59.1 The final challenge to preventive surgery

Thermonuclear annihilation is the ultimate in trauma, both in the severity of a single injury, and in the number of casualties. There are three dangers which are commonly confused: (1) Those associated with atomic power. (2) The release of a single atomic bomb by accident or design. (3) A multimegaton exchange of intercontinental ballistic missiles. The consequences of the first are comparatively minor, those of the second are survivable by mankind as a whole, as indeed were the bombs at Nagasaki and Hiroshima. The last is truely terrifying. If we in the Third World do not actually perish, we will see our sources of drugs, equipment, and spares, and much of our tenuous hope of development, vanish instantly.

Firstly, some facts, many of them in the words of The Lancet. The arsenals of the world now contain the equivalent of a million bombs of the kind that fell on Hiroshima, and are equal to about 4 tons of TNT for everyone of us here on earth. More energy can now be released by one weapon in one microsecond than in all the conventional wars of history. In the nations directly attacked tens to hundreds of millions of people would be killed instantly. Hundreds of millions more might starve to death. Millions might die from cancer caused by nuclear radiation.

Radioactive contamination would spread to vast areas and pollute the biosphere. The natural protective ozone layer round the earth might be damaged, with unpredictable consequences to all forms of life, and possibly even the extinction of the human species. Mankind might indeed destroy itself. At the very least, the social, cultural, environmental, and medical damage in the aftermath of a nuclear war would persist for generations.

Among those who might survive the initial effects of blast, fire, and radiation, many would endure prolonged agony and a slow death. Untold numbers would die from injuries for which no adequate medical care could be provided. Widespread starvation, epidemics, and civil disorder would be inevitable. The people who would not be immediately vaporized would suffer from radiation, and from many of the injuries discussed elsewhere in this manual. A ’nuclear winter’ might end all life on earth. Medically, the terms ’limited’ and ’winning’ have no meaning in the context of nuclear war.

Figure 59.1: ATOMIC CATASTROPHY The second world war ended with the atomic explosions at Hiroshima and Nagasaki. Here is one of the victims. The graph shows the world’s military expenditure in $–US billion at 1970 constant prices. Most of this expenditure is designed to produce death from the very injuries we describe here.

Mounting military expenditures and the intensification of the arms race heighten the tension, and each new crisis worsens the threat. World military spending in real terms, corrected for inflation, has increased four fold since World War Two. In the 1970’s it approached $5 trillion, or about $500 thousand million a year—a sum larger than that of the total goods and services created by mankind in one year. Most of this expenditure is carefully designed to cause the very injuries we describe here, if not death itself. It is also killing people now by diverting scarce resources from urgent health needs. Twenty times as much is spent on arms as on development aid. To provide everyone on earth with clean water and sanitation would cost less than the equivalent of seven months of the arms race. Smallpox was eradicated from the world for a cost equal to only five hours of it. One year of it would more than abolish all the international debts of the Third World. One nuclear aircraft carrier, the Ohio, launched in 1979, cost $6 billion-more than the total government budgets of Kenya, Tanzania and Uganda combined.

’Overkill’ is now such that 1000 times more bombs are available then are required to kill everyone on the other side. The balance of terror becomes daily more frightening. It is sometimes argued that it has kept Europe free of war for nearly 40 years. This is not correct since there has never been a sufficient cause for war during this period. If war does break out it will only be by accident; if it does it will annihilate most of the industrial world and perhaps all mankind.

Figure 59.2: NUCLEAR ARSENALS. The area of the small circle represents the power of all the explosives used in World War Two. The area of the larger circle represents the nuclear arsenals of the world now which are about 5,000 times greater. The scales at the bottom of the figure show zones of total destruction and of the survivors needing surgical care; they are those following a 1 megaton groundburst. The Hippocratic serpent symbolically surmounting the mushroom cloud is the the emblem of International Physicians for the Prevention of Nuclear War (IPPNW).

Not only is there a very real chance that all this will happen, but such is the unreliability of military computer systems that it is quite possible that it might even happen by mistake. The growth in sheer numbers of nuclear weapons and the increasing complexity and sophistication of their delivery systems increase the possibility that a nuclear conflict may be triggered by some tragic accident. Any technological system is liable to malfunction, and the people who direct them can easily make mistakes, or be sick, or mentally deranged, or tired, stressed, drunk, drugged, or senile. Until now their errors could kill only a few people. Now they can endanger the very existence of humanity.

The strategy of mutually assured destruction (’MAD’) was bad enough. Even more terrifying are the attractions of a ’prempive first strike’ to overwhelm the command, control and intelligence systems of the other side. The risk now is that, at a time of international tension, a defensive response by one side mignt be taken as an offensive one by the other side in a series of escalating responses that would culminate in catastrophe. The system itself may indeed have been mistakenly designed so that it cannot operate safely. For example, the carrying out of necessary additional defensive procedures during a high level alert may give the opposing side the mistaken impression that it is about to be attacked. Instead of escalation taking weeks as it did in the first world war, following the assination of an obscure archduke in Sarajevo, it might only take minutes—a "nuclear Sarajevo".

