Changing our ways of thinking. Health professionals and nuclear weapons

introduction

Health in the Nuclear Age

CHANGING OUR WAYS OF THINKING HEALTH PROFESSIONALS AND NUCLEAR WEAPONS

Mary Neal, M.S.

We must never re& our efforts to arouse in the people of the worki, and especially in their governments, an awareness of the unprecedented dkaster which they are absolutely certain to bring on themselves unless there k a fundamental change in their attitudes toward one another as well as in their concept of the future. The unleashedpower of the atom has changed everything except our way of thinking.

Albert Einstein (1, p. 3 j

ccording to an increasing number of health A professionals, the drift toward nuclear catastrophe of which Einstein spoke is becoming more and more imminent, posing the greatest public health problem in human history. A pri- mary reason for this concern is a new and more dangerous phase of the nuclear arms race, which substantially increases the risk of nuclear war. A new generation of technology has created nuclear weapons accurate enough for first strike attack on military targets. This increased accuracy has allowed a shift in strategy from preventing war by mutually assured destruction, to waging nuclear war by destroying the other side’s forces in a first strike. This nuclear war fighting strategy assumes that nuclear war can be won, that a strike against military targets can be limited without expanding to a full scale nuclear exchange and that a nuclear war can be survived. More- over, first strike weapons such as the Pershing I1 missiles planned for Europe will be able to reach Moscow within ten minutes, perhaps forcing computerized launch on warning by the

8 1984 by The Regents of the IJniversity of California

Soviet Union and increasing the risk of accidental nuclear war ( 2 ) .

As Mobius editor Lucy Ann Geiselman notes in her Editorial, Einstein also spoke of the power of individual action, the comfort of the “alive and undismayed” (3 ) . With public statements about winning nuclear war in the late 1970’s, many health professionals have become alarmed about these assumptions of survivability and the increasing risk of nuclear war. These health workers have joined with other concerned citizens in the United States, Europe and around the world to demand, and to help create, the changes in thinking by which this threat can be lessened and nuclear weapons controlled. The message o f this movement is that “survival is everybody’s business” and that the issue of nuclear weapons is the most crucial issue of our time, transcend- ing partisan politics and other differences between people. In health care, health professionals have stated concern in medicine, public health, nursing, psychiatry, psychology, and other mental health disciplines, social work, health education and the allied health professions.

Einstein’s call for new ways of thinking is reflected throughout movement activities, and is also congruent with social science theory concerning how such movements create change (4,5,6). Defining a set of ideas on which to base action has been seen as an important part of the mechanisms of social movements. Social movements document the need for change, the failings of the current state of affairs; develop and present viable alternatives to the current

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situation; and present individuals with courses o f collective action through which these alternatives can be put into effect.

Each o f the parts of this movement to control nuclear weapons contributes t o a collective and interrelated set of ideas and activities, each group applying its own expertise and authority. Health professionals have made substantial con- tributions t o this collective pool of ideas.

Health professionals have played a key role in documenting the need for change and in bringing this need to public attention. According t o these health workers, the potential for nuclear war poses a grave, unprecedented health danger, t o the extent that it demands a “new relationship to war” (7). In the past, health professionals could respond to war by treating the sick and wounded. N o such humane role is possible after a nuclear exchange. Nor can civil defense significantly affect the outcome. Prevention is the only possible alternative:

I f weexamine the consequences o f nuclear war in medical terms, we must pay heed to the inescapable lesson o f contemporary medicine: where treatment o f 3 given disease is ineffective or where costs are insupportable, attention must be given to prevention (8, p. 16).

Health professionals have also stressed the current costs o f the nuclear arms race. Spending for the arms race diverts economic resources from other parts of the economy, and from meeting basic health needs. The psychosocial threat of nuclear catastrophe has been shown t o have adverse effects on individuals. The production, testing and deployment of nuclear weapons also present health risks, in terms of exposure to radiation.

The alternatives which can prevent nuclear war involve political change, arms control and diplomatic proposals. Health professionals have applied psychosocial expertise to the psychological aspects of nuclear weapons systems and international relations in order to understand the ways of thinking which prevent change, and

those which can promote change. These health professionals suggest that we must develop new ways of dealing with conflict, and recognize interconnections in a global society. We now live together or we die together.

Finally, health professionals have proposed a “new relationship to war” as part o f the professional role. Health professionals have taken a number of kinds of approaches, acting in professional roles, to educate and communicate these ideas to other health professionals, the public and political decision makers, o r t o put proposals into effect through political action.

The purpose of this essay is t o outline the issues which have been raised by health profes sionals concerned about the threat o f nuclear weapons and nuclear war. This paper is based for the most part on written material by health professionals published in the United States from 1979 though mid-1983 (9). Several general collections of articles are currently available ( 10 16). Major controversial debates as retlected in the published literature are reviewed, but the paper is primarily an exposition o f this “new relationship to war” being proposed for health practitioners.

Not all health professionals agree with the conclusions presented here. We hope that this introductory paper will provide a conceptual framework useful for health professionals and Mobius readers interested in further examina tion of these complex issues. In the following papers in this issue o f Mobius, individual health professionals describe specific positions :mi activities that represent the kinds of choices they are making in response t o the dilemmas of health in the nuclear age.

The Problem: The Last Epidemic According to many health professionals, the

human reality behind abstract discussions o f collateral damage, although seemingly obvious, has apparently been widely forgotten or ig nored in the process of learning t o live with the bomb. A number of recent studies suggest

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that previous analyses of the effects of nuclear war have not been realistic about the extent of the damage (17).

Two groups have been active in documenting and communicating the effects o f nuclear war: health professionals, and the hibakusha, the survivors of the first two uses of nuclear weapons in Hiroshima and Nagasaki in August 1945. These groups have added consideration of human beings, and human values, to abstract military and technical arguments. George Kistia- kovsky, former science advisor to Presidents Eisenhower and Kennedy, has said that the physicians have shifted the debate from the means of destruction and the nature of the physical damage to the indescribable human tragedy ( 18 ).

The most telling accounts have been the testimony o f the survivors (19) . The results of scholarly studies o f the damage at Hircxhima and Nagasaki have also been recently summa- rized (20). In these cities,

The damage was so complex and extensive it has t o be seen as an interrelated array, massive physical and human loss, social disintegration, psychological and spiritual shock affecting all o f life and society (20, p. 337 1.

In this issue, Dr. Ichimaru describes the “hell on earth” he saw as a freshman at the Nagasaki Medical College (21 ). As terrible as this experience was, as Dr. Ichimaru notes, the destruction of Hiroshima and Nagasaki came from bombs with only a fraction of the power available in nuclear weapons technology today. Moreover, the damage was limited t o two specific areas, with an outside world left t o help. A nuclear exchange today would probably not stay limited.

In the health professions, Physicians for Social Responsibility ( PSR) have been especially active in documenting the medical consequences o f nuclear war (22). The model for PSR’s critique comes from a 1962 article in the New England Journal o f Medicine defining the effects o f a nuclear explosion over Boston (23). This model

of a single attack on a city has been adapted for many locations as a major part of PSR symposia and public speaking. The physicial effects of blast, thermal and radiation damage are described, as well as acute medical effects from thermal, mechanical and radiation injuries and the delayed medical effects o f radiation.

A further issue is the potential for epidemic disease after a nuclear attack. Abrams and Von Kaenel ( 24) discuss such factors as radiation effects on the immune system, lack of natural resistance to disease in the developed countries and public health problems. According to Abranis and Von Kaenel, deaths caused by acute communicable disease might amount to 25 per cent o f the surviving population.

Few psychological studies of the effects of nuclear war have been conducted. Robert Lifton studied survivors o f Hiroshima in 1962, seven- teen years after the bombings (29). Some o f the findings are described in his article in this issue (32). Lifton describes the study as a psychological kaleidoscope of an extraordinary im- mersion in death, lasting imagery o f fear surrounding the possibility o f radiation aftereffects and a lifelong struggle to integrate the event and its psychic consequences. Lifton describes what he considers a unique form of death: total, grotesque, invisible, and enduring over time, with a sense o f ultimate annihilation.

Lifton notes that part o f the reaction of the survivors was a psychic closing off, or psychic numbing. This cessation o f feeling is highly adaptive at the encounter, a reversible symbolic death to avoid permanent physical or psychic death. Lifton and Kai Erikson ( 3 3 ) extend this analysis to a projected nuclear war with current technology

The question so often asked ‘Would the suwivors envy the dead?’ may turn o u t to have a simple answer. No, they would be incapable o f such feelings. They would not so much e n w the dead as resemble the dead ( 33, p. 290 ).

This experience is not just individual death. In

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Iliroshima, there was a sense that the whole wortd was dying. In a full scale nuclear war,

the immobilization may reach the point where the psyche is n o longer connected to its own past and is, for all practical purposes severed from the social forms from which it drew strength and a sense of humanity (33, p. 292).

Nuclear weapons also destroy social systems, one o f which is the health care system. In Hiro- shima, “For all practical purposes, the well pre- pared medical care system was rendered totally useless (34, p. 5 16).” Of 298 mobilized doctors, 270 became A-bomb victims. Accounts of the personal experience of Japanese physicians, such as that of Dr. Ichimaru (21) in this issue, tell o f helplessness and moral dilemma.

