The Growing Threat of Nuclear War and the Role of the Health Community

Home , Doomsday Clock, Nuclear famine, Tilman Ruff

Ira Helfand Andy Haines Tilman Ruff Hans Kristensen Patricia Lewis Zia Mian

The Growing Risk cidents involving close encounters between Speaking in January, when the Bulletin of of Nuclear War nuclear capable NATO and Russian military the Atomic Scientists announced that its forces. A report issued by the ELN conclud- Doomsday Clock would remain at three After the end of the Cold War the intense ed, “These events add up to a highly disturb- minutes to midnight, former US Secre- military rivalry between the Soviet Union ing picture of violations of national airspace, tary of Defence William Perry stated, “The and the United States/NATO was replaced emergency scrambles, narrowly avoided danger of a nuclear catastrophe today, in by a much more cooperative relationship, mid-air collisions, close encounters at sea, my judgment is greater that it was during and fears of war between the nuclear super- simulated attack runs and other dangerous the Cold War … and yet our policies sim- powers faded. As recently as the 2014 US actions happening on a regular basis over a ply do not reflect those dangers” [6]. His Quadrennial Defence Review, conflict be- very wide geographical area” [3]. Further, assessment was echoed two months later tween the two former adversaries was not both sides have conducted large scale mili- by Igor Ivanov, Russian Foreign Minister considered a realistic possibility [1]. tary exercises in Europe, leading the ELN to from 1998 to 2004. Speaking in Brussels conclude, “Russia is preparing for a conflict on March 18, Ivanov warned that, “The risk Unfortunately, relations between Rus- with NATO, and NATO is preparing for a of confrontation with the use of nuclear sia and the US/NATO have deteriorated possible confrontation with Russia” [4]. The weapons in Europe is higher than in the dramatically since then. In the Syrian and danger inherent in this situation is magnified 1980’s” [7]. The increased tensions between Ukrainian wars, the two have supported op- by the current Russian military doctrine of the US and Russia have been matched by a posing sides, raising the possibility of open “nuclear de-escalation”. Rather than seeing similar escalation in the danger of nuclear military conflict and fears that such conflict nuclear weapons purely as a deterrent to nu- war in South Asia. could escalate to nuclear war. clear attack, this doctrine embraces “the idea that, if Russia were faced with a large-scale Since the nuclear weapon tests of May 1998 Over the past two years, both sides have en- conventional attack that exceeded its capacity by India and then Pakistan, the two states gaged in nuclear sabre rattling that is remi- for defence, it might respond with a limited have expanded many-fold their respective niscent of the worst periods of the Cold War. nuclear strike” in order to force the other side nuclear weapon and fissile material stock- Speaking about the conflict in Ukraine in to quickly end the conflict and return to the piles, and undertaken extensive develop- August 2014, Russian President Vladimir status quo ante” [5]. US/NATO military plan- ment and testing of a diverse array of ballis- Putin warned “it is better not to come against ning has always envisioned possible first use tic and cruise missiles (with ranges from 60 Russia as regards a possible armed conflict … of nuclear weapons in the face of a Soviet/ to 5000 km) to acquire the ability to deploy I want to remind you that Russia is one of Russian conventional attack in Europe. and launch nuclear weapons from the air, the most powerful nuclear nations” [2]. In the from land, and from submarines at sea. They months following the Russian annexation of In this setting prominent leaders on both have put in place command and control sys- Crimea, the European Leadership Network sides have expressed alarm about the grow- tems and doctrines that involve, in the case (ELN) documented a large increase in in- ing danger of nuclear war. of Pakistan, first use of nuclear weapons in

