Nuclear War

!e Growing !reat of Nuclear War and the Role of the Health Community

Ira Helfand Andy Haines Tilman Ru! Hans Kristensen Patricia Lewis Zia Mian

!e Growing Risk of Crimea, the European Leadership Net- In this setting prominent leaders on both of Nuclear War work (ELN) documented a large increase sides have expressed alarm about the grow- in incidents involving close encounters ing danger of nuclear war. After the end of the Cold War the in- between nuclear capable NATO and Rus- tense military rivalry between the Soviet sian military forces. A report issued by the Speaking in January, when the Bulletin of Union and the United States/NATO was ELN concluded, “"ese events add up to the Atomic Scientists announced that its replaced by a much more cooperative re- a highly disturbing picture of violations would remain at three lationship, and fears of war between the of national airspace, emergency scrambles, minutes to midnight, former US Secre- nuclear superpowers faded. As recently narrowly avoided mid-air collisions, close tary of Defence William Perry stated, “"e as the 2014 US Quadrennial Defence encounters at sea, simulated attack runs danger of a nuclear catastrophe today, in Review, con!ict between the two former and other dangerous actions happening on my judgment is greater that it was during adversaries was not considered a realistic a regular basis over a very wide geographi- the Cold War … and yet our policies sim- possibility [1]. cal area” [3]. Further, both sides have con- ply do not re!ect those dangers” [6]. His ducted large scale military exercises in Eu- assessment was echoed two months later Unfortunately, relations between Rus- rope, leading the ELN to conclude, “Russia by Igor Ivanov, Russian Foreign Minister sia and the US/NATO have deteriorated is preparing for a con!ict with NATO, and from 1998 to 2004. Speaking in Brussels dramatically since then. In the Syrian and NATO is preparing for a possible con- on March 18, Ivanov warned that, “"e risk Ukrainian wars, the two have supported op- frontation with Russia” [4]. "e danger of confrontation with the use of nuclear posing sides, raising the possibility of open inherent in this situation is magni#ed by weapons in Europe is higher than in the military con!ict and fears that such con!ict the current Russian military doctrine of 1980’s” [7]. "e increased tensions between could escalate to nuclear war. “nuclear de-escalation”. Rather than seeing the US and Russia have been matched by a nuclear weapons purely as a deterrent to similar escalation in the danger of nuclear Over the past two years, both sides have nuclear attack, this doctrine embraces “the war in South Asia. engaged in nuclear sabre rattling that is idea that, if Russia were faced with a large- reminiscent of the worst periods of the scale conventional attack that exceeded its Since the nuclear weapon tests of May 1998 Cold War. Speaking about the con!ict in capacity for defence, it might respond with by India and then Pakistan, the two states Ukraine in August 2014, Russian Presi- a limited nuclear strike” in order to force have expanded many-fold their respective dent Vladimir Putin warned “it is better the other side to quickly end the con!ict nuclear weapon and #ssile material stock- not to come against Russia as regards a and return to the status quo ante” [5]. US/ piles, and undertaken extensive develop- possible armed con!ict … I want to re- NATO military planning has always envi- ment and testing of a diverse array of ballis- mind you that Russia is one of the most sioned possible #rst use of nuclear weapons tic and cruise missiles (with ranges from 60 powerful nuclear nations” [2]. In the in the face of a Soviet/Russian convention- to 5000 km) to acquire the ability to deploy months following the Russian annexation al attack in Europe. and launch nuclear weapons from the air,