Sidel, Geiger and Lown ( 3 4 ) estimate the number of casualties and remaining physicians for a projected nuclear attack on Boston. Cal- culations showed a ratio of potentially 1700 acutely injured patients for each physician able to work. The study concluded:

Severe burn injuries would be common. Con- stable ( 3 6 ) discusses resources required for treatment of a severe burn case, including 30 to 50 operative procedures and months o f hos- pitalization. Even large 30 bed burn units can handle only two or three fresh severe burns at once. Hiatt ( 3 7 ) gives a particularly graphic example of resources expended for a burn vic- tim. Gellhorn and Janeway ( 3 5 ) suggest that in a nuclear attack on one medium sized llnited States city, the entire United States blood supply for a year could be required in the first 24 hours. According to Constable,

We can talk about how such injuries should be treated, but to transfer this knowledge to the practical possibilities o f the treatment o f the numbers o f victims that have been predicted is categorically out of the question.. . . The medical facilities o f the nation would choke totally on even a fraction o f the burn casualties alone (36, pp. 22,25 ).

Studies by the British Medical Association and the World Health Association (WHO) reach similar conclusions (3839) . The WHO report states:

I f the physician were to spend only 10 minutes on the diagnosis and of each injured patient, It is obvious that no health service in any are3 o f

if he worked 20 hours per day, it would require could be

the world Would be adequate to deal adequately With the hundreds Of thousands Of people SeriOUSly in- 8 14 days before every injured

seen for the first time ( 3 4 , p.1139). jured by blast, heat or radiation from even a single one megaton bomb. Even the death and disabilihi

Estimates were also made of remaining hospital beds and medical supplies, primarily concentrated in metropolitan target areas. Transporta- tion of patients and health workers would also be problematic.

Gelborn and Janeway ( 3 5 ) discuss the range of acute traumas, burns and radiation injuries which would occur with a nuclear blast, and the difficulties in treatment of individual cases of such injuries even with intact medical systems. In a nuclear blast, special problems would arise, such as the synergistic effects of combined injuries not usually seen in civilian accidents. Triage would pose major problems. For example, lethal, sublethal and mild exposures to radiation produce similar symptoms, yet require very different courses of treatment.

that could result kom an accidental explosion o‘f one bomb from among the enormous stockpiles o f weapons could overwhelm national medical resources (39, P.7).

Technical studies of the effects of nuclear weapons have omitted much of this human context. Moreover, according to Geiger (40 ) , studies implying the possibility of survival and recovery from a nuclear war use methods which are strongest and most valid for the determina- tion of immediate effects, and weakest in dealing with long term and indirect effects. These methods are also conservative, focusing primarily on levels of damage sure t o be inflicted in the most unfavorable cases.

In addition, the calculations are based on assumptions about characteristics o f a nuclear

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attack. The experiment of a full scale nuclear war has never happened, and one hopes that it never will. There is no experimental model, so that researchers must “invent their own reality,’’ Geiger suggests ( 6 4 ) , and define assumptions and a base for planning.

Varying assumptions can produce drastically varying results. Ervin et al ( 2 3 ) note that con- flicting conclusions may result from differences in interpretation or data, but are most often based on differing but unstated underlying assumptions concerning the nature of the assault. Sidel, Geiger and Lown ( 3 4 ) suggest that there are so many variables and imponderables in the complex equation of nuclear war that one can reach almost any conclusion by choosing appropriate assumptions.

A study of the multiple effects of nuclear war conducted by the Office of Technology Assess- ment ( 4 1 ) concludes that the situation would continue to deteriorate for some time after a nuclear war ended, and that effects which cannot be calculated in advance are at least as important as those which analysts attempt to quantify. The report classifies uncertainties in three categories: (1 ) assumptions in the calculation of death and direct economic damage (time of day, size, exact location of the detonations); ( 2 ) effects which would surely take place but whose magnitude cannot be calculated (the effect of fires, shortfalls in medical care and housing, the effects of disease); and ( 3 ) effects which are possible, but whose likelihood is as incalculable as their magnitude (the possibility of a long downard economic spiral, political disintegration, major epidemics, irre- versible ecological change).

The survival of economic and political systems may also be problematic. Galbraith ( 4 2 ) suggests that neither capitalism nor Communism would have existence or relevance in the wreck- age of a postnuclear world. Laulan ( 4 3 ) notes that while conventional warfare is usually limited to the destruction of human resources and wealth, nuclear war would be totally different,

destroying societal and economic infrastructures. The survival of more than local or regional PO- litical systems might also be problematic.

Environmental damage could also be extreme. A report published in the journal Ambio ( 4 4 ) examines such areas as possible effects on fresh water supplies and ecosystems as well as the potential for postattack agriculture and adequacy of global food supplies. A 1975 report by the National Academy of Sciences ( 4 5 ) pointed to possible depletion of stratospheric ozone, with increasing intensity of ultraviolet radiation at the earth’s surface. The Ambio report adds the possibility of debris in the atmosphere blocking sunlight for weeks or months. Vast fires might fill the lower atmosphere with tar, soot and ash particles, possibly resulting in a severe pho- tochemical smog over much of the northern hemisphere ( 4 4 ) . The report concludes that when environmental consequences are included in the study, many more people will be ulti- mately affected by nuclear war than are killed by direct effects of nuclear weapons (44, p. 162).

Nuclear war is thus fundamentally different from natural disasters, both in the quantitative amount of damage and in the qualitative nature of the effects. The destruction from nuclear weapons is total, destroying social and environmental systems, as well as creating physical damage and injury to human beings. Natural disasters are time-limited and affect a specific region, outside of which there is an intact world. Nuclear weapons defy the senses. The fear of contamination, radiation sickness, carrier and genetic mutations, is as intense as the fear of death and far more mysterious. N o natural phe- nomena arouse such anxiety ( 4 6 ) .

Technical studies of the effects of nuclear weapons have produced many differing conclusions, with contention over many specific points. One central aspect of the debates, however, is the concept of survival. Abrams, in an article entitled, “Surviving a Nuclear War is Hardly Surviving” ( 4 7 ) , suggests that there is more to survival as human beings than species

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survival, o r merely remaining alive. Abranis suggests that the concept of species survival does not guarantee political, economic or social sur- \rival, and does not address the quality of life. Wh:it must be defined is acceptable survival. Anything less distorts the meaning o f survival, the values o f being human.

For many health professionals, the evidence is clear enough. Ahrams and Van Kaenel ( 2 4 ) , for example, note that although they cannot prove that catastrophic epidemics will occur, it is certain that there will be a substantial threat t o health and recovery and that the resources t o deal with the threat will be inadequate. Cassel states, As a physician, I can only conclude that it is essentially irresponsible to point to those debates in sup- porting a claim of ignorance. We do not know it all, but we know all we need to know. For if any of what has been described as probable is even remotely pohsible, then there is no political reason on earth that c a n morally justify the continued uncontrolled existence o f these weapons (48) .

The Problem: No Defense Civil defense planning for nuclear war has

been the focus of much debate within the health professions (49-54). According to health professionals opposed to civil defense for nuclear war, this planning is based on faulty assumptions :ibout survival, and may mislead the public into thinking that effective measures exist to provide care in a large scale nuclear conflict, when in fact, no civil defense system could adequately cope with the consequences of a nuclear war, :is described in the last section. Moreover, civil defense is part of the strategy of nuclear war fighting, designed to foster the impression that nuclear war can be survived with acceptable losses, and is therefore a possible option. Civil defense for nuclear war also diverts hinds and energy fiom useful projects such as planning for natural disasters and efforts toward preventing nuclear war.

Two civil defense related plans have been at issue. Crisis relocation planning (CRP) calls for

moving the populations of major cities into rural reception areas on warning o f imminent nuc1e:ir attack. CRP is being proposed hy the Federal Emergency Management Agency ( FEMA ), the federal agency responsible for coordinxing dis aster planning, and would be implemented by local and state disaster management officials. The CiVihan-Mibtdry Contingency Hospital Sys tem (CMCHS) is a plan developed by the De partnient of Defense that asks selected hospitals to commit up to 50 beds to be used by the military in the event of a large scale conflict overseas.

An issue in regard to the CMCHS is what Abrams ( 5 5 ) calls the “credibility gap.” The Department of Defense states that the CMCHS is designed strictly for conventional casualties. Abrams and others see the plan as rekited t o nuclear war, citing evidence such as the profile of casualties described for the plan and NATO commitment to use force should the Soviet Union overwhelm conventional forces in ELI rope ( 5 6 ) .

Arguments in support of civil defense for nuclear war do not differentiate nuclear war from other types o f disasters. FEMA has integrated planning civil defense for nuclear war into the same structure as response plans for all other types of disaster management ( 5 7 ) . Arguments in sfipport of the CMCHS draw on the tradi tional ethical stance of health professionals in war, as opposed to the “new relationship t o war” proposed for nuclear weapons. 13iscard ( 5 8 ) suggests that the CMCHS is a simple matter of healing the sick, the traditional neutral role of medicine in war, “the moral obligation this country has to ensure care for military casual ties.” The CMCHS is therefore just doing what hospitals always do, making beds available for the sick and injured. Moreover, the obligation t o do no harm is consistent with the planning aspect, in that the result of unpreparedness is increased morbidity and mortality, and it is un- ethical to take action which could only increase suffering ( 5 9 ) .