86 a conflict and, in the case of India, massive tween India and Pakistan could escalate to NATO attack in progress. In November of retaliatory strikes against population centres include the use of nuclear weapons” [18]. that year the Soviet leadership incorrectly [8–10]. Should Pakistan use nuclear weapons concluded that a NATO military exercise against Indian conventional forces in such was the cover for an actual attack that was In May-July 1999, the two countries fought a situation, Indian nuclear doctrine calls for about to be launched. On January 25, 1995, a war which apparently included mobiliza- massive retaliation directed at Pakistani cit- a full 5 years after the end of the Cold War, tion of nuclear weapons by Pakistan, mak- ies and Pakistan has threatened to respond Russian military radar incorrectly identi- ing it the most significant military conflict in kind. fied a Norwegian Black Brant XII rocket between two nuclear armed states [11]. They launched to study the aurora borealis as a also went through a major military crisis With Pakistan building ever closer mili- Trident missile aimed at Moscow. (December 2001 to June 2002) triggered by tary and economic ties to China, and India an attack on India’s parliament by Islamist becoming a strategic partner of the United In each of these situations preparations for a militants believed in India to be backed by States, such a future South Asian conflict counterstrike were initiated and nuclear war Pakistan, which included the two countries may quickly take on a global dimension was averted by minutes. moving a combined total of over half a mil- given the increasingly tense nature of the lion troops to their border [12]. The slow great power rivalry between China and the The danger of this kind of mistake occurring pace of Indian deployment and inconclu- US [20]. North Korea has a track record of again is amplified by current deficiencies in sive outcome of the stand-off led India’s repeatedly threatening the use of nuclear Russian radar warning systems. Russia has army to begin planning and training for a weapons; for example, in March 2016 it no space-based satellite early warning sys- more decisive and rapid conventional attack warned it would make a “pre-emptive and tems to alert them to the launch of nuclear- on Pakistan [13]. Pakistan began testing a offensive nuclear strike” in response to joint armed ballistic missiles from the ocean, so short-range truck-mounted mobile missile US-South Korean military exercises [21]. their warning time could be as short as 10 to deliver low-yield nuclear weapons on the It is capable of enriching uranium and pro- to 15 minutes. The only way for Russia to battlefield [14]. This latter development has ducing weapons-grade plutonium and has guarantee the ability to launch its forces increased long-standing international con- deployed short- and medium-range ballistic before they are destroyed by a pre-emptive cerns about the security of nuclear weapons missiles as well as testing long–range mis- attack would be to pre-delegate launch au- and fissile materials in Pakistan given the siles [22]. thority to field commanders. Under these large-scale and frequent Islamist militant conditions, the time pressure to make a attacks on military targets in the country launch decision could greatly increase the and the ideological polarization within the Unintended Use of chance of an accidental launch, especially if armed forces and broader society associated Nuclear Weapons a computer error caused a false warning of with the rise of hard-line Islamist political attack during a crisis [24]. Recently, military groups over the past three decades [15]. While these growing tensions amongst nu- leaders have begun to warn of a new threat clear armed states could lead to the deliber- that might cause the unintended launch of Potential triggers for armed conflict be- ate use of nuclear weapons, there is also the nuclear weapons: cyberterrorism. In a June tween Pakistan and India include another continuing danger that they could trigger 2015 speech, retired Marine Gen. James major attack on India by Islamist militant the unintended or accidental use of these Cartwright, former head of the US Stra- groups like the one in Mumbai in Novem- weapons. tegic Command, warned that it might be ber 2008 that was linked to intelligence possible for terrorists to hack into Russian agencies in Pakistan [16]. A second possible There have been at least five occasions since or American command and control systems trigger is the recurring artillery exchanges 1979 when either Washington or Mos- and launch one or more nuclear missiles, a along the line of control in Kashmir, and oc- cow prepared to launch nuclear weapons launch which would have a high probability casionally the international border between in the mistaken belief that the other side of triggering a wider nuclear conflict. This Pakistan and India, which often claim sig- had already launched a nuclear attack or danger is intensified by the continued US nificant military and civilian casualties [17]. was preparing to do so [23]. In 1979 and and Russian policy of maintaining their mis- again in 1980 computer errors in the US siles on hair trigger alert, fully prepared for In April 2016, at the conclusion of the Nu- caused American radar systems to display, use and simply awaiting an order to launch clear Security Summit, the White House incorrectly, incoming Soviet missiles on [25]. There is also extensive evidence that Press secretary expressed concern about, their monitors. In September 1983, So- individuals with responsibility for nuclear “the risk that a conventional conflict be- viet military radar incorrectly reported a weapons have breached safety regulations.

BACK TO CONTENTS 87 8000 In 2003, for example, half of the US Air 7300 6970 Force units responsible for nuclear weapons 7000 safety failed their safety inspections. In 2007 six cruise missiles armed with nuclear war- +000 Retired heads were mistakenly loaded onto a B-52 5000 Stockpiled bomber which sat on the tarmac overnight without armed guards before taking off and 4000 Deployed flying 1500 miles in violation of regulations Note: North Korea has produced ﬁssile 3000 material for 10–12 warheads and detonated which prohibit transportation of nuclear 4 test assemblies, but we’re not aware of public information that shows it has yet weapons by air over the USA [26]. 2000 stockpiled weaponized warheads.

1000 300 260 215 130 120 80 Nuclear Weapons 0 Modernization Russia USA France China UK Pakistan India Israel The nuclear danger is amplified further by the extensive plans of all nine nuclear armed Figure. Estimated Global Nuclear Warhead Inventories, 2016 states to enhance their nuclear arsenals. weapons and are carrying out extensive and regional nuclear war will also have cata- Although the world’s inventory of nuclear costly modernizations of their nuclear arse- strophic effects worldwide. weapons has declined significantly over the nals [28]. (see table) past two-and-a-half decades, from around We undertook a literature search using 58,300 warheads in 1991, there remain The scope of these modernization plans has the Web of Science database Topic Search roughly 15,375 warheads today of which led observers to characterize them as the function, on 14 March 2016, covering doc- 4,200 are deployed with operational forces. beginning of a new arms race and a new uments in English published from 2005 to Nearly 1,800 warheads are on alert and Cold War [29]. 2016, using the search strategy: ((“Nuclear ready for use on short notice [27]. (Fig. 1) Weapon*” OR “nuclear war*” OR “atomic weapon*” OR “atomic war*” OR “nuclear While Russia, the US, and Britain con- The Health Consequences conflict*”) and (Climate OR “Climate tinue to reduce their inventories, the pace of Nuclear War Change” OR environment* OR “Ozone of reduction has slowed compared with the Depletion” OR ozone OR Starvation OR past two decades. In fact, four of the world’s Given the growing danger of nuclear war, it famine OR Agriculture* OR crop* OR nuclear-armed states (China, Pakistan, In- is important to consider the health conse- Food)). dia and North Korea) are increasing their quences of such a conflict. nuclear arsenals. The scenario that has been studied most fre- The acute effects of nuclear weapons are quently is a limited nuclear war between In- There are currently no negotiations between well described in previous major reports by dia and Pakistan involving 100 Hiroshima nuclear-armed states about reducing war- WHO and the US Institute of Medicine sized warheads, small by modern standards, head inventories or curtailing operations [30,31]. While there have been important targeted on urban centers. (This is a delib- and modernizations. Instead, there are signs developments regarding ionising radiation erate underestimate of the full potential of that the deepening crises in Europe and the health effects in recent decades, it in rela- war in South Asia: the combined arsenals South China Sea are causing nuclear-armed tion to the impacts of nuclear war on cli- of India and Pakistan actually contain more states to increase the role of their nuclear mate, agriculture and nutrition that scien- than 220 nuclear warheads.) The direct ef- forces. tific advances of the greatest moment have fects in South Asia are catastrophic. Some been made in the past decade, and these 20 million people would die in the first Instead of moving decisively toward deep are therefore our focus here. As a result of week from the direct effects of the explo- cuts of their nuclear arsenals and mak- these, we have come to understand that it is sions, fire and local radiation [32]. ing plans for the eventual elimination of not just large scale nuclear war between the nuclear weapons, the nuclear-armed states US and Russia that poses a global threat. A The global consequences-global climate are reaffirming the importance of nuclear series of studies have shown that localized, disruption and resultant famine-would be