86 Nuclear War

from land, and from submarines at sea. "ey In April 2016, at the conclusion of the Nu- and again in 1980 computer errors in the have put in place command and control sys- clear Security Summit, the White House US caused American radar systems to dis- tems and doctrines that involve, in the case Press secretary expressed concern about, play, incorrectly, incoming Soviet missiles of Pakistan, #rst use of nuclear weapons in “the risk that a conventional con!ict be- on their monitors. In September 1983, a con!ict and, in the case of India, massive tween India and Pakistan could escalate to Soviet military radar incorrectly reported retaliatory strikes against population centres include the use of nuclear weapons” [18]. a NATO attack in progress. In November [8–10]. Should Pakistan use nuclear weapons of that year the Soviet leadership incor- against Indian conventional forces in such rectly concluded that a NATO military In May-July 1999, the two countries fought a situation, Indian nuclear doctrine calls for exercise was the cover for an actual attack a war which apparently included mobiliza- massive retaliation directed at Pakistani cit- that was about to be launched. On Janu- tion of nuclear weapons by Pakistan, mak- ies and Pakistan has threatened to respond ary 25, 1995, a full 5 years after the end ing it the most signi#cant military con!ict in kind. of the Cold War, Russian military radar between two nuclear armed states [11]. incorrectly identi#ed a Norwegian Black "ey also went through a major military With Pakistan building ever closer mili- Brant XII rocket launched to study the crisis (December 2001 to June 2002) trig- tary and economic ties to China, and India aurora borealis as a Trident missile aimed gered by an attack on India’s parliament by becoming a strategic partner of the United at Moscow. Islamist militants believed in India to be States, such a future South Asian con!ict backed by Pakistan, which included the two may quickly take on a global dimension In each of these situations preparations for countries moving a combined total of over given the increasingly tense nature of the a counterstrike were initiated and nuclear half a million troops to their border [12]. great power rivalry between China and the war was averted by minutes. "e slow pace of Indian deployment and US [20]. inconclusive outcome of the stand-o% led "e danger of this kind of mistake oc- India’s army to begin planning and train- North Korea has a track record of repeatedly curring again is ampli#ed by current de- ing for a more decisive and rapid conven- threatening the use of nuclear weapons; for #ciencies in Russian radar warning sys- tional attack on Pakistan [13]. Pakistan example, in March 2016 it warned it would tems. Russia has no space-based satellite began testing a short-range truck-mounted make a “pre-emptive and o%ensive nuclear early warning systems to alert them to the mobile missile to deliver low-yield nuclear strike” in response to joint US-South Ko- launch of nuclear-armed ballistic missiles weapons on the battle#eld [14]. "is latter rean military exercises [21]. It is capable of from the ocean, so their warning time development has increased long-standing enriching uranium and producing weapons- could be as short as 10 to 15 minutes. "e international concerns about the security grade plutonium and has deployed short- only way for Russia to guarantee the abil- of nuclear weapons and #ssile materials in and medium-range ballistic missiles as well ity to launch its forces before they are de- Pakistan given the large-scale and frequent as testing long–range missiles [22]. stroyed by a pre-emptive attack would be Islamist militant attacks on military targets to pre-delegate launch authority to #eld in the country and the ideological polariza- commanders. Under these conditions, the tion within the armed forces and broader Unintended Use of time pressure to make a launch decision society associated with the rise of hard-line Nuclear Weapons could greatly increase the chance of an ac- Islamist political groups over the past three cidental launch, especially if a computer decades [15]. While these growing tensions amongst nu- error caused a false warning of attack dur- clear armed states could lead to the deliber- ing a crisis [24]. Recently, military lead- Potential triggers for armed con!ict be- ate use of nuclear weapons, there is also the ers have begun to warn of a new threat tween Pakistan and India include another continuing danger that they could trigger that might cause the unintended launch major attack on India by Islamist militant the unintended or accidental use of these of nuclear weapons: . In a groups like the one in Mumbai in Novem- weapons. June 2015 speech, retired Marine Gen. ber 2008 that was linked to intelligence James Cartwright, former head of the agencies in Pakistan [16]. A second possible "ere have been at least #ve occasions US Strategic Command, warned that it trigger is the recurring artillery exchanges since 1979 when either Washington or might be possible for terrorists to hack along the line of control in Kashmir, and oc- Moscow prepared to launch nuclear weap- into Russian or American command and casionally the international border between ons in the mistaken belief that the other control systems and launch one or more Pakistan and India, which often claim sig- side had already launched a nuclear attack nuclear missiles, a launch which would ni#cant military and civilian casualties [17]. or was preparing to do so [23]. In 1979 have a high probability of triggering a

