MEDICAL PROBLEMS AFTER NUCLEAR WAR By A

MEDICAL PROBLEMS AFTER NUCLEAR WAR     By A.F. Phillips, M.D.

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

        Consider the following figures:

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

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

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

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

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

        What would happen to individuals in an attacked city?

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

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

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

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

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

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

THE SURVIVAL PERIOD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

                       TABLE I
    EXAMPLES OF DISORDERS THAT REQUIRE CONTINUING TREATMENT

                CONDITIONS               CLASSES OF DRUGS
                Diabetes                 Insulin (or oral med.)
                Cardiac                  Digitalis, Nitrites
                various                  Diuretics
                Hypertension             Reserpine, Propranolol
                Asthma, etc.             Salbutamol, etc.
                Peptic Ulcer             Antacids, Cimetidine
                various                  Cortisone derivatives
                some Cancers             Hormones, Chemotherapy
                Epilepsy, etc.           Dilantin, Phenobarbital
                Arthritis                Anti-inflammatory drugs
                Hypothyroidism           Thyroxine
                Tuberculosis             Antibacterials

CONCLUSION

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

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

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

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

"There is no doubt that the experience of conventional warfare is
irrelevant [emphasis in original report] to the scene that would
confront whatever survivors remained after a major nuclear attack." {9}

"Survivors would be preoccupied exclusively with the search for food and
shelter. They would be unlikely to devote attention to the care of the
sick and dying." {10}

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

   From the Ontario Medical Association:

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

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

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

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

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

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

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

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

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