88 Table. Modernization Activities of the Nine Nuclear-armed States

Russia France • replacing all Soviet-era SS-18, SS-19 and SS-25 intercon- • modernizing its SSBN fleet with the new M51 SLBM that tinental ballistic missiles (ICBMs) by the early-2020s with will soon receive a new warhead. different versions of the SS-27 and a new “heavy” silo-based • arming its bomber force with ALCMs. ICBM. • replacing Mirage 2000N aircraft with the Rafale which will • building eight new ballistic missile submarines (SSBNs) be armed with a new ALCM. with the new SS-N-32 (Bulava) missile to replace eight op- United Kingdom erational Soviet-era Delta-class SSBNs and their missiles. • developing a new SSBN class to replace the current Van- • upgrading its old Tu-160 (Blackjack) and Tu-95MS (Bear) guard-class SSBNs which will carry the life-extended Tri- bombers so they can continue to operate until a new bomber dent II D5 with a new guidance system. can replace them sometime in the 2020s. • equipping current SLBMs with enhanced warheads. • gradually replacing the old AS-15 air-launched cruise missile (ALCM) with a new ALCM known as the Kh-102. Pakistan • modernizing some of its non-strategic nuclear forces, re- • deploying new and longer-range Shaheen-III ballistic mis- placing the old SS-21 short-range ballistic missile (SRBM) siles, Ra’ad ALCMs, Babur ground-launched cruise mis- with the SS-26 (Iskander), replacing the old SS-N-21 siles, and developing a nuclear SLCM. sea-launched land-attack cruise missile (SLCM) with the • deploying a tactical nuclear weapon, the 60-kilometer SS-N-30A (Kalibr), and replacing the old Su-24 (Fencer) NASR missile. fighter-bomber with the Su-34 (Fullback). • increasing production of fissile material for additional warheads. United States • building a new fleet of 12 SSBNs to replace the current 14 India SSBNs. The new submarines will carry an improved version • deploying and developing longer-range ballistic missiles of the Trident II D5 sea-launched ballistic missile (SLBM) that can target all of Pakistan and China, including several with new guidance system and enhanced warheads. new versions of the Agni missile family. • modernizing its B-2 and B-52 bombers and developing the • conducting sea-trials of its first SSBN, which will carry new new B-21 stealth-bomber to replace the B-52s (and B-1s) types of SLBMs. from the late-2020s. • building new reactors that can produce plutonium for ad- • developing a new guided nuclear bomb (B61-12) with in- ditional warheads and expanding uranium enrichment ca- creased accuracy, and a new ALCM with longer range and pacity enhanced warhead. Israel • designing a new ICBM with enhanced warheads to replace • modernizing its Jericho ballistic missiles and probably also the current Minuteman III ICBM by 2030. its fighter-bombers. • modernizing its non-strategic nuclear forces by replacing • Possibly equipping its new German-built Dolphin-class F-16s (and eventually F-15E) fighter-bombers with the F- submarines with a nuclear cruise missile. 35A stealthy fighter-bomber that will be carrying the new B61-12 guided nuclear bomb. North Korea • deploying two new ballistic missiles (Musudan and Hwa- China song-13) that could potentially in the future be equipped • replacing old liquid-fuel land-based missiles with DF-26 with weaponized versions of the nuclear devices it has tested. and DF-31A solid-fuel missiles on road-mobile launchers. • developing a new longer-range missile. • equipping some of its missiles with multiple warheads. • deploying a small fleet of Jin-class SSBNs with the new Jl-2 SLCBM.