BACK TO CONTENTS 87 Nuclear War

8000 wider nuclear con!ict. "is danger is in- 7300 6970 tensi#ed by the continued US and Rus- 7000 sian policy of maintaining their missiles on hair trigger alert, fully prepared for use 6000 Retired and simply awaiting an order to launch 5000 Stockpiled [25]. "ere is also extensive evidence that individuals with responsibility for nuclear 4000 Deployed weapons have breached safety regulations. Note: North Korea has produced fissile 3000 material for 10–12 warheads and detonated In 2003, for example, half of the US Air 4 test assemblies, but we’re not aware of public information that shows it has yet Force units responsible for nuclear weap- 2000 stockpiled weaponized warheads. ons safety failed their safety inspections. In 2007 six cruise missiles armed with 1000 300 260 nuclear warheads were mistakenly loaded 215 130 120 80 0 onto a B-52 bomber which sat on the tarmac overnight without armed guards Russia USA France China UK Pakistan India Israel before taking o% and !ying 1500 miles in violation of regulations which prohibit Figure. Estimated Global Nuclear Warhead Inventories, 2016 transportation of nuclear weapons by air over the USA [26]. South China Sea are causing nuclear-armed tion to the impacts of nuclear war on cli- states to increase the role of their nuclear mate, agriculture and nutrition that scien- forces. ti#c advances of the greatest moment have Nuclear Weapons been made in the past decade, and these are Modernization Instead of moving decisively toward deep therefore our focus here. As a result of these, cuts of their nuclear arsenals and mak- we have come to understand that it is not "e nuclear danger is ampli#ed further by ing plans for the eventual elimination of just large scale nuclear war between the US the extensive plans of all nine nuclear armed nuclear weapons, the nuclear-armed states and Russia that poses a global threat. A se- states to enhance their nuclear arsenals. are rea&rming the importance of nuclear ries of studies have shown that localized, 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 e%ects worldwide. weapons has declined signi#cantly 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 "e 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]. (Figure) Weapon*” OR “nuclear war*” OR “atomic weapon*” OR “atomic war*” OR “nuclear While Russia, the US, and Britain con- !e Health Consequences con!ict*”) 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 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 con!ict. nuclear arsenals. "e scenario that has been studied most fre- "e acute e%ects of nuclear weapons are quently is a limited nuclear war between In- "ere 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. ("is 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 e%ects in recent decades, it is in rela- war in South Asia: the combined arsenals