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Biscard and others suggest that effectiveness is not the key moral issue. Doctors for Disaster Preparedness suggest that even if a nuclear war does not remain Limited, doctors should do what they can. If there are thousands of casualties, they will not be able to give the same standards of care, but that does not change the moral picture. N o matter what the scope, the responsibility is to provide the best care to as many people as possible (60).

Others suggest that prevention may not be possible and that something is better than nothing, that it would be foolish to ignore the fact that the threat of a conflict does exist, or that there are other possibilities short of total nuclear disaster, such as terrorist attacks. Some see the position against civil defense as just giving up, without constructive criticism to develop better plans. Others state that prevention o f nuclear war is probably not possible, and that i t may be best t o help minimize loss o f lives in case it does occur (61,62).

Kornfeld (63) and Jameton and Jackson in this issue ( 7 ) examine the medical and nursing literatures concerning civil defense for nuclear war during the 1950's. Neither discipline discussed a health role in preventing nuclear war, or conducted an independent critique of the health problems posed by nucle? r war.

Health professionals currently opposing civil defense insist that nuclear war is quantitatively and qualitatively different from other disasters, and can only be prevented. According to FEMA, 80 per cent of the population o f the United States could be relocated and survive with CRP, and the United States could survive and recover as a national entity. However, the studies o f the effects of nuclear war on which FEMA planning is based use the same methods and have the same weaknesses as those discussed in the previous section. Civil defense measures are included among the assumptions. FEMA's pro jections focus on short-term salvage, use "best case analysis," and assume that civil defense works perfectly (51 ). Geiger (64) suggests that

the 80 per cent figure is not derived from the calculations as much as it is built into the assumptions.

Without considering long-term effects, relocation measures may only postpone death, fiom immediate death in cities t o more protracted death in relocated areas. Geiger says the choice in civil defense for nuclear war is to die now o r die later (64).

Both CRP and CMCHS have been questioned as well on the basis of practical feasibility. The CMCHS raises such issues as transportation of casualties and a projected 5500 severe burns with only 1300 burn beds in the country. The General Accounting Offce (GAO) has noted that the CMCHS does not consider civilian health care capabilities, is poorly coordinated with other systems, and has not planned for support capability as well as estimating casualties and counting beds (50,51,55).

Many practical questions arise in regard to crisis relocation planning as well. The plan assumes: three to five days warning, a panic-free population, transportation systems operating at peak capacity, an error-free central authority, receptive relocation areas with available shelters with food, water, communications and radiation protection, and no retargeting. The evacuation period would involve some 145 million people moving an average of several hundred miles, a vast migrant social system with such problems as crime and disease and the delivery of health care en route (51,55).

Projections of human behavior during evacuation and shelter periods as well as in the postattack situation may also be unrealistic. As- sumptions about American undefeatability may not hold true after a nuclear war. Evidence suggests that the destruction would be so great that positive behavior o f any kind would be difficult. Psychic numbing would shut off normal func- tioning (51,65).

A crucial issue is the place o f civil defense in the strategy of nuclear war fighting. Nuclear war fighting cannot be advocated without at least

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minimal civil defense without appearing to be willing to annihilate the population, which makes the threat unbelievable, and the weapons therefore unusable. The United States could not be willing to escalate to nuclear war if it had not tried t o protect its population and made that evident. Moreover, putting evacuation plans into operation in a crisis might precipitate firther escalation o r even a preemptive attack (50,51, 56).

Public statements about civil defense clearly acknowledge political and military purposes. A FEMA press release in March 1982, for example, states that the purpose of civil defense is to enhance deterrence and stability, decrease the possibility of coercion in crisis, and provide for survival and continuity of government (51) . Leaning (51 ) states that advocates of nuclear war fighting have called for a triad composed of accurate first strike weapons such as the MX, improved communications to enhance command and control capabilities while under nuclear attack and CRP and other civil defense plans.

I t has also been alleged that there is a “civil defense gap,” that the Soviet Union has an extensive civil defense program which will give them a strategic edge. Soviet civil defense plans have been cited as evidence that they are planning to fight and win a nuclear war. However, a 1978 CIA report concludes:

They cannot have confidence.. . in the degree of protection their civil defense would afford them given the many uncertainties attendant to a nuclear exchange. We do not believe that the Soviets’ present civil defenses would embolden them deliberately t o expose the U.S.S.R. to a higher risk of nuclear war (52).

In the Soviet civil defense plan, 20 million people would evacuate on foot.

Opposing civil defense for nuclear war is seen as particularly important in that civil defense is the method by which survivability is supposedly assured. According to Leaning and Leighton (57) , FEMA is the major public advocate of the

notion that with adequate education and shelter a full scale nuclear war is survivable.

From this perspective, civil defense for nuclear war is not equivalent to civil defense for natural disasters. Wearing seat belts does not cause accidents, because seat belts are not part of the cycle of events which cause accidents, as civil defense for nuclear war is part of the cycle of nuclear weapons strategy.

From this point of view, civil defense for nuclear war is not just a health issue of cleaning up after the military, but rather part of a larger set of ideas surrounding nuclear war fighting which could put many more lives at risk than civil defense could possibly save. From this perspective, participating in civil defense is not just caring for patients. Murray (66) suggests that it is one thing for a doctor to care for the casualties of war, and quite another to participate in planning for it.

Moreover, emphasis on preparing civil defense for nuclear war may divert attention and resources from other needs. CRP detracts from much needed planning for natural disasters, such as earthquakes. Civil defense also detracts from efforts toward preventing nuclear war, such as bilateral arms control negotiations.

Geiger sees civil defense as a profoundly un- ethical act, the mirror image of nuclear war planning. He suggests that the moral calculation weighs the potential benefits, if any, against the increased risk to millions of others, and in addition judges the act in the light of the health professional’s commitment to the prevention o f needless injury and death when palliation is insignificant and cure impossible (56) . Beverlee Myers, director of the California Department of Health Services, suggests that military prepara- tion for nuclear war is one thing, but preparing the population for nuclear war is another:

The more time and effort we devote toward war, the more likely that vision wiU become reality. Con- versely, the more energy we devote toward peace, the more likely that goal can be obtained. (67, p. 121 ).

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The Problem: The Current Costs of the Nuclear A r m s Race

Health professionals have also pointed to current effects of the nuclear arms race. In this issue, Sidel (68) asks, “Is the health of people here and around the world already being harmed by the nuclear arms race?” Economically, military spending consumes resources that could be put to use in other parts of the economy, in health services and other efforts that would increase the duration and quality of life. Psychosocial effects of the constant threat of nuclear disaster have also been examined. Moreover, the production, testing and deployment of nuclear weapons also create potential health risks.

Nuclear weapons and the allocation of scarce resources

Sidel suggests that military expenditures are themselves destructive of life, even if the weap- on is never fired (68-70). Major advances could be made, for example, in preventable endemic and epidemic disease, hunger and premature death with redirection of only a fraction of the human and natural resources now being directed to nuclear weapons. Hiatt (71 ) discusses examples of health programs being cut back as military spending increases in the United States, including public health and preventive programs such as childhood immunization. Three Army AH-64 helicopters would restore $90 million for community health centers and the migrant health program (68).

The most striking examples come from the developing countries. Here again, relatively small additional expenditures could make a significant difference:

*Six months of world arms spending would pay for a ten year program providing health and food needs in developing countries (68, 71).

Ruth Sivard, in World Military and Social &- penditures (72), examines military and social spending for all major countries of the world. Sivard traces the relationship of spending priorities and the military burden of the country with such social indicators as literacy and infant mortality, as well as economic indicators such as capital investment and productivity.

Military spending also causes deleterious effects on the economy. Military spending de- creases productivity. Galbraith (42) suggests that the nuclear arms race has contributed to our industrial decline by transferring resources away from civilian industry, preventing modern- ization of industrial capacity.

The military monopolizes research and development funding. Hiatt (71) notes the need for continuing fundamental and applied biomedical research. In 1982, research and development funds were reduced eight per cent in overall nonspace and military research, compared to a 26 per cent increase in the Department of De- fense research budget.

Military spending also increases inflation, by pumping money into the economy without producing purchasable goods and services. Spend- ing for nuclear weapons also produces far fewer jobs than investment in other sectors of the economy. According to Sidel (68), one billion dollars in 1982 spent on guided missiles would produce 1900 jobs; on construction, 20,500 jobs; and on hospital services, 50,000 jobs.

