ingredients essential to its manufacturing operations. Japan's economy benefited equally from the aid it received. The Korean War served to stimulate demand for Japanese products at a point when U.S. aid was dwindling. That, plus a postwar economic boom which fueled demand for vessels fabricated in Japanese shipyards, all provided a sound platform for recovery. Even though a plentiful supply of cheap energy throughout the 1950s and 1960s provided both countries the opportunity to maintain a sound long-term growth path, energy shortages which materialized immediately after the war were a source of hardship and suffering. Germany was forced to relinquish territories amounting to 25 percent of the Third Reich's land area. The expulsion of German nationals from these areas caused a rapid rise in population which resulted in a homeless rate of nearly one family in three. The loss of 17 percent of Germany's coal-producing capacity to Poland and the imposition of mandatory coal exports as part of reparations contributed to an energy crisis. In the particularly bad 1946-1947 winter deaths per 1,000 of the population were 10 percent higher than in the following years (Owen-Smith, 1983; p. 29~. Despite the short-term hardships both countries benefited greatly from a fortuitous combination of factors which are unlikely to be repeated. No nation would have the resources or possibly the will to come to the aid of a United States devastated by a nuclear exchange. Foodstuffs would be hoarded rather than shared. No worldwide economic boom would ensue. Without an external source of demand for its products, the U.S. economy would languish. CONCLUSIONS The medical consequences of nuclear war have proven more elusive than first thought. The number of immediate casualties anticipated and the potential for the spread of disease over the long term hinge on more than the number of warheads targeted at American cities. How the pop- ulace responds to the warnings of war cannot be ignored. It is difficult to believe that an attack would occur without foreknowledge, either provided

AN ECONOMIC AND SOCIAL PERSPECTIVE 405 by FEMA or otherwise. Nonetheless, it is safe to say that the medical consequences of an attack depend on whether warnings/rumors of war produce an orderly exodus from cities to rural host communities (as FEMA may have planned it), trigger a spontaneous flight from areas thought to be vulnerable, or are ignored altogether. To our knowledge the required research to answer this question has yet to be initiated. Abrams (1984) has shown that the administration of aid to the survivors of a CRP-2B attack (assuming minimal evacuation) would be an enormous task, far exceeding available manpower and stockpiles of pharmaceuticals. How health care organizations might respond to the challenge is open to debate, since even the lessons learned from Nagasaki and Hiroshima may not apply to attacks of the CRP-2B magnitude. The totality of the de- struction would make it virtually impossible for local health care units to receive external assistance within a reasonable time span. The longer-term prospects for maintaining the health of the survivors are just as grim. Malnutrition, an immune system weakened by the effects of radiation, and poor sanitary conditions would combine to boost the death toll. Contrary to first impressions, the availability of pharmaceuticals may not be as important a factor as initially expected. The fact that manufacturing facilities located abroad contribute an increasing proportion of world drug supplies should alleviate concern about persistent shortages. One might even expect a relatively rapid rebound of domestic production. U.S. pharmaceutical research, on the other hand, might never reattain its prewar status. How long survivors must endure such deprivation depends on the speed with which a viable economy can be rebuilt. Without an adequate means of mobilizing manpower to distribute food and other necessities, the health of the survivors would remain in jeopardy. There is sufficient reason to believe that the period of reconstruction would far exceed the 3 to 5 years often reported by economic analysts. The vast quantities of fossil fuel required to reconstitute the nation's destroyed stock of shelter and indus- trial capital may be the single most important limiting factor. The United States should expect little in the way of international assistance, and trade would most certainly be conducted on a quid pro quo basis. Aid on the scale of that provided to Japan and Germany at the conclusion of World War II would amount to only a minuscule fraction of the estimated $3 trillion to $5 trillion in losses resulting from a CRP-2B exchange. The pace of rebuilding would also be inhibited by the destruction of the nation's data banks and information processing centers. No one seems to know at this point how electronic networks and equipment may function as a result of EMP. Nor has anyone asked the more general questions regarding information processing failures how records would be recre