88 Nuclear War

Table. Modernization Activities of the Nine Nuclear-armed States

Russia France 5R55, *&#(!5&&5)0# .7 ,57gn657go5(57hk5#(. ,)(- 5R55') ,(#4#(!5#.-55ł .51#."5." 5( 15 kg5  5.".5 tinental ballistic missiles (ICBMs) by the early-2020s with will soon receive a new warhead. di%erent versions of the SS-27 and a new “heavy” silo-based 5R55,'#(!5#.-5)' ,5 ), 51#."5  -8 ICBM. 5R55, *&#(!5 #,! 5hfff5#,, .51#."5." 5 & 51"#"51#&&5 5R55/#&#(!5 #!".5 ( 15 &&#-.#5 '#--#& 5 -/',#( -5 B-C5 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. 5R55 0 &)*#(!55( 155&--5.)5, *& 5." 5/,, (.5(- 5R55/*!,#(!5#.-5)&5/7glf5B&%$%C5(5/7ok 5B ,C5 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. 5R55 +/#**#(!5/,, (.5  -51#."5 ("( 51," -8 5R55!,/&&35, *&#(!5." 5)&57gk5#,7&/(" 5,/#- 5'#-- sile (ALCM) with a new ALCM known as the Kh-102. Pakistan 5R55') ,(#4#(!5 -)' 5 ) 5 #.-5 ()(7-.,. !#5 (/& ,5 ), -65 , - 5R55 *&)3#(!5( 15(5&)(! ,7,(! 5"" (7 5&&#-.#5'#-- 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 5R55 *&)3#(!5 5 ..#&5 (/& ,5 1 *)(65 ." 5 lf7%#&)' . ,5 SS-N-30A (Kalibr), and replacing the old Su-24 (Fencer) NASR missile. #ghter-bomber with the Su-34 (Fullback). 5R55#(, -#(!5*,)/.#)(5) 5ŀ--#& 5'. ,#&5 ),5#.#)(&51,- heads. United States 5R55/#&#(!55( 15ł .5) 5gh5-5.)5, *& 5." 5/,, (.5gj5 India SSBNs. "e new submarines will carry an improved version 5R55 *&)3#(!5 (5  0 &)*#(!5 &)(! ,7,(! 5 &&#-.#5 '#--#& -5 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. 5R55') ,(#4#(!5#.-57h5(57kh5)' ,-5(5 0 &)*#(!5." 5 5R55)(/.#(!5- 7.,#&-5) 5#.-5ŀ,-.5651"#"51#&&5,,35( 15 new B-21 stealth-bomber to replace the B-52s (and B-1s) types of SLBMs. from the late-2020s. 5R55/#&#(!5( 15, .),-5.".5(5*,)/ 5*&/.)(#/'5 ),5- 5R55 0 &)*#(!55( 15!/# 5(/& ,5)'5Blg7ghC51#."5#(- ditional warheads and expanding uranium enrichment ca- creased accuracy, and a new ALCM with longer range and pacity. enhanced warhead. Israel 5R55 -#!(#(!55( 15  51#."5 ("( 51," -5.)5, *& 5 5R55') ,(#4#(!5#.-5 ,#")5&&#-.#5'#--#& -5(5*,)&35&-)5 the current Minuteman III ICBM by 2030. its #ghter-bombers. 5R55') ,(#4#(!5 #.-5 ()(7-.,. !#5 (/& ,5 ), -5 35 , *&#(!5 5R55)--#&35 +/#**#(!5 #.-5 ( 15  ,'(7/#&.5 )&*"#(7&--5 F-16s (and eventually F-15E) #ghter-bombers with the F- submarines with a nuclear cruise missile. 35A stealthy #ghter-bomber that will be carrying the new B61-12 guided nuclear bomb. North Korea 5R55 *&)3#(!5.1)5( 15&&#-.#5'#--#& -5B /-/(5(51- China song-13) that could potentially in the future be equipped 5R55, *&#(!5 )&5 &#+/#7 / &5 &(7- 5 '#--#& -5 1#."5 7hl5 with weaponized versions of the nuclear devices it has tested. and DF-31A solid-fuel missiles on road-mobile launchers. 5R55 0 &)*#(!55( 15&)(! ,7,(! 5'#--#& 85 5R55 +/#**#(!5-)' 5) 5#.-5'#--#& -51#."5'/&.#*& 51," -85 5R55 *&)3#(!55-'&&5ł .5) 5 #(7&--5-51#."5." 5( 15 &7h5 SLCBM.