Hiatt (7 1 ) suggests that national security should be redefined to include the health and

0 Four hours of the arms race would pay for all of the World Health Organization’s $230 million annual budget.

0 In 1967, WHO launched a campaign to eradi- cate smallpox, and ten years later recorded the last case. The cost was estimated at $300 million, equal to five hours of the arms race.

well being of citizens. According to Hiatt, physicians and other health professionals should inform themselves of the wider implications of health programs and inform the public and political leadership of the potential health effects of funding priorities geared toward military spending. Sidel agrees:

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. . . a nation that cares for its missiles as though they the danger comes Erom us and our technology, were children and exposes many of its children to drawing on the mad scientist version of extinc. obscene living conditions and health hazards can in my view be neither just nor secure (68, p. 63). tion (31). Lifton says that only man can render

the meaningful totally meaningless.

In the nuclear shadow. Psychosocial costs of the nuclear arms race

According to mental health professionals concerned about the threat of nuclear war, nuclear weapons have created a new reality in modern society, with widespread and profound psychological effects. The major theoretical statement of these issues comes from psychohistorian Robert Jay Lifton. Lifton suggests that in every age, there is a pervasive theme which defies man’s engagement and yet must be engaged. For Freud, it was sexuality and moralism. Now, it is unlimited technological violence and absurd death (29, p. 541 ).

Lifton suggests that this form of death which he found in his study of the Hiroshima survivors is common to all of modern society: “We are all survivors.” This unique form of death presents a sense o f radical futurelessness, which is both a psychological and symbolic predicament.

Psychologicdfly, living in this threatening context may undermine confidence in the possibility o f a meaningful future, with the unprecedented threat of dealing not only with one’s own agony or sudden death, but also with the potential destruction of everything one knows and cares about. If we lose our future, we question our past. Nothing seems secure. Relationships cannot be guaranteed, their permanence thrown into question (31 ).

Symbolically, nuclear weapons threaten not only individual lives, but also ultimate meaning and continuity, by a grotesque, absurd and meaningless form of death. By threatening to destroy all o f social life, the past as well as the future, nuclear weapons threaten immortal- ity, in its various forms. In religious imagery of Armageddon, the end of the world is part of a meaningful world view with positive meaning accompanying the terror. With nuclear weapons,

Empirical studies of the current psychosocial effects of nuclear weapons have also been conducted, primarily in regard to children and adolescents. The influence of the threat of nuclear weapons on psychological development has been of most concern. Observers have noted a sense of powerlessness, cynical resignation, and protest at the adults who put them in the situation of potentially having no future. Beardslee and Mack (73) report on a survey conducted by a task force of the American Psychiatric As- sociation, reviewing earlier work such as that by Schwebel (74) and Escalona (75). Carey (76) interviewed adults who had grown up during the bomb scares of the 1950’s.

In this issue of Mobius, Halfon (77) reviews the empirical literature, concluding that all the studies support the general notion that the issue of nuclear war is on the minds of many children and may have some psychological effect, although the nature of that effect as it is mani- fested in children’s lives is uncertain.

Further research is underway as well. Golden- ring (78), for example, surveyed 930 young people. Nuclear war was third on their list of fears, after the death of a parent and poor grades in school.

Halfon (77) also discusses important theoretical and methodological issues, such as the nature o f processes of socialization to political attitudes through home, school and the media; children’s understanding of the concept o f war; and implications of the participation of children in political activity. Halfon also discusses the importance of talking with children in terms they can understand, and practical implications of health professional skills in helping children cope with the threat as they perceive it. Social workers Ahern (79) and Pollis (80) also address clinical implications of the stresses o f the nuclear age.

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Health effects of production, testing and deployment of nuclear weapons

The activities involved in producing, testing and deploying nuclear weapons also produce potential health risks. A number of groups have been put at risk by these activities, as reviewed by Wasserman and Solomon (81). United States military personnel and Pacific Island communities were exposed to the atmospheric tests conducted &om 1946 to 1962. Many of these people have experienced substantial health problems. Saffer and Kelly (82) provide a personal account of the experience of atomic veterans. Residents of the area surrounding the Nevada Test Site have also become concerned, as well as the communities surrounding the Rocky Flats production site near Denver, discussed by Irving in this issue (83), and Native Americans affected by uranium mining in the southwestern United States (84).

Kalven (85) notes that the core dilemma fat- ing anyone who seeks to establish a causal link between a health problem and radiation exposure is that the nature of the illness induced by radiation may take years to become apparent, and then may not be clearly distinguishable fi-om other causes. Moreover, there is no clear scientific consensus as to the relationship between low level radiation and various health problems. This complex literature cannot be reviewed here. John Goffman (86) provides a critical overview.

Vyner (87) has examined the psychological effects of exposure to radiation for atomic veterans. Vyner examines their search for meaningful answers to the “mystery” of radiation induced disease and undiagnosable somatic symptoms, and consequent identity conflicts and perceived stigma and social isolation.

The hibukushu, survivors of Hiroshima and Nagasaki, are also among the groups currently affected by nuclear weapons. About 700 hibu- k u s h currently live in the United States, primarily in California and Hawaii.

The potential health hazards from nuclear waste, nuclear power accidents and transporta-

tion of nuclear materials are also of concern, as Hanckel and Faden (88) note in this issue. PSR first became reactivated in the late 1970’s with concern about nuclear power, including the problems of radioactive wastes, the danger of nuclear accidents, and connections between nuclear power and nuclear weapons proliferation (89).

The nuclear accident at Three Mile Island occurred only a few days after PSR’s initial an- nouncement in 1979. MacLeod noted that, “Pub- lic health preparedness has been tested in a nuclear reactor accident and has been found wanting” (90, p. 238). The American College of Physicians issued a position paper in 1982 stressing both radiation accidents and the potential effects of nuclear war (91).

New Ways of Thinking: Psycho- social Aspects of Nuclear Weapons and International Relations

The psychosocial expertise of health professionals and other behavioral scientists has been put to use analyzing the nature of the social and psychological systems surrounding nuclear weapons. Particularly of interest have been factors which prevent change directed toward control of nuclear weapons. This analysis focuses both on the scientists, military and political leaders who control nuclear weapons, and the general public who have learned to live with the bomb.

Several themes in this work consider gaps between current ways of thinking and the empirical realities of nuclear weapons and international relations. The concept of pre-nuclear age thinking suggests that current ideas about war do not fit the reality of nuclear weapons. A distorting, stereotypical image of the enemy has been suggested as a complicating factor in international relations. Human fallibility has also been seen as a source of risk in nuclear weapons systems.

Approaches toward achieving change have also been explored. Improved international

18 MOBIUS

communication and cooperation have been proposed as means o f counteracting distorted perceptions of the enemy. The need for better structures for handling international conflict has been examined, as well as processes of individual change.

Many o f these issues overlap with other bodies o f literature in a number o f disciplines, which cannot be reviewed here. Studies o f the psychosocial aspects of international relations have covered a variety of topics (92-95). Related literature can also be found in fields such as international diplomacy and the other social sciences.

Prenuclear age thinking A major theme of current discussions of nu-

clear weapons is the madness of the nuclear arms race. Defined as irrational or flawed thinking, nuclear illusions or social madness, all im- ply that the concepts and strategies of nuclear wespons are not congruent with the empirical reality o f what nuclear weapons would bring.

The logic of the movement to control nuclear weapons suggests that these weapons are not even properly considered weapons of war. There are n o political ends in a nuclear war, no winners, only mutual destruction. General Douglas MacArthur is often quoted:

l h e very triumph of scientific annihilation has de- stroyed the possibility of war being a niedium of practical settlement o f international differences. If you lose, you are annihilated. If you win, you stand only t o lose. [Nuclear] war contains the germ of double suicide ( 1 ).

Moreover, nuclear weapons have changed what it means to be strong, breaking the link between military strength and security. Having more weapons does not make a nation safer. There is no such thing as being number one, or having nuclear superiority when both sides have more than enough weapons to destroy the other many times over. The nuclear arms race is like two people standing in a pool of gasoline. One

has eight matches and the other has ten. Add- ing more matches will not make anyone more secure.

Social psychiatrist Jerome Frank (96-98) suggests that perceptions of events are more important than the events themselves. The problem now is that the facts have changed with the introduction o f nuclear weapons, but national leaders still perceive then1 as simply larger conventional weapons t o be dealt with in the same way.

Frank suggests that leaders by definition perceive reality in terms of power relationships; the accumulation of power becomes an end in itself. With nuclear weapons, the reality is that they cannot be used without damage t o the user, but they still have the function of demon- strating superior will. Leaders must believe they can control events and seek at all costs t o pre- serve this belief in the face of uncontrollable eventualities.

, , . the pursuit o f power and security through illusory nuclear superiority is in reality a race for prestige. The nuclear arms race is an especially dangerous form o f psychological warfare. It is an effort t o achieve psychological security at the expense of rictual secur ity (97, p.4 1.

Deutch (99) notes that nuclear weapons are the purest and most concentrated form o f power. Lifton (31 ) sees quasi-religious aspects of the power of nuclear weapons, as they seem close t o an ultimate source of power, unending, invisible and mysterious. Observers of test explo- sions report an absolute sense of awe. Lifton suggests that this sense of ultimate power leads to a sort of worship of the bomb, the embrace o f the bomb as a “new fundamental, as a source of salvation and a way of restoring our lost sense of reality” (31, p.87).