BACK TO CONTENTS 89 far more devastating. The fires caused by In addition, there are nearly a billion people that cold since the last ice age. In the tem- these nuclear weapons would loft 6.5 mil- in China with incomes of $5 a day or less perate regions of the Northern Hemisphere, lion tons of soot into the upper atmosphere. who are adequately fed today, but who have the temperature would fall below freezing The impact of this soot has been examined shared little in China’s growing prosperity for some portion of every day for at least two by three teams of climate scientists using over the last several decades. All of these years [43]. Under these conditions food pro- three different climate models and mak- people, around two billion, would be at risk duction would stop and the vast majority of ing the conservative assumption that only under the potential famine conditions that the human race would starve. 5 million tons of soot are injected into the would result from this limited, regional nu- atmosphere [33-35]. Each model shows clear war [40]. Large scale war between the significant drops in average surface temper- US and Russia would be far worse. In early Efforts to Eliminate ature and average precipitation across the 2016, Russia and the US were estimated to Nuclear Weapons globe with the effects lasting for more than possess 7300 and 6970 nuclear warheads re- a decade. The most sophisticated and recent spectively, 93% of the global total of 15,375. Understanding of the unprecedented ex- model shows the most persistent declines in Under the provisions of the New START istential threat posed by nuclear weapons temperature and precipitation, which have treaty, each of these countries will retain was widely recognized in the very first not yet returned to baseline after 26 years, some 1550 strategic (long range) nuclear resolution of the United Nations General as long as the model was run. While the warheads when the Treaty is fully imple- Assembly in January 1946, calling for the fuel density of modern cities varies, there mented in 2018. Most of these weapons elimination of atomic weapons [44]. The is nothing specific to India/Pakistan about are 10 to 50 times more powerful than the preamble of the 1970 nuclear Non-Prolif- such a scenario. Nuclear weapons are ex- bombs which destroyed Hiroshima [41]. A eration Treaty (NPT) opens: “Considering tremely efficient at igniting, over large areas, 2002 study showed that if just 300 of the the devastation that would be visited upon simultaneous fires which rapidly coalesce weapons in the Russian arsenal hit urban all mankind by a nuclear war and the conse- and inject large volumes of soot and smoke targets in the US, 75 to 100 million people quent need to make every effort to avert the into the stratosphere. would die in the first half hour from the danger of such a war …” [45]. Yet for most firestorms and explosions [42]. This attack of the past 70 years, the shared interests of This climate disruption would in turn have would also destroy most of the infrastruc- humanity, based on the real consequences profoundly negative impact on food pro- ture – the electric grid, internet, banking of any use of nuclear weapons, have been duction. The maize crop in the US, the and public health systems, food distribution sidelined by the perceived interests of the 9 world’s largest producer, would decline an network – needed to support the rest of the governments that possess and threaten use average by 12% over a full decade [36]. In population, most of who would succumb to of nuclear weapons, which have dictated the China, the world’s largest producer of grain, exposure, starvation and epidemic disease in pace and extent of nuclear arms control and middle season rice would decline by 17% the months following. A US counterattack disarmament. However, the obligation to over a full decade, maize by 16%, and winter would be expected to cause the same level pursue effective measures towards nuclear wheat, by a truly catastrophic 31% [37]. of destruction in Russia, and if NATO were disarmament is a shared responsibility of all involved in the conflict, Canada and much 190 NPT signatory states, and the Interna- Under current conditions, adequate human of Europe would face similar destruction. tional Court of Justice in its 1996 Advisory nutrition cannot be sustained in the face of Opinion on nuclear weapons unanimously declines of food production of this magni- These direct effects are only part of the sto- ruled that there exists an obligation not only tude. Total world grain reserves in January ry, however. As is true for a limited war in to pursue in good faith, but to bring to a 2016 amounted to only 84 days of global South Asia, the global climate effects would conclusion, negotiations leading to nuclear consumption, and would not begin to offset be far worse. A war involving only the stra- disarmament [46]. the shortfall over a full decade [38]. Fur- tegic weapons that will still be deployed thermore, there are currently 795 million when New START is fully implemented The contemporary ‘Humanitarian Initiative’ people who are already undernourished at would put some 150 million tons of soot in on nuclear weapons began with Interna- baseline [39]. There are also some 300 mil- the upper atmosphere, and drop tempera- tional Committee of the Red Cross (ICRC) lion people who enjoy adequate nutrition tures around the world by 8°C. In the inte- president Jacob Kellenberger informing the today, but live in countries highly depen- rior regions of North America and Eurasia, Geneva Diplomatic Corps in 2010 that the dent on food imports which would probably temperatures would fall by 25 to 30°C. These world’s largest humanitarian organization not be available as grain exporting countries conditions would persist for more than a de- would make elimination of nuclear weap- suspended exports to feed their own people. cade. Temperatures on Earth have not been ons – something it first called for on 5 Sep-