BACK TO CONTENTS 89 Nuclear War

of India and Pakistan actually contain more consumption, and would not begin to o%set in South Asia, the global climate e%ects than 220 nuclear warheads.) "e direct ef- the shortfall over a full decade [38]. Fur- would be far worse. A war involving only fects in South Asia are catastrophic. Some thermore, there are currently 795 million the strategic weapons that will still be de- 20 million people would die in the #rst people who are already undernourished at ployed when New START is fully imple- week from the direct e%ects of the explo- baseline [39]. "ere are also some 300 mil- mented would put some 150 million tons sions, #re and local radiation [32]. lion people who enjoy adequate nutrition of soot in the upper atmosphere, and drop today, but live in countries highly depen- temperatures around the world by 8°C. In "e global consequences-global climate dent on food imports which would probably the interior regions of North America and disruption and resultant famine-would be not be available as grain exporting countries Eurasia, temperatures would fall by 25 to far more devastating. "e #res caused by suspended exports to feed their own people. 30°C. "ese conditions would persist for these nuclear weapons would loft 6.5 mil- In addition, there are nearly a billion people more than a decade. Temperatures on Earth lion tons of soot into the upper atmosphere. in China with incomes of $5 a day or less have not been that cold since the last ice "e impact of this soot has been examined who are adequately fed today, but who have age. In the temperate regions of the North- by three teams of climate scientists using shared little in China’s growing prosperity ern Hemisphere, the temperature would fall three di%erent climate models and mak- over the last several decades. All of these below freezing for some portion of every ing the conservative assumption that only people, around two billion, would be at risk day for at least two years [43]. Under these 5 million tons of soot are injected into the under the potential famine conditions that conditions food production would stop and atmosphere [33-35]. Each model shows would result from this limited, regional nu- the vast majority of the human race would signi#cant drops in average surface temper- clear war [40]. Large scale war between the starve. ature and average precipitation across the US and Russia would be far worse. In early globe with the e%ects lasting for more than 2016, Russia and the US were estimated to a decade. "e most sophisticated and recent possess 7300 and 6970 nuclear warheads re- E"orts to Eliminate model shows the most persistent declines in spectively, 93% of the global total of 15,375. Nuclear Weapons temperature and precipitation, which have Under the provisions of the New START not yet returned to baseline after 26 years, treaty, each of these countries will retain Understanding of the unprecedented ex- as long as the model was run. While the some 1550 strategic (long range) nuclear istential threat posed by nuclear weapons fuel density of modern cities varies, there warheads when the Treaty is fully imple- was widely recognized in the very #rst is nothing speci#c to India/Pakistan about mented in 2018. Most of these weapons resolution of the United Nations General such a scenario. Nuclear weapons are ex- are 10 to 50 times more powerful than the Assembly in January 1946, calling for the tremely e&cient at igniting, over large areas, bombs which destroyed Hiroshima [41]. A elimination of atomic weapons [44]. "e simultaneous #res which rapidly coalesce 2002 study showed that if just 300 of the preamble of the 1970 nuclear Non-Prolif- and inject large volumes of soot and smoke weapons in the Russian arsenal hit urban eration Treaty (NPT) opens: “Consider- into the stratosphere. targets in the US, 75 to 100 million people ing the devastation that would be visited would die in the #rst half hour from the upon all mankind by a nuclear war and the "is climate disruption would in turn have #restorms and explosions [42]. "is attack consequent need to make every e%ort to profoundly negative impact on food pro- would also destroy most of the infrastruc- avert the danger of such a war …” [45]. Yet duction. "e maize crop in the US, the ture – the electric grid, internet, banking for most of the past 71 years, the shared world’s largest producer, would decline and public health systems, food distribution interests of humanity, based on the real an average of 12% over a full decade [36]. network – needed to support the rest of the consequences of any use of nuclear weap- In China, the world’s largest producer of population, most of whom would succumb ons, have been sidelined by the perceived grain, middle season rice would decline to exposure, starvation and epidemic disease interests of the 9 governments that pos- by 17% over a full decade, maize by 16%, in the months following. A US counterat- sess and threaten use of nuclear weapons, and winter wheat, by a truly catastrophic tack would be expected to cause the same which have dictated the pace and extent 31% [37]. level of destruction in Russia, and if NATO of nuclear arms control and disarmament. were involved in the con!ict, Canada and However, the obligation to pursue e%ective Under current conditions, adequate human much of Europe would face similar destruc- measures towards nuclear disarmament is nutrition cannot be sustained in the face of tion. a shared responsibility of all 190 NPT sig- declines of food production of this magni- natory states, and the International Court tude. Total world grain reserves in January "ese direct e%ects are only part of the of Justice in its 1996 Advisory Opinion on 2016 amounted to only 84 days of global story, however. As is true for a limited war nuclear weapons unanimously ruled that