According to Lifton, from this experience comes a blocking of reality and the need for security. The central existential fact of the nu clear age is insecurity, which creates the strongest possible psychological impulse to security.

NEAL 19

Like Frank, he suggests that psychological security is purchased at the price of increasing the threat, through illusions of limit and control, of protection, and rationaliry.

Margaret Clark (loo), in this issue, suggests that the nuclear arms race can be seen as a form of risk-seeking, as opposed to the rational weighing of value gained and potential harm of risk-taking. In risk-seeking, evil is perceived as omnipresent, and must be confronted with extraordinary forces. Risk-seeking also contains elements of play:

Danger can be a transcendent experience, provided one finally escapes it, and in play, one always expects to win (100, p. 102).

Risk-seeking gives social rewards to those who seek risks, and often incorporates supernatural elements such as a demonic world view, rituals of divine protection and a sense of personal righteousness.

Part of the underpinnings of nuclear illusions of rationality, Lifton suggests, is the inability of the human mind to comprehend the reality of what nuclear war would actually bring. Nuclear weapons are basicly unimaginable, the enormous consequences defying both intellectual and emotional comprehension. What this absolute nothingness would be like cannot be held in the mind.

Mack (101) distinguishes between “thinkables” who plan for nuclear war, and “unthinkables” who assume it would be so severe that planning is not meaningful. Mack suggests that “unthinkables” seem to be more willing to experience directly or hold emotionally the reality of nuclear war, while the “thinkables” avoid the terror by reverting to old, more comfortable, and familiar ways of thinking.

Moreover, it has been suggested that there are no words capable of communicating this im- mense reality. The technical distance of “nukespeak’ uses euphemistic terms for weapons, and “collateral damage” for the destruction of human beings (102). Mack (101) suggests that we

need new words for the likelihood of the extinction of life.

This special technical language is also one of the organizational factors surrounding nuclear weapons which reinforces specialized ways of thinking. Frank (97) suggests that perhaps the most important contribution psychologists should be able to make is to understand the psychological forces that keep political and military leaders trapped in the nuclear arms race.

The political and military organizations which control nuclear weapons are closed systems, with bureaucratic controls and closed social networks maintaining boundaries and a common way of thinking. Mack (101) suggests that there is a “mind set” which accompanies the system. Inside the black box of nuclear bureaucracies, “reality and imagination, psychology and politics are intertwined” (101, p. 20). Bureaucratic dynamics also contribute to the perception that the weapons are out of control, through the inertia of the organizations as well as the technological drive of the arms race.

Secrecy is an important part of these dynamics, as Lifton also notes. Carson (104) discusses the internal dynamics of secrecy and the ten- dency for the secrecy apparatus to persist and grow. Manoff (105) suggests that the epistemio- logical structure of the nuclear regime which insists on information control and restrained inquiry is not consistent with that of democracy. Secrecy concentrates control, while the open- ness of democracy seeks to defuse it.

Human Mlibility and accidental nuclear war

The risk of nuclear weapons also comes from the possibility of accidental nuclear war. Nuclear weapons systems provide many opportunities for human and technological failure (106, 107). Dumas (107) suggests that no system design produced or activated by human beings can ever achieve perfection. Dumas reviews human factors in the control and operation of military systems such as mental illness, alcohol or drug

20 MOBIUS

addiction; stress, boredom and social isolation; the nature of socially isolated groups and inter- personal relationships; as well as control difficulties in bureaucracies, such as the transfer of infomiation.

The designs for technological systems are also produced by human beings, and similarly are subject t o error. Computer Professionals for So- cial Respc)nsibility are preparing a position paper examining soLirces of failure in computer systems. This danger is increasing with advances in technology. For example, Pershing I1 missiles will be able t o reach Moscow within ten minutes, possibly forcing the Soviet llnion into computerized launch on warning. Computers make mistakes. Physicist Kosta Tsipis has said that he would hate t o see the security o f the Llnited States in the hands o f Soviet computers ( 108).

The image of the enemy Few discussions o f nuclear weapons fail t o

raise the question, “What about the Russians?” While enemies certainly do exist, and can be dangerous, pvchosocial an;ilysts have also noted that part of the perception of enemies is formed i n ;I process o f stereotyping, which distorts perceptions o f the countiy, creates a self fillfilling propheq about their actions, and prevents us from seeing common interests. The unknown is ;in especially potent source o f fear. The enemy image, according t o Frank (97), reduces uncer- tainn, by provicling a clear set o f black and white simplifications of what t o expect from

Progressive mutual distortions lead t o mirror images o f each other, each side attributing the same virtues t o tlienisehw and vices t o the other. Both see the other side as aggressive and untrustworthj’, rather than engaging in self pres- emation. Foreign aid from our side is altruistic; from the other side, expansionist. Both sides see the leaders o f the other as villains, and the niasses disaffected and exploited ( 109).

The rigidity o f this image o f the enemy comes from such factors ;IS being ;I coinvnient scape-

the enem)’.

goat for internal problems and mobilizing the population. Moreover, the image becomes a self fillfilling prophecy, as it elicits behavior that reinforces the image. Information becomes dis torted through restriction o f coniiiiiiiiication and selective filtering o f information, as in news- paper reporters writing what the), think people want to hear. Ideological differences with religious overtones make the political conflict into ;I battle between good and evil, leading t o de- humanization o f the enemy (97).

One consequence o f this image is that if the enemy wants something, it must be bad for us. Frank notes that the worst argument against the. bilateral nuclear weapons freeze has been that the Soviets are for it (96).

Erik Erikson ( 110) proposes that the human race has divided into groups through a process o f ~’seudospeciation, in which each group de velops a sense o f superior identity and distrust of others, which intensifies in times o f danger. Now, the need is for ;i broader collective iden tity, a widening sense o f the human species.

Developing a more realistic and di fferentiatecl perception o f the enemy is a high priority for many organizations concerned about nuclear weapons. Frank (77) notes that the enem!’ image is subject to change when nations see interests in common. For example, one study investigated ad ject ives attributed t o German, Japanese and Russians by Americans i n 1942 and 1966. I n 1742, the Germans and the Japan- ese were warlike, trciclieroiis and cruel; in 1766, the Russians were. The Chinese are still atheistic like the Soviets, but n o one talks about the godless Chinese (96).

International connections are an important theme in health professional groups and in the movement as a whole. Many national professional associations have brought resolutions to international congresses. Individuals have ex- changed visits and developed personal contacts with health workers in other countries, as individuals or in formal exchange programs.

International Physicians for the Prevention o f

NEAL 21

Nuclear War (IPPNW) considers the image of the enemy a crucial factor. IPPNW advocates large increases in the volume of scientific, technical and cultural exchanges, as well as increasing the amount of information each has of the other through mass media and other means, as described by Shea and Muller in this issue (111). The Federation of American Scientists (FAS) has for some time been campaigning to persuade senators and congressional represen- tatives to visit the Soviet Union, with compar- able exchange visits from Soviet officials. The Association for Humanistic Psychology sponsors a program encouraging the exchange of photo- graphs between Soviet and American families. Ground Zero is preparing a major public educational program on the subject, “What about the Russians?” ( 112-1 16). George Kennan, former United States ambassador to the Soviet Union, has written extensively about Soviet-American relations (1 15).

IPPNW considers the development of physicians’ groups in Eastern Europe and the Soviet Union one of the most important achievements of the international physicians’ movement. Phy- sicians speaking on the dangers of nuclear war have also received considerable attention in the Soviet media, including an hour long television program with three physicians from each country (114). IPPNW suggests that points of contention are easy to find, but that the growth of the physicians movement offers American and Soviet leadership the knowledge that significant points of agreement also exist.

Nuclear 7 ~ a r : A common enemy? The major points of agreement between So-

viet and American physicians are that there are no winners in a nuclear war and that nuclear weapons pose a common threat to both countries. The movement suggests that nuclear weapons pose such a great threat that the United States and the Soviet Union essentially have a common enemy in the threat of nuclear war, despite other hostilities and differences. Lifton (31 ) says the key is the revision of our concept

of security. The basis for nuclear awareness is a conception of shared fate: If I die, you die; if you survive, I survive. The LJnited States and the Soviet LJnion are like two boys in a boat. If one pokes a hole in one end, they both go down. Admiral Noel Gaylor (1 17) suggests that when we invented the atomic bomb we created the one thing that could threaten the security of the United States. As Kornfeld (118) points out in this issue, there are many kinds of problems requiring global cooperation.

Most Americans also consider the Soviets a dangerous enemy (119, 120). Ian Thiermann (121) suggests that the question most Ameri- cans want answered is how do we maintain our national security and stop the arms race. “You can’t trust the Russians.” They break treaties, are aggressive and determined to take over the world. The only thing the Soviets understand is force (124).

In this view, Soviet aggression is more of a threat than nuclear weapons. An editorial in a health journal (122), for example, says that the movement position addresses only the consequences of the failure to prevent nuclear war, and asks what if we shed our weapons and lost our freedom. The larger issue is not how to decrease the arsenal, but how to decrease the threat of war. Similarly, Smith Christ (123) says that one reality a previous editorial did not confront was the reality of Soviet strike potential.