90 tember 1945 – a renewed priority [47]. A few structive and indiscriminate of all weapons flows from a long history of medical and weeks later, the five yearly 2010 NPT Review are the only weapon of mass destruction not scientific concern about nuclear weapons. Conference outcome document referred for yet explicitly prohibited under international After the hydrogen bomb code named Cas- the first time to “deep concern about the law [54]. At the end of Vienna conference, tle Bravo was detonated at Bikini Atoll with catastrophic consequences of any use of nu- the Austrian government issued a pledge a yield of around 15 megatons (millions of clear weapons” [48]. In 2011, the Council of “to cooperate with all relevant stakeholders tons of TNT equivalent), double that pre- Delegates, the highest governing body of the … to stigmatize, prohibit and eliminate nu- dicted, there was widespread protest from Red Cross/Red Crescent Movement, called clear weapons in light of their unacceptable many world leaders together with Albert on all states “to ensure that nuclear weapons humanitarian consequences and associated Einstein and the Federation of American are never again used”, and “to pursue in good risks”; to “fill the legal gap for the prohibi- Scientists [62]. In 1957, as atmospheric faith and conclude with urgency and deter- tion and elimination of nuclear weapons” testing of nuclear weapons continued un- mination negotiations to prohibit the use [55]. As of 20 March 2016, 127 states have abated, an appeal from Albert Schweitzer of and completely eliminate nuclear weap- endorsed this Humanitarian Pledge, with for a ban on nuclear tests was broadcast to ons through a legally binding international an additional 22 states voting in favour audiences in 50 nations and a petition initi- agreement, based on existing commitments of a resolution bringing the Pledge to the ated by Linus Pauling, 1954 Nobel laure- and international obligations” [49]. A special UNGA [56]. ate in Chemistry, also demanding a test ban issue of the Movement’s flagship journal, the was signed by 9000 scientists in 43 coun- International Review of the Red Cross, “The The General Assembly also voted over- tries. Pauling was awarded the Nobel Peace human costs of nuclear weapons”, was re- whelmingly to establish an Open Ended Prize in 1963 for his opposition to nuclear cently published. Working Group (OEWG) to address testing. Also in 1957 the British Atomic this legal gap, which is open to all states Scientists’ Beginning in 2012, at every NPT meet- but thus far boycotted by all the nuclear- ing and UN General Assembly (UNGA), a armed states. It will report back to the 2016 Association set up a committee to assess the growing number of states, from 16 in 2012 UNGA on effective legal measures required risks of cancer arising from the fallout from to 144 in 2015, have supported resolutions to attain and maintain a world free of nucle- atmospheric nuclear tests, chaired by Pro- affirming the centrality of humanitarian ar weapons. At its first substantive sessions fessor Joseph Rotblat, a medical physicist considerations in advancing nuclear dis- in February and May 2016, numerous states (and during the 2nd World War an atomic armament, and the need to prevent use of made proposals for negotiations for a new scientist, working on the atomic bomb at nuclear weapons under any circumstances treaty prohibiting nuclear weapons, some Los Alamos). It concluded that for every [50]. In 2013 and 2014 three successive with detailed proposals for the content of 1 megaton exploded in the atmosphere, fact-based international conferences on the such a treaty and for specific timelines [57]. around 1000 people were likely to develop Humanitarian Impact of Nuclear Weapons This is increasingly seen as the most prom- bone cancers, and made other estimates of were held in Norway [51], Mexico [52] and ising and realistic step which could now be the likely health consequences of atmo- Austria [53], the last with participation of taken by the states determined to progress spheric nuclear testing [63]. 146 states. Remarkably, 68 years into the the eradication of nuclear weapons. Trea- nuclear age, these were the first ever inter- ties unequivocally prohibiting unacceptable A series of four [64-67] influential articles governmental meetings dedicated to the weapons and providing for their subsequent appeared in the New England Journal of humanitarian impacts of nuclear weapons. elimination has been the approach success- Medicine in 1962 describing the medical There was no significant disagreement at fully used in relation to every other kind of effects of a thermonuclear attack on Mas- these conferences regarding the exten- indiscriminate, inhumane weapon – biolog- sachusetts, the (limited) role of the medical sive expert evidence presented, leading to ical, toxin [58] and chemical weapons [59], profession in dealing with the consequenc- the conclusions 1) that any use of nuclear followed by antipersonnel landmines [60] es, and the psychiatric and social aspects weapons would be catastrophic; 2) that no and cluster munitions [61]. of civil defence. The authors, who were effective humanitarian response was pos- members of a new organization Physicians sible to even a single nuclear detonation in for Social Responsibility, concluded that as an urban centre; 3) that the risk of nuclear The Role of the Health no effective clinical response was possible, weapons use had previously been underesti- Community doctors “must begin to explore a new area mated, is growing, and exists as long as the of preventive medicine, the prevention of weapons do; and 4) that there is a legal gap Involvement of the medical community in thermonuclear, chemical and biological for nuclear weapons, in that the most de- these efforts to eliminate nuclear weapons warfare”.

BACK TO CONTENTS 91 Negotiations on a ban on nuclear testing medical ethics and international law. The progress and efforts could come to nought continued inconclusively until 1963 because primary medical responsibility under such if we do not succeed in eradicating nuclear of concerns about the potential to conceal circumstances is to participate in attempts weapons before they are again used in war. clandestine tests. With evidence of wide- to prevent nuclear war”[72]. New evidence There has never been a better opportunity spread radioactive fallout and accumulation about the pervasive threats to health of the nor greater need for united and effective of strontium-90 in the deciduous teeth of detonation of even a small percentage of health professional engagement to remove children around the world, public opinion the world’s nuclear arsenals, together with the most acute existential threat to global swung strongly in favour of banning atmo- the failure of the Non-Proliferation Treaty health and survival. spheric nuclear testing and the Limited Test to prevent the retention and modernization Ban treaty was agreed in 1963, but progress of nuclear weapons has given impetus to a towards a comprehensive treaty proved new global movement to ban nuclear weap- References frustratingly slow. ons. The health professions therefore have a 1. http://archive.defense.gov/pubs/2014_Quad- central role in advocating for the abolition rennial_Defense_Review.pdf (accessed May 9, 2016). In the early 1980s a number of reports on of nuclear weapons, reflecting their ethical 2. http://www.cnn.com/2014/08/29/world/eu- the health effects of nuclear weapons ap- responsibility to protect health and prevent rope/ukraine-crisis/ (accessed April 21, 2016). peared including a BMA report of 1983 illness. 3. Frear T, Kulesa L, Kearns I. Dangerous Brink- which concluded that the casualties from manship: Close Military Encounters Between the detonation of a single megaton weapon In 2007, IPPNW founded the Internation- Russia and the West in 2014. European Leader- ship Network, November 2014. would overwhelm the resources of the en- al Campaign to Abolish Nuclear Weapons 4. Frear T, Kearns I, Kulesa L. Preparing for the tire UK National Health Service [68]. The (ICAN) – a broad global campaign coalition Worst: Are Russian and NATO Military Exer- World Health Assembly adopted a resolu- working for a treaty banning nuclear weap- cises Making War in Europe More Likely? Eu- tion in 1983 including reference to nuclear ons. ICAN now has 440 partner organisa- ropean Leadership Network, August 2015. weapons as “the greatest immediate threat tions in 98 countries, is the lead civil society 5. Sokov N. Why Russia calls a limited nuclear strike “de-escalation”. BAS 13 March 2014. http://the- to the health and welfare of mankind” partner for the governments hosting the bulletin.org/why-russia-calls-limited-nuclear- [69]. Scientific and medical evidence that Humanitarian conferences, and continues strike-de-escalation (accessed April 16, 2016). civil defence programs against nuclear war to grow as a major civil society coordinating 6. http://cisac.fsi.stanford.edu/news/stanford- provided at best an illusion of protection initiative and partner for governments seri- experts-reveal-latest-%E2%80%9Cdoomsday- led to their widespread abandonment [70]. ous about the humanitarian imperative for clock%E2%80%9D-estimate (accessed April 16, 2016). Evidence on the catastrophic health ef- nuclear disarmament. 7. http://www.reuters.com/article/us-ukraine-cri- fects of nuclear war brought by physicians sis-russia-idUSKCN0WL0EV accessed April to Presidents Ronald Reagan and Mikhail In Moscow in October 2015, the World 16 (accessed April 21, 2016). Gorbachev had profound effect, bringing Medical Association General Assembly 8. Mian Z, Ramana M. Going MAD: Ten Years of the Bomb in South Asia. Economic and Political them to declare in 1985 that “A nuclear war unanimously updated its Statement on Weekly 2008;43(26-27):201–8. cannot be won and must never be fought”; Nuclear Weapons, adopted in 1998 and 9. Mian Z. Pakistan-2015. Assuring Destruction to end their nuclear arms race; agree on the amended in 2008, requesting all National Forever: 2015 Edition, edited by Ray Acheson, elimination of intermediate range nuclear Medical Associations to educate their pub- Reaching Critical Will, New York, April 2015. missiles; and come close to an agreement lics and governments about the health im- 10. Ramana M. India-2015. Assuring Destruction Forever: 2015 Edition, edited by Ray Acheson, to eliminate their nuclear arsenals entirely. pacts of nuclear war and “to join the WMA Reaching Critical Will, New York, April 2015. Gorbachev wrote that without the efforts in supporting this Declaration and to urge 11. Lavoy P. editor, Asymmetric Warfare in South of IPPNW – awarded the Nobel Peace their respective governments to work to ban Asia: The Causes and Consequences of the Kar- Prize in 1985 – these disarmament initia- and eliminate nuclear weapons” [73]” gil Conflict (Cambridge University Press, Cam- tives “would probably have been impossible” bridge, 2009). 12. Ramana M, Mian Z. The Nuclear Confrontation [71]. Given the potential for nuclear war In April 2016, the WMA joined with in South Asia. SIPRI Yearbook 2003: Arma- to occur as a result of error and the lack of IPPNW, the World Federation of Public ments, Disarmament and International Secu- evidence that a planned medical response Health Associations and the International rity:195–212 (Oxford University Press, Oxford, can have any perceptible impact on the Council of Nurses, in submitting to the 2003). outcome, it has been suggested that “sup- UN Working Group the first such united 13. Ladwig W III. A Cold Start for Hot Wars? The Indian Army’s New Limited War Doctrine. In- port for deterrence with these weapons as a statement detailing the health and humani- ternational Security 2007/2008; 32(3):158–90. policy for national or global security appears tarian imperative to ban and eliminate nu- 14. Nayyar A, Mian Z. Pakistan and the Nasr Mis- 4 to be incompatible with basic principles of clear weapons [74] All other global health sile: Searching for a Method in the Madness.