90 Nuclear War

there exists an obligation not only to pur- governmental meetings dedicated to the a treaty. "is recommendation was taken sue in good faith, but to bring to a conclu- humanitarian impacts of nuclear weapons. forward in a resolution co-sponsored by 57 sion, negotiations leading to nuclear disar- "ere was no signi#cant disagreement at states [58] and adopted by the UNGA First mament [46]. these conferences regarding the exten- Committee on 27 October 2016, with 123 sive expert evidence presented, leading to States voting yes, 38 (predominantly nucle- "e contemporary ‘Humanitarian Initiative’ the conclusions 1) that any use of nuclear ar-armed and nuclear-allied) voting no, and on nuclear weapons began with Interna- weapons would be catastrophic; 2) that no 16 abstentions. "e full UNGA will under- tional Committee of the Red Cross (ICRC) e%ective humanitarian response was pos- take a #nal vote in early December 2016, president Jacob Kellenberger informing the sible to even a single nuclear detonation in and the #rst negotiating conference will Geneva Diplomatic Corps in 2010 that the an urban centre; 3) that the risk of nuclear convene in New York on 27 March 2017. world’s largest humanitarian organization weapons use had previously been underesti- A new international treaty comprehensively would make elimination of nuclear weap- mated, is growing, and exists as long as the prohibiting nuclear weapons is thus within ons – something it #rst called for on 5 Sep- weapons do; and 4) that there is a legal gap sight. "is is increasingly seen by a substan- tember 1945 – a renewed priority [47]. A for nuclear weapons, in that the most de- tial majority of states as the most promising few weeks later, the #ve yearly 2010 NPT structive and indiscriminate of all weapons and realistic step which can now be taken to Review Conference outcome document are the only weapon of mass destruction progress the eradication of nuclear weapons, referred for the #rst time to “deep concern not yet explicitly prohibited under interna- and the conclusion of such a treaty would about the catastrophic consequences of any tional law [54]. At the end of the Vienna constitute the most signi#cant development use of nuclear weapons” [48]. In 2011, the conference, the Austrian government is- in nuclear disarmament since the end of the Council of Delegates, the highest govern- sued a pledge “to cooperate with all relevant Cold War. Treaties unequivocally prohibit- ing body of the Red Cross/Red Crescent stakeholders … to stigmatize, prohibit and ing unacceptable weapons and providing for Movement, called on all states “to ensure eliminate nuclear weapons in light of their their subsequent elimination has been the that nuclear weapons are never again used”, unacceptable humanitarian consequences approach successfully used in relation to ev- and “to pursue in good faith and conclude and associated risks”; to “#ll the legal gap ery other kind of indiscriminate, inhumane with urgency and determination negotia- for the prohibition and elimination of nu- weapon – biological, toxin [59] and chemi- tions to prohibit the use of and completely clear weapons” [55]. As of 20 March 2016, cal weapons [60], followed by antipersonnel eliminate nuclear weapons through a legally 127 states have endorsed this Humanitarian landmines [61] and cluster munitions [62]. binding international agreement, based on Pledge, with an additional 22 states voting existing commitments and international in favour of a resolution bringing the Pledge obligations” [49]. A special issue of the to the UNGA [56]. !e Role of the Health Movement’s !agship journal, the Interna- Community tional Review of the Red Cross, “"e human "e 2015 General Assembly also voted costs of nuclear weapons”, was recently pub- overwhelmingly to establish an Open End- Involvement of the medical community in lished. ed Working Group (OEWG) to address these e%orts to eliminate nuclear weapons this legal gap, which though open to all !ows from a long history of medical and Beginning in 2012, at every NPT meet- states, was opposed and boycotted by all the scienti#c concern about nuclear weapons. ing and UN General Assembly (UNGA), a nuclear-armed states. "e Working Group After the hydrogen bomb code named growing number of states, from 16 in 2012 was charged with reporting back to the Castle Bravo was detonated at Bikini Atoll to 144 in 2015, have supported resolutions 2016 UNGA on e%ective legal measures with a yield of around 15 megatons (mil- a&rming the centrality of humanitarian required to attain and maintain a world lions of tons of TNT equivalent), double considerations in advancing nuclear dis- free of nuclear weapons. It “recommended that predicted, there was widespread pro- armament, and the need to prevent use of with widespread support for the General test from many world leaders together nuclear weapons under any circumstances Assembly to convene a conference in 2017, with Albert Einstein and the Federation [50]. In 2013 and 2014 three successive open to all States, with the participation of American Scientists [63]. In 1957, as fact-based international conferences on the and contribution of civil society, to negoti- atmospheric testing of nuclear weapons Humanitarian Impact of Nuclear Weapons ate a legally-binding instrument to prohibit continued unabated, an appeal from Albert were held in Norway [51], Mexico [52] and nuclear weapons, leading towards their total Schweitzer for a ban on nuclear tests was Austria [53], the last with participation of elimination …”[57]. "e Working Group’s broadcast to audiences in 50 nations and a 146 states. Remarkably, 68 years into the report provided detailed suggestions on spe- petition initiated by Linus Pauling, 1954 nuclear age, these were the #rst ever inter- ci#c elements that could be included in such Nobel laureate in Chemistry, also demand-