However, it could be said that one thing the Soviets can be trusted to do is to act in their own self interest, and it is in their interest to reduce the threat of nuclear war. The Soviets have positive incentives to reduce nuclear armaments. The Soviet economy cannot even provide basic consumer goods. They fear war, having lost 20 million people in World War I1 alone.

Moreover, negotiating practical agreements on areas of common interest does not mean ap- proving of Soviet behavior. In fact, the worse relations are between the United States and the U.S.S.R., the greater the need for control of nuclear weapons.

22 MOBIUS

Most importantly, structures and mechanisms for realizing common interests and minimizing risks can be established. In arms control, the question is not can the Soviets be trusted, but rather can agreements be verified. Many experts including William Colby, former director of the Central Intelligence Agency (125), agree that technical means o f verification are available. All that is lacking is the political will.

Moreover, mechanisms can be established to facilitate international communication and the resolution of conflict without violence. An extensive literature exists in the study of conflict resolution (126). Kelman (127) o f the Harvard Negotiation Project has worked, for example, with Arabs and Israelis, facilitating communicd- tion so that mutually acceptable solutions can emerge. Kelman suggests that the Korean plane incident demonstrated that rigid protocols and lack of communication are not conducive to problem solving and that there are no mechanisms for managing crises and resolving conflict before they lead to peace-threatening action.

In sum, it is imperative that our social engi- neering in creating mechanisms for resolving conflict become equal to our technical engi- neering in creating means of destruction. Arch- bishop Quinn, in this issue, quotes from John F. Kennedy’s address to the United Nations:

Unless man can match his strides in weaponry and technology with equal strides in social and political development, ou r great strength, like that of the dinosaur, will become incapable of proper control and man, like the dinosaur, will vanish h m the earth (128, p. 109).

While some would judge it naive to negotiate with the Russians, it may be equally naive to think that the nuclear arms race can continue unchecked without a nuclear war by accident or design. N o alternatives come without risks. As with drugs, all solutions have potential side effects, but the risk is taken because of the greater risk of illness.

Mobilizing Individuals Lifton (32) suggests that the predominant

state of mind in regard t o nuclear weapons has been psychic numbing, which keeps the threat of nuclear weapons from emotional reality and may prevent adaptive responses. Lifton says survival requires a balance between feeling and not feeling. The goal is to break through the psychic numbing, to force people to confront what nuclear war would mean, and to encourage them to become actively involved in prevention.

To create change, one must know the reality of the thing, emotionally as well as cognitively. The movement is often decried as naive and emotional, but Helen Caldicott suggests

I f I had two parents who came into my office and I told them their child had leukemia and showed them what the prognosis was and what might happen, and they showed no emotional response, I would get them to a psychiatrist straight away (129, 1x9).

Caldicott uses such terminal illness as an analogy for the nuclear arms race, suggesting that we have a “terminally ill planet.”

Rational and persuasive discourse is essential as well. The first step is to inform yourself, and then to inform others. “Through accurate pre- sentation of the facts, illusions are shattered and make believe undermined” (102). Many people assume that the facts about nuclear weapons are too complex to understand. Mack suggests that behind the technical language, the jargon, statistics and strategic discussions, the basic concepts are not difficult (101). One does not have to know all the technical details to know there are no winners in a nuclear war.

A prominent part of the current movement activities are workshops on the emotional aspects of living in the nuclear age, through groups such as Interhelp (see Appendix I for address). The purposes of these workshops is to provide people with the opportunity to explore and share with others their deepest emotional response to the dangers which threaten the world, and in so doing to enable them to know the

NEAL 23

power that comes from their interconnected- ness with all life, so that they can move beyond powerlessness and numbness into action. These workshops are based on the premise that pros- pects for the future create normal and widespread feelings o f distress which are largely repressed, paralyzing action and creating a sense of isolation and powerlessness and resistance t o painfill but essential information. Individuals need help processing information on the affect- ive level if they are to understand it on the cognitive level.

Moreover, action can be an antidote to despair. In this issue, Theirmann (121) notes that the counterpart of fear is action. The way to overcome or at least lessen feelings of despair and defenselessness is through personal involvement. Kelly (133), in this issue, also discusses these issues.

Some of the survivors of Hiroshima and Naga- saki have chosen to speak about their experi- ences in order to help prevent nuclear weapons from being used again, and also as a way of affirming and reintegrating their own lives (20, 19,112). Making the experience real is seen as a key to realizing the changes necessary to control nuclear weapons. One survivor notes,

I believe that the pledge not to repeat the mistakes of Hiroshima and Nagasaki can be made a lasting reality if the people of the world realize and understand the suffering of those under the mushroom clouds in the two cities (1 13, p. 106).

New Ways of Thinking: A New Relationship to War

Health professionals have suggested that the potential effects of nuclear war require a new ethical position in regard to nuclear war, and a new approach based on preventing war, as opposed to the traditional role of health professionals in caring for the victims of war. There has been considerable debate concerning these issues in the health professions. First, are nuclear weapons and nuclear war appropriately

considered a health issue on which health professionals can speak with authority, and do health professionals have an ethical responsibility in regard t o the issue? Secondly, if so, to what actions does this responsibility lead? As Cassel and Jameton (134) note, people who agree on the first issues may not agree on the second.

Are nuclear weapons a health issue? Health professionals have insisted that nu-

clear weapons and nuclear war are a health issue, as well as a political issue. Health expertise is relevant to many aspects of the issue, as described in previous sections of this paper. The technical language and scientific objectivity draws on an important form of professional authority and credibility.

Expertise is an important tool in the control o f nuclear weapons, as scientists and political and military leaders assert that only they have the expertise necessary to understand the issues. Health professionals have played a key role in asserting that there are other forms of expertise appropriate to the nuclear issue as well (135).

There is also a strong pragmatic sense to these arguments. Lown, Muller and Chivian, for example, suggest that the problem of civil defense relates “not to professional intent but to practical possibilities” (136). Cassel and Jameton (134) suggest that one need not be especially idealistic or pacifistic to support such a position, that it can be supported even by minimal humanism.

In the health professions, though, scientific objectivity is combined with the ethic of service. Jameton and Jackson (7) suggest that even though much of the discussion is in technical terms, the basic structure is firmly within the tradition of moral debate. Health care is also concerned with basic social values. As Jameton and Jackson note, the health professions reflect deep and widely held values in regard to life and health. Jameton and Jackson propose

24 MOBIUS

that the involvement of health professionals in nuclear weapons issues has particular social importance because health care is dedicated to values not confined to the occupation, but to broad human values universally respected and deeply held. Health workers also have experience with death and dying, both with individual patients and with the social issues surrounding technology and the very definition of life and death.

Do health professionals have an ethical responsibility?

Murray (137) proposes succinctly that the social value to which medicine and its practitioners are committed is health. The more apparent and weighty the health consequences of a policy, the firmer the grounds for physician involvement.

In one sense, knowing the facts about nuclear weapons leads to the responsibility to promul- gate that knowledge.

Recent talk by public figures about our winning or even surviving a nuclear war must reflect a wide. spread failure to appreciate a medical reality: any nuclear war would inevitably cause death, disease and suffering of epidemic proportions, and without effective medical intervention (37, p. 2314).

I f these basic facts are ignored, health professionals have the responsibility to see that the information reaches public attention.

In some ways, the relationship between health care and war has been positive. Medical knowledge has been regarded as important t o the conduct of war. War has also been in some cases a resource to health care, as in the advancement of medical skills in trauma medicine. Military service in wartime has played an important role in the development of the nursing profession, as discussed by Jameton and Jackson (7).

Health professionals have questioned the use of health services as instruments of war. Nazi war crimes, for example, involved physicians in such acts as medical experimentation and mass euthanasia of the mentally ill. Capt. Howard B. Levy rehsed to give training to Special Forces medics during the Vietnam War, alleging that they were using medical care as a tool of war to gain the allegiance of the local people. The involvement of physicians in torture has also been of concern (139,140).

The legitimacy of certain types of weapons in modern warfare has also been questioned on ethical grounds, particularly biological and chemical weapons. The debate over biological weapons involves such issues as the likelihood of use against noncombatants, and the possibility of vast unintended damage t o both com- batants and noncombatants. The role o f the biomedical sciences in developing biological agents to be used as weapons has been seen as violating the principle of doing no harm (141). Abrams notes,

Health pfessionak and war While germs and chemicals [as weapons] have been

and in war, thermonuclear weapons, far more devas- and disruption, but profes- tating, have become acceptable to the international

community (142).

wars have ahays produced injury, death, dis- outlawed a.5 Contrary tO the ethics of Society in peace

sionals have rarely questioned war itself. As Jameton and Jackson point out in this issue, the primaq emphasis in ethical discussions in health care has been the ethics of the health professional in war, performing the function of caring for the sick and wounded. The Geneva Conven- tions define the role of the health professional in war, separating the wounding and healing roles (138).