92 Economic and Political Weekly 2015; 50(39): 32. Toon O, Turco R, Robock A, Bardeen C, Oman icj-cij.org/docket/index.php?p1=3&p2=4&k= 62–6. L, Stenchikov G. Atmospheric effects and so- e1&p3=4&case=95 (accessed May 6, 2016). Kel- 15. Hoodbhoy P, Mian Z. Securing Pakistan’s Nu- cietal consequences of regional scale nuclear lenberger J. Bringing the era of nuclear weapons clear Arsenal – The Threat from Within. -Nu conflicts and acts of individual nuclear terrorism. to an end. Statement to the Geneva Diplomatic clear Terrorism: Countering the Threat, edited Atm Chem Phys 2007; 7:1973–2002. Corps, Geneva, 20 April 2010. https://www.icrc. by Volders B, Sauer. (Routledge Global Security 33. Robock A, Oman L, Stenchikov G, Toon O, org/eng/resources/documents/statement/nucle- Studies Series, New York, 2016): 182–94. Bardeen C, Turco R. Climatic consequences ar-weapons-statement-200410.htm (accessed 16. Barry E, Kumar. Mumbai Attacks Plotter Says of regional nuclear conflicts. Atm Chem Phys May 6, 2016). Pakistan’s Spy Agency Played a Role. New York 2007;7:2003–12. 48. 2010 Review Conference of the Parties to the Times, 8 February 2016. 34. Mills M, Toon O, Lee-Taylor J, Robock A. Treaty on the Non-Proliferation of Nuclear 17. Craig T. Clashes erupt between India and Paki- Multi-decadal global cooling and unprec- Weapons. Final Document Vol 1 Part 1 Con- stan along disputed border. Washington Post, 28 edented ozone loss following a regional nu- clusions and recommendations for follow-on August 2015. clear conflict. Earth’s Future 2015; 2:161–76, actions. NPT/CONF.2010/50 (Vol. 1). New 18. https://www.whitehouse.gov/the-press-of- doi:10.1002/2013EF000205. York: United Nations, 2010. http://www.reach- fice/2016/04/04/press-briefing-press-secretary- 35. Stenke A, Hoyle CR, Luo B, et al. Climate and ingcriticalwill.org/images/documents/Disarma- josh-earnest-4416 (accessed April 16, 2016). chemistry effects of a regional scale nuclear con- ment-fora/npt/revcon2010/FinalDocument.pdf 19. Hoodbhoy P, Mian Z. Nuclear battles in South flict. Atm Chem Phys 2013,13:9713–29. (accessed May 6, 2016). Asia. Bulletin of the Atomic Scientists, 4 May 36. Özdoğan M, Robock A, Kucharik C. Impacts 49. International Committee of the Red Cross. 2016, http://thebulletin.org/nuclear-battles- of a nuclear war in South Asia on soybean Council of Delegates 2011: Resolution 1. Work- south-asia9415 (accessed May 5 2016). and maize production in the Midwest United ing towards the elimination of nuclear weapons. 20. Mian Z, Ramana M. Asian War Machines. States. Climatic Change 2013;116:373–87, Geneva: ICRC, 2011. http://www.icrc.org/eng/ Critical Asian Studies 2014; 46(2):345–60. doi:10.1007/s10584-012-0518-1. resources/documents/resolution/council-dele- 21. http://edition.cnn.com/2016/03/06/asia/ 37. Xia L, Robock A, Mills M, Stenke A, Helfand. gates-resolution-1-2011.htm (accessed May 6, north-korea-preemptive-nuclear-strike-threat/ Decadal reduction of Chinese agriculture after a 2016). (accessed April 18. 2016). regional nuclear war. Earth’s Future 2015; 3:37– 50. UN General Assembly. Humanitarian con- 22. http://www.nti.org/learn/countries/north-ko- 48, doi:10.1002/2014EF000283. sequences of nuclear weapons. Resolution. rea/ (accessed April 18, 2016). 38. http://www.usda.gov/oce/commodity/wasde/ A/C.1/70/L.37. New York: United Nations, 23. Lewis P, Williams H, Pelopidas B, Aghlani S. latest.pdf (accessed January 24, 2016). 2015. http://reachingcriticalwill.org/disarma- Too Close for Comfort: Cases of Near Nuclear 39. https://www.wfp.org/hunger/stats accessed ment-fora/unga/2015/resolutions (accessed Use and Options for Policy. Chatham House April 17,2016 (accessed April 17, 2016). May 6, 2016). Report, April 2014. 40. Helfand I. Nuclear Famine: Two Billion People 51. Ministry of Foreign Affairs (Norway). www. 24. Postol T. How the US Nuclear Weapons Mod- at Risk. International Physicians for the Preven- regjeringen.no/en/topics/foreign-affairs/hu- ernization Program Is Increasing the Chances tion of Nuclear War, 2013. http://www.ippnw. manitarian-efforts/humimpact_2013/id708603/ of Accidental Nuclear War with Russia. lecture org/nuclear-famine.html (accessed April 17, (accessed May 6, 2016). Harvard College, February 25, 2016. 2016). 52. Chair’s Summary. Second Conference on the 25. http://www.sfchronicle.com/opinion/openfo- 41. Kristensen H, Norris. op. cit Humanitarian Impact of Nuclear Weapons. Na- rum/article/What-happens-when-our-nuclear- 42. Helfand I, Forrow L, McCally M, Musil R. yarit: Government of Mexico, 2014. http://www. arsenal-is-hacked-6333739.php (accessed April Projected US Casualties and Destruction of US reachingcriticalwill.org/images/documents/Dis- 16, 2016). Medical Services From Attacks by Russian Nu- armament-fora/nayarit-2014/chairs-summary. 26. Schlosser. Command and Control. Penguin clear Forces. Medicine & Global Survival 2002; pdf (accessed May 6, 2016). Press, London, 2013. 7(2):68–76. 53. Europe Integration and Foreign Affairs Fed- 27. Kristensen H, Norris R. Status of World Nu- 43. Robock A, Oman L, Stenchikov G. Nuclear eral Ministry, Republic of Austria. Report and clear Forces. Federation of American Scientist, winter revisited with a modern climate model Summary of Findings of the Conference, Vi- 2016 http://fas.org/issues/nuclear-weapons/ and current nuclear arsenals: Still catastrophic enna Conference on the Humanitarian Im- status-world-nuclear-forces/ (accessed April 16, consequences. J Geophys Res 2007;112:D13107, pacts of Nuclear Weapons, 9 Dec 2014. https:// 2016) doi:2006JD008235. www.bmeia.gv.at/fileadmin/user_upload/Zen- 28. Kristensen H. World Nuclear Weapon Mod- 44. United Nations General Assembly. Resolution trale/Aussenpolitik/Abruestung/HINW14/ ernization Programs. http://fas.org/wp-content/ UNGA Res. 1, 24 January 1946: Establishment HINW14_Chair_s_Summary.pdf (accessed uploads/2014/05/Brief2015_NPT1a.pdf (ac- of a Commission to deal with the problems May 6, 2016). cessed April 16, 2016). raised by the discovery of atomic energy. 54. Europe Integration and Foreign Affairs Fed- 29. http://www.nytimes.com/2016/04/17/science/ 45. Treaty on the Non-Proliferation of Nuclear eral Ministry, Republic of Austria. Humanitar- atom-bomb-nuclear-weapons-hgv-arms-race- Weapons (NPT), 1 July 1968, 729 UNTS 161. ian Pledge. https://www.bmeia.gv.at/fileadmin/ russia-china.html accessed April 21 2016. https://www.iaea.org/publications/documents/ user_upload/Zentrale/Aussenpolitik/Abrues- 30. World Health Organization, Effects of Nuclear infcircs/treaty-non-proliferation-nuclear-weap- tung/HINW14/HINW14vienna_Pledge_Doc- War on Health and Health Service, 2nd ed. Ge- ons (accessed May 6, 2016). ument.pdf (accessed May 6, 2016). neva, 1987. 46. International Court of Justice. Legality of the 55. Europe Integration and Foreign Affairs Fed- 31. Institute of Medicine, The Medical Implications Threat or Use of Nuclear Weapons: eral Ministry, Republic of Austria. Support of Nuclear War, National Academy Press. Wash- 47. Advisory Opinion of 8 July 1996. Hague: In- for Pledge. https://www.bmeia.gv.at/filead- ington, 1986. ternational Court of Justice, 1996. http://www. min/user_upload/Zentrale/Aussenpolitik/