BACK TO CONTENTS 91 Nuclear War

ing a test ban was signed by 9000 scientists the detonation of a single megaton weapon In 2007, IPPNW founded the Internation- in 43 countries. Pauling was awarded the would overwhelm the resources of the en- al Campaign to Abolish Nuclear Weapons Nobel Peace Prize in 1963 for his opposi- tire UK National Health Service [69]. "e (ICAN) – a broad global campaign coalition tion to nuclear testing. Also in 1957 the World Health Assembly adopted a resolu- working for a treaty banning nuclear weap- British Atomic Scientists’ Association set tion in 1983 including reference to nuclear ons. ICAN now has 440 partner organisa- up a committee to assess the risks of cancer weapons as “the greatest immediate threat tions in 98 countries, is the lead civil society arising from the fallout from atmospheric to the health and welfare of mankind” partner for the governments hosting the nuclear tests, chaired by Professor Joseph [70]. Scienti#c and medical evidence that Humanitarian conferences, and continues Rotblat, a medical physicist (and during civil defence programs against nuclear to grow as a major civil society coordinating the 2nd World War an atomic scientist, war provided at best an illusion of protec- initiative and partner for governments seri- working on the atomic bomb at Los Ala- tion led to their widespread abandonment ous about the humanitarian imperative for mos). It concluded that for every 1 mega- [71]. Evidence on the catastrophic health nuclear disarmament. ton exploded in the atmosphere, around e%ects of nuclear war brought by physi- 1000 people were likely to develop bone cians to Presidents Ronald Reagan and In Moscow in October 2015, the World cancers, and made other estimates of the Mikhail Gorbachev had profound e%ect, Medical Association General Assembly likely health consequences of atmospheric bringing them to declare in 1985 that “A unanimously updated its Statement on nuclear testing [64]. nuclear war cannot be won and must never Nuclear Weapons, adopted in 1998 and be fought”; to end their nuclear arms race; amended in 2008, requesting all National A series of four [65-68] in!uential articles agree on the elimination of intermediate Medical Associations to educate their pub- appeared in the New England Journal of range nuclear missiles; and come close to lics and governments about the health im- Medicine in 1962 describing the medical an agreement to eliminate their nuclear pacts of nuclear war and “to join the WMA e%ects of a thermonuclear attack on Mas- arsenals entirely. Gorbachev wrote that in supporting this Declaration and to urge sachusetts, the (limited) role of the medical without the e%orts of IPPNW – awarded their respective governments to work to ban profession in dealing with the consequences, the Nobel Peace Prize in 1985 – these dis- and eliminate nuclear weapons” [74]. and the psychiatric and social aspects of civ- armament initiatives “would probably have il defence. "e authors, who were members been impossible” [72]. Given the potential In April 2016, the WMA joined with of a new organization Physicians for Social for nuclear war to occur as a result of er- IPPNW, the World Federation of Public Responsibility, concluded that as no e%ective ror and the lack of evidence that a planned Health Associations and the International clinical response was possible, doctors “must medical response can have any perceptible Council of Nurses, in submitting to the begin to explore a new area of preventive impact on the outcome, it has been sug- UN Working Group the #rst such united medicine, the prevention of thermonuclear, gested that “support for deterrence with statement detailing the health and humani- chemical and ”. these weapons as a policy for national or tarian imperative to ban and eliminate nu- global security appears to be incompatible clear weapons [75]. All other global health Negotiations on a ban on nuclear testing with basic principles of medical ethics and progress and e%orts could come to nought continued inconclusively until 1963 because international law. "e primary medical re- if we do not succeed in eradicating nuclear of concerns about the potential to conceal sponsibility under such circumstances is to weapons before they are again used in war. clandestine tests. With evidence of wide- participate in attempts to prevent nuclear "ere has never been a better opportunity spread radioactive fallout and accumulation war” [73]. New evidence about the per- nor greater need for united and e%ective of strontium-90 in the deciduous teeth of vasive threats to health of the detonation health professional engagement to remove children around the world, public opinion of even a small percentage of the world’s the most acute existential threat to global swung strongly in favour of banning atmo- nuclear arsenals, together with the failure health and survival. spheric nuclear testing and the Limited Test of the Non-Proliferation Treaty to prevent Ban treaty was agreed in 1963, but progress the retention and modernization of nu- towards a comprehensive treaty proved clear weapons has given impetus to a new References frustratingly slow. global movement to ban nuclear weapons. 1. http://archive.defense.gov/pubs/2014_Quad- "e health professions therefore have a rennial_Defense_Review.pdf (accessed May 9, 2016). In the early 1980s a number of reports on central role in advocating for the abolition 2. http://www.cnn.com/2014/08/29/world/eu- the health e%ects of nuclear weapons ap- of nuclear weapons, re!ecting their ethical rope/ukraine-crisis/ (accessed April 21, 2016). peared including a BMA report of 1983 responsibility to protect health and prevent 3. Frear T, Kulesa L, Kearns I. Dangerous Brink- which concluded that the casualties from illness. manship: Close Military Encounters Between