406 MEDICAL RESOURCE NEEDS AND AVAILABILITY ated, how money and credit would be tracked, how economic sectors would be coordinated, and how essential information regarding prices and production would be generated and transmitted to the surviving firms. Research into the role that telecommunications and information processing plays in the economy seems vital. Finally, much of what has been written regarding nuclear war inad- vertently assumes that institutions and behavioral norms would remain unaltered. It is not uncommon, for example, to read economists' assess- ments of reconstruction which assume that property rights would be re- spected or Cat government fiscal and monetary policy would be implemented to alleviate the effects of war on the economy. These, of course, are foolish bases upon which to build realistic projections. The tools currently available to economists and sociologists tend to paint a picture which is overly optimistic. Experience gained from the study of past disasters provides little insight as to how society may cope with the aftermath of nuclear war. Certainly snowstorms, floods, and even earthquakes pose sufficiently different problems than those upon which the papers in this volume have centered, and the social response to natural hazards may be an unsound basis for extrapolation. It is clear that knowledge about the physical and biological aspects of nuclear war have advanced significantly in recent years. Even the cli- matological and environmental issues have attained greater focus, despite the controversy surrounding the prospects of nuclear winter. The same cannot be said about the state of socioeconomic knowledge. We know that nuclear war will change the foundation of man's relationship to man and to nature, but we are either unwilling or unable to imagine what forms these new social arrangements will take and how they relate to the well- being of the surviving population. A significant change in the extent and direction of socioeconomic research appears warranted. ACKNOWLEDGMENTS The authors acknowledge the assistance of Laurie Walters, Jung Soo Kim, and Marjorie Muench, who assisted in the preparation of this paper. NOTES iAt high altitudes, gamma rays are produced in the first nanoseconds of a nuclear ex- plosion, which can travel hundreds of kilometers before encountering electrons in atmos- pheric molecules. After being knocked out of their original molecular configuration, these electrons would be deflected toward Earth in a downward rotating motion along the Earth's magnetic field lines. These high-energy electrons would be picked up by any metal object. The resultant pulse would peak rapidly (within 10 nanoseconds) to a level of 50,000 to 100,000 V/m. The greater the surface area, the greater the amount of EMP absorbed.

AN ECONOMIC AND SOCIAL PERSPECTIVE 407 2In passing the Electronic Funds Transfer Act (1978), Congress attempted to assign liabilities, rights, and responsibilities to both the consumer and the financial institutions. Interest in backup facilities was spurred by the requirement that transactions be processed within a reasonable length of time. The legal consequences of not fulfilling this obligation were felt to be more than sufficient reason to take protective measures. 3The scale would change with the attack scenario, however; even given a very limited war involving 10 major cities, the imbalances Abrams points out would still prevail, albeit to a lesser extent. The approach may in fact understate the effects, since no account is taken of the location of surviving resources relative to where they are needed. Nor is any consideration given to the mix of resources available. The ratios Abrams utilizes are based on normal conditions, wherein personnel, equipment, and pharmaceuticals are available in desired proportions. How effective will a medical staff be in the event that equipment is rendered inoperable? 4Contrary to what one might first think, cholera, typhoid, plague, and small pox con- tributed in only a minor way to the world's morbidity and mortality rate this century. Surprisingly, the influenza virus proved to be the most lethal. Over the 2-year period between 1918 and 1919 flu resulted in nearly 21.6 million deaths worldwide. In the United States alone nearly 20 percent of the population was infected, producing nearly 400,000 deaths in a single month (Ayres, 1965; p. 411). Most of the fatalities were the result of complications such as pneumonia. sThe attack was assumed to reduce industrial output to less than 3 percent of the preattack level. The industries considered critical are (1) petroleum refining; (2) iron and steel works; (3) primary smelting and refining of zinc, copper, lead, and aluminum; (4) engines; (5) electrical distribution products; (6) drugs; (7) office mechanisms; and (8) mechanical . . measuring ~ .evlces. 6This methodology establishes a normalized pattern of trade which weaves the industrial sectors together. A technical coefficient is simply the percentage of one industry's output that another industry comprises. 7The most important is that the disaster-stricken region exhibits a cost of production equal to or in excess of its competitors. These trends can be explained in part by the following: (a) U.S. Food and Drug Ad- ministration regulations which impose significantly greater costs and delays on U.S. research efforts; (b) liability regimes for consumer product claims which are more cumbersome and risky in the United States than in competitor nations; (c) antitrust legislation which prevents the achievement of scale economies in terms of pharmaceutical research and development; (d) foreign nontariff trade barriers such as discriminatory safety regulations and pricing. 9An average of 60 new drugs were subjected to clinical trials in the mid 1960s. The number has declined to 25 per year in 1982. In contrast, the number of trials conducted by foreign-owned companies has remained constant (at 20 per year). i°Statistical Abstract of the United States, 1985. The total comprises the following: $1.4 trillion (nonresidential equipment); $1.6 trillion (nonresidential structures); $2.8 trillion (residential structures); $2.0 (government); and $1.2 trillion (household durables). REFERENCES Abrams, H. L. 1984. Medical resources after nuclear war: availability vs. need. J. Am. Med. Assoc. 252:653-658. Abrams, 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.