BACK TO CONTENTS 93 Abruestung/HINW14/HINW14vienna_up- setts of an assumed thermonuclear attack Ira Helfand, MD date_pledge_support.pdf (accessed May 6, on the United States. N Engl J Med 1962; Co-President, International Physicians 2016). 266:1127-37. 56. UN General Assembly. Taking forward mul- 65. Sidel V, Geiger.J, Lown B. The physician’s role for the Prevention of Nuclear War, tilateral nuclear disarmament negotiations. in the postattack period. N Engl J Med 1962; Malden, Massachusetts, 413 320 7829, Resolution. A/C.1/70/L.13/Rev.1. New York: 266:1137-45. E-mail: [email protected] United Nations, 2015. http://reachingcriti- 66. Leiderman PH, Mendelson JH. Some psychiat- calwill.org/images/documents/Disarmament- ric considerations in planning for defense shel- Andy Haines, So P fora/1com/1com15/resolutions/L13Rev1.pdf ters. N Engl J Med 1962; 266:1149-55. Professor, Departments of Social and (accessed May 6, 2016). 67. Aronow S. A glossary of radiation terminology. 57. Reaching Critical Will. May session of the 2016 N Engl J Med 1962; 266:1145-9. Environmental Health Research and of open-ended working group on nuclear disar- 68. British Medical Association. The medical effects Epidemiology and Population Health, mament. http://www.reachingcriticalwill.org/ of ’ nuclear war. Chichester: Wiley, 1983 London School of Hygiene and Tropical disarmament-fora/oewg/2016/may (accessed 69. The role of Physicians and other health Medicine, London, WC1H 9SH, May 6, 2016). workers in the preservation of peace as the E-mail: [email protected] 58. Convention on the Prohibition of the Develop- most significant factor for the attainment of ment, Production and Stockpiling of Bacterio- health for all http://apps.who.int/iris/bit- logical (Biological) and Toxin Weapons and on stream/10665/160590/1/WHA36_R28_eng. Tilman Ruff, Their Destruction. http://www.apminebancon- pdf (accessed May 9th 2016). FRACP, Nossal Institute for Global Health, vention.org/overview-and-convention-text/ (ac- 70. Leaning J, Keyes L. The counterfeit ark. Crisis School of Population and Global Health, cessed May 6, 2016). relocation for nuclear war. Cambridge (MA): University of Melbourne, Melbourne, 59. Convention on the Prohibition of the Devel- Ballinger, 1984. Co-President, International Physicians opment, Production, Stockpiling and Use of 71. Gorbachev MS. Perestroika. New Thinking for Chemical Weapons and on their Destruction. Our Country and the World. New York: Harper for the Prevention of Nuclear War, https://www.opcw.org/chemical-weapons-con- & Row; 1988. E-mail: [email protected] vention/ (accessed May 6, 2016). 72. Haines A, White c de B, Gleisner J. Nuclear 60. Convention on the Prohibition of the Use, weapons and medicine; some ethical dilemmas. Hans Kristensen Stockpiling, Production and Transfer of Anti- Journal of Medical Ethics 1983: 9:200-6. Federation of American Scientists, Personnel Mines and on their Destruction. 73. World Medical Association. WMA Statement Washington DC, www.icrc.org/ihl/INTRO/580 (accessed May on Nuclear Weapons. 66th WMA General As- 6, 2016). sembly, Moscow, Russia, October 2015. www. E-mail: [email protected] 61. Convention on Cluster Munitions. http://www. wma.net/en/30publications/10policies/n7/ (ac- clusterconvention.org/the-convention/conven- cessed May 9, 2016). Patricia Lewis, PhD tion-text/ (accessed May 6, 2016). 74. UN General Assembly. The health and humani- Chatham House, London, 62. Haines A, Hartog M. Doctors and the Test Ban: tarian case for banning and eliminating nuclear E-mail: [email protected] 25 years on. BMJ 1988;297:408–411 weapons. Working paper A/AC.286/NGO/18, 63. British Atomic Scientists’ Association. Stron- 4 May 2016. https://ippnweupdate.files.word- tium hazards. Bulletin of- the Atomic Scientists press.com/2016/04/health-and-humanitarian- Zia Mian, PhD 1957;XIII:202–3. case-for-banning-and-eliminating-nuclear- Program on Science and Global Security, 64. Ervin FR, Glazier JB, Aronow S, et al. Hu- weapons_oewg-may-2016.pdf (accessed May 6, Princeton University, Princeton, NJ, man and ecologic effects in Massachu- 2016). E-mail: [email protected]