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Russia and the West in 2014. European Leader- 2016, http://thebulletin.org/nuclear-battles- and maize production in the Midwest United ship Network, November 2014. south-asia9415 (accessed May 5 2016). States. Climatic Change 2013; 116: 373–87, 4. Frear T, Kearns I, Kulesa L. Preparing for the 20. Mian Z, Ramana M. Asian War Machines. doi:10.1007/s10584-012-0518-1. Worst: Are Russian and NATO Military Exer- Critical Asian Studies 2014; 46(2):345–60. 37. Xia L, Robock A, Mills M, Stenke A, Helfand. cises Making War in Europe More Likely? Eu- 21. http://edition.cnn.com/2016/03/06/asia/ Decadal reduction of Chinese agriculture after a ropean Leadership Network, August 2015. north-korea-preemptive-nuclear-strike-threat/ regional nuclear war. Earth’s Future 2015; 3:37– 5. Sokov N. Why Russia calls a limited nuclear (accessed April 18. 2016). 48, doi:10.1002/2014EF000283. strike “de-escalation”. 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94 Medical Education

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 su%ering and substantial "e WMA Declarations of Geneva, of Helsinki and of Tokyo death toll together with catastrophic e%ects 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 signi#cant portion of the world’s population at crate itself to the service of humanity. "e 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 !erefore the WMA: resources to educate the general public and to urge their respec- tive 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.

a critical trait for resident doctors. Training !e Value of Resiliency Training in residents in resiliency skills equips them to e%ectively identify, cope with, and recover Postgraduate Medical Education from challenging experiences in their per- sonal and professional lives, while setting them up for rewarding and sustainable ca- Residency is a dynamic and stressful relationships with family and friends reers. time. Trainees must continually balance (Resident Doctors of Canada National their roles as both learners and clini- Resident Survey, 2015). "e overall de- With content support from the Mental cians within a high-stakes environment. pression rate in U.S. medical students and Health Commission of Canada and the Whether it’s hearing that #rst code pager, residents is as high as 1 in 5 [1]. Burnout, Department of National Defence’s Road witnessing a patient death, feeling the cu- a work-related syndrome due to chronic to Mental Readiness Program, Resident mulative impact of long hours and on-call exposure to occupational stress, is preva- Doctors of Canada (RDoC) has developed responsibilities, or missing an important lent in 27–75% of residents, depending on a practical, skills-based resiliency curricu- life event at home – every resident deals specialty [2]. lum to help mitigate the negative conse- with stress. quences of stress during residency and beyond. Stress impacts physician well-being. "e RDoC’s Resiliency Curriculum majority of Canadian medical residents "e curriculum is based on the importance report that work-related fatigue a%ects Resiliency is the ability to recover from or of promoting mental resiliency in physi- their mental health, physical health, and adjust easily to adverse situations, and it is cians by fostering supportive and positive

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