408 MEDICAL RESOURCE NEEDS AND AVAILABILITY Allen, G. C. 1963. A Short Economic History of Modern Japan. New York: Praeger. Allen, G. C. 1981. The Japanese Economy. New York: St. Martins Press. Anderson, C. G. 1982. Emergency Medical Response Capability Analysis. Fairfax, Va.: Associated Research Analysis Corporation. Ayres, R. U. 1965. Environmental Effects of Nuclear Weapons, Vol. I, HI-418-RR. The Hudson Institute, Harmon-On-Hudson, New York. Barton, A. H. 1969. Communities in Disaster: A Sociological Analysis of Collective Stress Situations. New York: Doubleday. Cochrane, H. 1984. Knowledge of loss and the efficiency of public/private protection. Paper presented at the Economics of Natural Hazards Conference, University of Florida, December 14-15. Dynes, R. 1970. Organized behavior in disasters. Lexington, Mass.: D. C. Heath. Egan, J. W., H. N. Higinbotham, and J. F. Watson. 1982. Economics of the Pharmaceu- tical Industry. P. 205. New York: Praeger Publishers. Ehrlich, P., C. Sagan, D. Kennedy, and W. Roberts. 1985. The Cold and the Dark: The World After Nuclear War. New York: Norton. Form, W. H., and C. P. Loomis. 1956. The persistence and emergence of social and cultural systems in disaster. Am. Soc. Rev. 21 (April): 180-185. Fritz, C. E. 1961. Disaster. Pp. 651-694 in R. Merton and C. Nislet, eds., Contemporary Social Problems, New York: Harcourt. Fritz, C. E., J. F. Rayner, and S. L. Guskin. 1958. Behavior in an Emergency Shelter: A Field Study of 800 Persons Stranded in a Highway Restaurant During a Heavy Snow- storm. Washington, D.C.: National Academy of Sciences. Fuchs, V. R. 1974. Who Shall Live? New York: Basic Books. Goen, R. L., R. B. Rothun, and F. E. Walker. 1970. Potential Vulnerability Affecting National Survival. Menlo Park, Calif.: Stanford Research Institute. Greer, D. S., and L. S. Rifkin. 1986. The Immunological Impact of Nuclear Warfare. This volume. Haaland, C. M., C. V. Chester, and E. P. Wigner. 1976. Survival of the Relocated Pop- ulation of the U.S. After Nuclear Attack. Oak Ridge, Tenn.: Oak Ridge National Lab- oratory. Katz, A. M. 1982. Life After Nuclear War. Cambridge, Mass.: Ballinger. Keller, B. G., and M. C. Smith. 1969. Pharmaceutic Marketing. Baltimore: The Williams & Wilkins Co. Krenz, J. H. 1977. Energy and the economy: an interrelated perspective. Energy 2:115- 130. Leaning, J. 1983. Civil Defense in the Nuclear Age: What Purpose Does It Serve and What Survival Does It Promise? Leaning-Link,J.,M. Klig, end M. E. Lord. 1983. Disaster Medicine. Vol. I(Fall):386. Lifton, R. J. 1967. Death in Life Survivors of Hiroshima. New York: Random House. Lucas, R. A. 1969. Men in Crisis: A Study of a Mine Disaster. New York: Basic Books. Mileti, D. S. 1975. Natural Hazard Warning Systems in the United States. Boulder: Uni- versity of Colorado. Mileti, D. S., J. E. Haas, and T. E. Drabek. 1975. Human Systems in Extreme Environ- ments. Boulder: University of Colorado. Mileti, D. S., J. R. HuKon, and J. A. Sorensen. 1981. Earthquake Prediction Response and Options for Public Policy. Boulder: University of Colorado. National Academy of Sciences. 1983. The Competitive Status of the U.S. Pharmaceutical Industry. Prepared by the Pharmaceutical Panel, Committee on Technology and Inter- national Economics and Trade Issues. P. 102. Washington, D.C.: National Academy Press.