Hitherto it has been asumed that the ultimate authority for pressing the button to release the holocaust would lie, in the West, with the President of the United States. There are however good grounds for believing that he has already given ’preauthorisation’ to end life on this earth to his generals in their bunker. If the Strategic Defence Initiative (’Star wars’) is implemented, they will have to be given this authority, and may in turn have to hand it on to a computer. In matters of military technology the East usually follows the West

In the face of this unimaginable calamity, our response, as mere humans, is to deny reality and to try to forget it, and to hope that it won’t happen. Most of us can just cope with the little tragedies of our daily lives, but a cataclysm of this kind is too much for us. We become apathetic, and our response is in no way appropriate to the magnitude of the threat that faces us.

Perhaps this is not surprising. We have slowly evolved over millennia, yet in the space of only one lifetime, we have found ourselves able to fly, to unravel the chemistry of our own genes, to reach for the moon, to probe the very limits of the universe—and to destroy ourselves. Unfortunately, with it we retain an attitude to war which is at best mediaeval. Many of us even enjoy some aspects of it. We need time, much time, in which to adapt to our new powers. Above all, we need to look into the future with a much longer time perspective. Instead of seeing it in terms of years, or tens of years, we must look at it, not in the span of our own lifetime, but of that of our children’s children, far into the centuries ahead.

Both East and West see themselves, almost certainly falsely, is being about to be overrun, but even if they were, they should take comfort from the fact that all previous dominations have ultimately come to an end, often suprisingly quickly. Against such a longer time perspective, what happens in the next decade or two will not matter very much. Both sides—and mankind— will ultimately survive. So will our beautiful green earth.

Henceforward, the greatest threat to man’s life and health may not be the diseases with which medicine presently concerns itself, but his propensity to make war and destroy himself. If so, the greatest challenge to preventive medicine (and preventive surgery) in the closing years of this millennium and the next one (if we reach it), must be the prevention of war, both between East and West, and between the countries of the Third World. In some countries one person in 20 is a health worker, so if every health worker could become a ’peace worker’, the massive challenge of ’global health education for a nuclear age’ is not an impossible one. In the Third world it would allow money spent on arms to be spent on development.

Paradoxically, this is less a challenge to our intellects than to our courage, to our imagination, and to our willingness to face reality. We have yet to realize that the real courage required of us now is not courage in battles as it used to be, but courage to stand against the opinions of our fellows, who have yet to see things as clearly as we think we do, and conceivably, when the time comes, to resist domination—not violently but with an even greater kind of courage. The weapons of today are not tritium and plutonium but vision, hope, courage, perseverance, and indomitableness, together with the solidarity and good humour which several nations are already showing to magnificent effect against just such domination. If an atomic holocaust is the ultimate challenge to preventive traumatology, then these are our vaccines against global trauma and insane suicide, the "new community medicine (and surgery)".

NEAR DISASTERS There have indeed been many mistakes: (1) to 1961 near Goldsboro, North Carolina a B–52 bomber broke up in flight, releasing two 24 megaton bombs. Airforce experts found that on one of the bombs five of the six interconnecting safety devices had been set off by the fall, leaving only one to prevent an explosion. (2) In September 1980 a technician working on a Titan II intercontinental ballistic missile droppped a socket wrench onto a fuel tank below. The tank lost fuel and some hours later exploded, blasting open the silo’s 740 ton door and shooting the 9–megaton warhead 600 feet into the air. Frantic radio messages were overheard as the survivors tried to find the missing warhead. (3) In November 1979, a war game training tape was accidentally fed into a NORAD computer, and was accepted as real, initiating a low level nuclear war alert as personnel prepared launch procedures. (4) On another occasion the military systems of the USA were alerted, B–52s took to the air and readied to counter attack. Within six minutes of the time that this was to happen, the hostile missiles identified on the radar screens were seen to be only a flock of Canadian geeseEast and West had come to within 6 minutes of destroying one another, and perhaps the Third World too. This happened when the superpowers faced one another over the poles, where missiles have ajourney of half an hour. Now that they confront one another in Europe, where there are only three minutes in which to react, the possiblities of a mistake are ever more frightening. LESSONS "You may reasonably expect a man to walk along a tightrope safely for ten minutes, it would be unreasonable to expect him to do so without accident for two hundred years". The risks have grown greatly since Bertrand Russell wrote this.

Not only are all thinking people in the West frightened, but from many accounts those in the East are even more so. If it does happen by mistake, or intention, and you do have the fortune or misfortune to survive, here is an atomic ABC.