The current concern about nuclear weapons suggests that the nature of nuclear weapons is such that health professionals would no longer be able to fulfill the traditional roles o f caring for the sick and wounded. A “new relationship to war” is required. In fact, not only is preventing nuclear war an appropriate role for health

NEAL 25

professionals, it is the only feasible role in regard to nuclear war.

In discussing ethical problems physicians might face in the postattack period, Sidel, Geiger and Lown suggest,

Neither the Hippocratic Oath, the published codes o f ethics o f the AMA nor the personal morality on which every physician relies provides an easy answer to these questions. In fact, a review of these trusted and cherished guides in light of the problems of thermonuclear war makes them seem curiously and sadly obsolete, as if they reflected the human inno- cence o f an earlier era (34, p. 1144).

support a bilateral nuclear weapons freeze, and condemn first use of nuclear weapons (146).

Universal values and health care The universality o f values o f health care has

been discussed as well. Bruwer (147) focuses on this principle of universality, suggesting that it may be that there is no choice but to focus on global interconnections and commitment to humanity, as stated in the Declaration of Geneva, as opposed to the limited goals of nation states.

Geiger says that participating in civil defense “requires suspension of medical judgment and

ks Shes and Muller report in this issue, the abandonment of reasonable reliance on medi- third International Congress ofthe International cine and scientific data that should not be sanc- physicians for the Prevention of Nuclear war tioned even in the name of patriotism” (40).

Geiger also questions FEMA’s plan for allocation has recommended that the Hippocratic Oath be of health care in the postattack period, based amended to include on usefulness to economic recovery. The allo-

As a physician of the 20th century, I recognize that nuclear weapons have presented my profession with a challenge of unprecedented proportions and that a nuclear war would be the final epidemic for hu- mankind. I will do all in my power to work for the prevention of nuclear war (11 1, p. 92).

Porter (143) suggests that there are precedents for ethical problems raised by new technology. As a philosophy is beginning to emerge in regard to life support systems, “in a similar view.. .all physicians must become convinced that the prevention of nuclear war is the only alternative worthy of our pursuit” ( 143, p. 1377).

The ethics of nuclear weapons can also be considered in the more general tradition of ‘just‘ war theory in western religious and phil- osophical thought (144,145). Two important aspects of historical codes o f just war are the immunity of noncombatants, and the principle of proportionality, the values lost weighed against those gained or protected. Both principles are challenged by nuclear weapons. The recent statement by the Roman Catholic bishops of the United States concludes that deterrence is unacceptable as a long-term basis for peace, but tolerable on a temporary basis. The bishops

cation plan proposes to treat key personnel first, their functions weighted in order to treat the injured who would provide the most man-hours at the most opportune times. The basis of this approach to triage is need to the fatherland, a new kind of moral prescription, Geiger suggests (40) .

As Shea and Muller discuss in this issue ( 1 1 I), the International Physicians for the Prevention of Nuclear War (IPPNW) is based on the principle that physicians of all nations share a commitment to the preservation of life and health that transcends national boundaries. IPPNW as- serts that physicians speak a common language and share common values that transcend political differences. These common goals have enabled colkaboration in the eradication of many dis- eases. From their first meeting, Soviet and Amer- ican physicians agreed to act as healers, rather than spend their time debating partisan political differences, focusing on the fundamental issues of no victory in a nuclear war.

What actions should health professionals take?

There has been much debate about the ap-

26 MOBIUS

propriateness o f health professionals becoming involved in what has been primarily defined as a political issue. Commenting on the Roman Catholic bishops’ statement on the morality of nuclear war, William Safire (148) describes the issue as one o f “institutional tidiness,” and suggests that the bishops stick to religion and the Prcsident to politics.

Debates about political involvement are often referred to precedents in the public health tradition. According to Abrams (142), the government has always been involved in any massive attack on health problems. Together the government and health care workers have controlled plague, smallpox, polio, tuberculosis; initiated broad attacks on cancer and heart disease; or- ganized and implemented with the media and health organizations a national campaign against cigarette smoking. Hiatt (149) notes that since the surgeon general’s report on cigarettes in 1965, physicians have acted in patient and public education, sometimes complemented by government action, as in the American Medical Association House of Delegates opposition to federal tobacco subsidies. Cassel (150) discusses the example of infant seat belts. One must look at the scope of the problem and likely sources of successful intervention. As with nuclear weapons, intervention requires education and political action. If one cannot inoculate, one must educate.

A major issue here is whether the role of the health professional should focus primarily on education, or also include political action. Cassel (151) suggests that the goal is clear: to bring the information to the level of public discourse and to inform policymakers through education and the empowerment it provides. Education and dissemination of factual information is essential.

The aim is to educate and alert the widest possible public. Only an alert and aroused citizenry can alter the course of history and veer humanity away from the precipice ( 152, p. 20).

Murray ( 137) suggests that physicians should be encouraged to pursue the debate, raising the level of public understanding and the lucidity o f policy discussions. Health professionals are ed- ucators who have the opportunity to inform themselves, colleagues and the general public; they are respected as teachers and able to inter- pret complex science for patients and the public.

The extent of this responsibility has been debated. In an editorial in the New England Journal of Medicine, Arnold Relman ( 153) suggests that medical organizations and individual physicians should speak out on matters that directly concern medical care and public health, but have no obligation to speak on issues where physicians have no special expertise, such as military and political affairs, and should therefore not engage in potentially controversial political action. Physicians can have opinions as citizens.

What they should not do is confuse personal convic- tion with professional expertise or make the dangerous assumption that medical professional societies have any special competence or authority in dealing with purely political problems (153, p. 744).

Physicians should distribute information, but the American people must decide how best t o L I S ~

the information. Irvin Redlener of PSR (154), responding to

Relman’s editorial, suggests that the medical profession has been involved in such areas as automobile safety legislation, with no protest at doctors being neither legislators nor auto- motive engineers. Redlener also points out that medicine is indeed involved in politics, as the American Medical Association Political Action Committee was the second highest spending lobby in Washington in 1982. Redlener suggests that “...it is unlikely we will ever witness any significant separation of medicine and politics’’ (154, p.4).

In 1983, PSR “extended the medical model,” from maintaining a primarily educational position to directly challenging government policies

NEAL 27

which would escalate the arms race. PSR takes positions on policies by analyzing whether they contain underlying assumptions that nuclear war can be limited, won or survived (155). PSR has a Washington office and is lobbying for the bilateral nuclear weapons freeze and the com- prehensive test ban, and against civil defense for nuclear war and against the MX and other first strike weapons.

Cassel and Jameton (134) note that for medicine, the preventive and educational role of the physician is less clearly defined than diagnostic and therapeutic aspects. Thus, the former has a more problematic ethical basis, especially when directed toward a broader group than the clini- cian’s individual patients. In other health disciplines, educational and preventive roles may be more clearly defined. Specht (156) considers similar issues in social work, and Jameton and Jackson (7), characteristics o f the nursing role.

Health professionals as community leaders Cassel ( 151 ) notes that health professionals

have a symbolic role in the community. This may not be a strictly professional role, but often extends to areas with no direct health reference, where the symbolic authority of the profession has weight. Murray ( 137) similarly suggests that physicians are not just a collection o f individuals, but an institution vested by society with a special prerogative, vital responsibility in protecting the public health, and as such are in a powerful position to focus public attention. The social prestige, esteem and trust of the public which lends special force to their remarks, adds to the duty to speak out if health consequences are not given adequate attention.

the local or national level. Activities vary in form, goals, and organizational style. A common theme is, as Halfon (77) notes, providing people with the opportunity to address global problems in their own local ways.

A number of organizations have been formed within health disciplines to fbcus specifically on the issue o f nuclear weapons and nuclear war. A list o f major national health organizations is provided in Appendix I.

Educational activities include making literature and bibliographies available, major symposia, speakers’ bureaus t o talk to local health or community groups (157), or film or lecture series at health facilities or for the community. Films such as The Last Epidemic have been especially effective.

Many groups also sponsor internal education projects as members develop their skills, such as training programs for speakers ( 158) or study groups. Physicians have especially targeted the media, receiving wide coverage in national and local press and electronic media.

Credit courses have been established in many universities, as Cassel and McCally (159) discuss in this issue. Symposia and training events for speakers may also be made available for continuing education credit.

Professional associations have been another focus, as well as publishing in health journals. Symposia, workshops, paper sessions or exhibit booths have been conducted in conjunction with many professional meetings. Resolutions of various kinds have been proposed at many associations. Appendix I1 shows a partial listing of professional associations which have taken some form of action on the issue of nuclear weapons and nuclear war.

Providing services that offer access to professional skills is another area for many organizations. Psychological workshops that deal with the emotional aspects of the nuclear age are conducted, and volunteer health care is offered to survivors of Hiroshima and Nagasaki or atomic veterans, for example, who cannot afford health

Education, direct sewice, political action The specific types of activities health pro-

fessionals have chosen are varied. Groups may target specific audiences, organizing within their own profession, for example, or targeting the general public or political decision makers, at

28 MOBIUS

care. The Massachusetts chapter of Social Work- ers for Peace and Nuclear Disarmament is work- ing with High Technology Professionals for Peace on the impact of the defense industry on families ( 160). Some health professionals attempt t o integrate the issue with their regular work with clients, putting brochures in the waiting room, for example.