AN ECONOMIC AND SOCIAL PERSPECTIVE 409 Office of Technology Assessment. 1979. The Effects of Nuclear War. Washington, D.C.: U.S. Government Printing Office. Owen-Smith, E. 1983. The West German Economy. New York: St. Martins Press. Pugh-Roberts Associates, Inc. 1981. Development of a Dynamic Model to Evaluate the Effect of Natural Resource Policies on Recovery Following Nuclear Attack- Final Re- port Vol. I: Description and Simulations. Cambridge, Mass.: Pugh-Roberts Associates, Inc. Quarantelli, E. L. 1970. Emergent accommodation groups: beyond current collective be- havior topologies. Pp. 111-123 in T. Shilretani, ea., Human Nature and Collective Behavior. Englewood Cliffs, N.J.: Prentice Hall. Sassen, J., and K. Willis. 1974. Data Base and Damage Criteria for Measurement of Arms Limitation Effects on War Supporting Industry. ACDA/WEC-242. Alexandria, Va.: Metis Corporation. Southwest Research Institute. 1969. Final Report. Evaluation of Industrial Systems Inter- relationships and Vulnerability to Nuclear Attack. San Antonio-Houston: Southwest Research Institute. Stanford Research Institute. 1969. Postwar Monetary Reform in Severely Damaged Econ- omies: Its Role in Recovery from Nuclear Attack. For Office of Civil Defense, Office of the Secretary of the Army. Contract DAHC 20-67-C-0136, Work Unit 3331D. Menlo Park, Calif.: Stanford Research Institute. Tonnies, F. 1957. Gemeinschaft and Gesellschaft. New York: Harper and Row. U.S. Department of Congress, Bureau of the Census. 1985. Statistical Abstract of the United States. 105th Edition. Washington, D.C.: U.S. Government Printing Office. Weinstein, J. M. 1981. Soviet Civil Defense and the Credibility of the U.S. Deterrent: An End to This M.A.D.ness? U.S. Army War College, Carlisle Barracks, Pa. Williams, H. B. 1964. Human factors in warning and response systems. Pp. 79-104 in G. Grosser, H. Wechsler, and M. Greenblatt, eds., The Threat of Impending Disaster. Cambridge, Mass.: MIT Press.

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Written by world-renowned scientists, this volume portrays the possible direct and indirect devastation of human health from a nuclear attack. The most comprehensive work yet produced on this subject, The Medical Implications of Nuclear War includes an overview of the potential environmental and physical effects of nuclear bombardment, describes the problems of choosing who among the injured would get the scarce medical care available, addresses the nuclear arms race from a psychosocial perspective, and reviews the medical needs--in contrast to the medical resources likely to be available--after a nuclear attack. "It should serve as the definitive statement on the consequences of nuclear war."--Arms Control Today

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