94 WMA Calls on Governments to Ban and Eliminate Nuclear Weapons

World Medical Association (WMA) use of nuclear weapons and to work in good faith towards the Statement on Nuclear Weapons elimination of nuclear weapons; Adopted 17 October 2015 2.3 Advises all governments that even a limited nuclear war would bring about immense human suffering and substantial The WMA Declarations of Geneva, of Helsinki and of Tokyo death toll together with catastrophic effects on the earth’s ecosys- make clear the duties and responsibilities of the medical profession tem, which could subsequently decrease the worlds food supply to preserve and safeguard the health of the patient and to conse- and would put a significant portion of the world’s population at crate itself to the service of humanity. The WMA considers that it risk of famine; and has a duty to work for the elimination of nuclear weapons. 2.4 Requests that all National Medical Associations join the WMA in supporting this Declaration, use available educational Therefore the WMA: resources to educate the general public and to urge their respective governments to work towards the elimination of nuclear 2.1 Condemns the development, testing, production, stockpiling, weapons. transfer, deployment, threat and use of nuclear weapons; 2.5 Requests all National Medical Associations to join the WMA 2.2 Requests all governments to refrain from the development, in supporting this Declaration and to urge their respective govern- testing, production, stockpiling, transfer, deployment, threat and ments to work to ban and eliminate nuclear weapons.

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