Other valuable skills include the organizational skills of social workers and others trained in community organizing and program adminis- tration. In Massachusetts, social workers have worked with movement groups in improving process and decision making and coping with burnout.

I n regard to political decision makers, health professionals have given expert testimony on numeroiis issues, at local, state and national levels. Groups may be involved in congressional lobbying, electoral politics, referenda on specific issues, or in direct action. A number o f health organizations, including NASW and APHA, be- long t o Citizens against Nuclear War (CAN), and other national lobbying networks.

A Call to Life . . , t h e issue is deadly ser ious, b u t our call is n o t a gr im o n e . It is a call t o life.

Robert Lifton (32, p. 54)

Apocalyptic imagery perfuses the literature on nuclear war, the extinction of life, the dusk of civilization. The empirical threat is very real, but the imagery may be seen not as a forecast of inevitable doom, but rather a call to positive change. The problem is urgent, but the possibilities are great.

Ian Thiermann (101) suggests that if these ultimate questions are not answered, all other questions become irrelevant. Yet Bernard Lown states,

The g u a r d e d o p t i m i s m pervading t h e physicians’ m o v e m e n t der ives from an abid ing faith in t h e concept that what humani ty creates , humani ty can control (131, p. 20,21 ).

Achieving these changes will not be easy, and may take generations. Archbishop Quinn ( 1 10 ) suggests that the same kind of courage, iniag- ination, patience and skill will be required t o construct the kind of new international order that marked the beginnings of the LJnited States. The original settlers had a vision o f what could happen, in the same way that abolitionists fore- saw the end of slavely, and the women’s suffrage movement anticipated achieving the vote for women. The current movement to control the arms race has a similar vision of a world free from the threat of nuclear weapons and dedicated to health and human security. 00

REFERENCES/FOOTNOTES 1. Center for Defense Information. Quotes: nuclear w;u: Washington, DC: Center for Defense Information, n.d. 2. Cf. Suggested readings: Weapons systems and arms control. In: Chivian E, Chivian S, Lifton RJ, Mack JE, eds, List aid: the medical dimensions of nuclear war. San Francisco: WH Freeman, 1982333. 3. Geiselman IA. Connexion. M6bius 1984; (Jan) 1:5. 4. Geenz C. Ideology as a cultural system. In: Geertz C. The interpretation of cultures. New York: Basic Books, 1973: 193-234. 5. Gerlach Lp, Hine VH. People, power and change: movement of stxial transformation. Indianapolis: Bobbs Merrill,

6. Simcock BL. Developmental aspects of antipollution prci test in Japan. Research in Social Movements Conflct and Change 1979; 2:83-104. Z Jameton A, Jackson EM. Nuclear war and nursing ethics: what is the nurse’s responsibility? Mobius 1984; (Jan) 1 :75 88. 8. Hiatt HH. Preventing the final epidemic. h11 Atom Sci

9. A complete bibliography is available on request. 10. Aronow S, Ervin FR, Side1 W, eds. The fallen sky the medical consequences of thermonuclear war. New York: Hill and Wan, 1963. 11 . A d a m R, Cullen S, eds. The final epidemic: physicians and scientists on nuclear war. Chicago: University of Chi- cago Press, 1981. 12. Chivian E, Chivian S, Lifton RJ, Mack JE, eds. last aid: the medical dimensions of nuclear war. San Francisco: WH Freeman, 1982. 13. The medical consequences of nuclear war. West J Med (Special issue) 1983; 138:206-26.

1981.

1980; 36:16.

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Appendix I ORGANIZATIONS - partial listing

Physicians for Social Responsibility (PSR) 639 Massachusetts Avenue Cambridge, MA 02139 International Physicians for the Prevention of

225 Longwood Ave. Boston, MA 021 15 Nurses Alliance for the Prevention of Nuclear War P.O. Box 319 Chestnut Hill, MA 02167 Health Network Against Nuclear War 1855 Folsom St. San Francisco, CA 94103 Society for Public Health Education (SOPHE) National Task Force Against Nuclear Proliferation 511 Earl Warren Hall School of Public Health University of California, Berkeley Berkeley, CA 94720 Social Workers for Peace and Nuclear Disarmament National Association of Social Workers (NASW) 7981 Eastern Avenue Silver Spring, MD 20910 Psychologists for Social Responsibili 1841 Columbia Road, N.W., Suite 21 Washington, D.C. 20009 Psychotherapists for Social Responsibility 152 Anza St. Fremont, CA 94539 Interhelp/U.S. P.O. Box 331 Northhampton, MA 01060

Nuclear War (IPPNW)

k"

Radiation Research Institute 2288 Fulton, Suite 306 Berkeley, CA 94704 Committee of Atomic Bomb Survivors in the U.S. c/o Japanese American Citizens League 1765 Sutter St. San Francisco, CA 941 15 Friends of Hibakusha Pine United Methodist Church 426 33rd Ave. San Francisco, CA 94121 National Association of Atomic Veterans 702 Highway 54 East Eldon, M O 65026 National Association of Radiation Survivors 231 27th Street San Francisco, CA 94131 Rocky Flats Project/AFSC 1660 Lafayette St., Suite D Denver, CO 80218 Downwinders 1321 East 400 South Salt Lake City, UT 84102 US. Nuclear Free Pacific Network 924 Market St., Room 712 San Francisco, CA 94102 Pacific Concerns Resource Center P.O. Box 27692 Honolulu, Hawaii 96827 Nurses' Environmental Health Watch 12713 Palfrey Drive Austin, Texas 78727

14. Prescription for prevention: nuclear war, our greatest health hazard. Proceedings of Conference by Stanford and mid-Peninsula chapter of Physicians for Social Responsibility (Oct. 7-8, 1983), Stanford: PSR, in press. 15. American Psychiatric Association. Psychosocial aspects of nuclear developments. Task force report no. 20. Wash- ington, D.C.: American Psychiatric Association, 1980. 16. Forum: preparing for nuclear war: the psychological effects. h e r J Onhopsychiat 1982; 52:578-645. 17. Cf. Suggested readings: consequences of nuclear weapons and nuclear war. In Chivian E, Chivian S, Lifton RJ, Mack JE, eds, Last aid: the medical dimensions of nuclear war. San Francisco: WH Freeman, 1982:320-21. 18. Quoted in Physicians for Social Responsibility brochure. 19. Cf. Suggested readings: Hiroshima and Nagasaki. In: Chivian E, Chivian S, Lifton RJ, Mack JE, eds, Last aid:

the medical dimensions of nuclear war. San Francisco: WH Freeman, 1982319.

20. Committee for the Compilation of Materials on Damage Caused by the Atomic Bombs in Hiroshima and Nagasaki. Hiroshima and Nagasaki: the physical, medical and social effects of the atomic bombings. New York: Basic Books, 1981.

21. lchimaru M. The Nagasaki atomic bomb and nuclear w x Mobius 1984; (Jan) 1:68-69.

22. Caldicott H. Our greatest challenge. Miibius 1984; (Jan) 1 : 143-1 50. 23. Ervin FR et al. The medical consequences of nuclear war 1. human and ecological effects in Massachusetts of an assumed thermonuclear attack on the United States. N Engl J Med 1962; 266:1126-36.

30 MOBIUS

Mental Health

Public Health

Appendix II PROFESSIONAL ASSOCIATIONS - partial listing

Medicine American Medical Association American College of Physicians American College of Pediatrics American College of Emergency Medicine New York Academy of Medicine Institute of Medicine State and local medical societies American Medical Students Association International Federation of Medical Student Associations Forum of American Psychiatric Association American Psychological Association American Association for Social Psychiatry American Orthopsychiatric Association World Association for Social Psychiatry American Public Health Association Society for Public Health Education California Conference of Local Health Officers Association of State and Territorial Health Officers World Health Organization

Nursing American Nurses Association California Nurses Association National Student Nurses Association Oncology Nursing Society National Association of Social Workers International Federation of Social Work American Association of Art Therapy National Union of Hospital and Health Care Employees American Federation of State, County and Municipal Employees (AFSCME) Service Employees International Union (SEIU)

Social Work

Allied Health

24. Abrams HL, Von Kaenel WE. Medical problems of survivors o f nuclear war: infection and spread of communicable disease. N Engl J Med 181; 305:1226-32. 29. Lifton RJ. Death in life: survivors of Hiroshima. New York: Random House, 1968. 30. Lifton RJ. The broken connection: on death and the continuity o f life. New York: Simon and Schuster, 1979. 31. Lifton RJ, Falk R. Indefensible weapons: the political and moral case against nuclear arms. New York: Basic Books, 1982. 32. Lifton RJ. Beyond psychic numbing. Mobius 1984; (Jan) 1:54. 33. Lihon RJ, Erikson K. Survivors of nuclear war: psychological and communal breakdown. In: Chivian E, Chivian S, Lifton RJ, Mack JE, eds, Last aid: the medical dimensions of nuclear war San Francisco: WH Freeman, 1982: 287-94. 34. Side1 W, Geiger HJ, b w n B. The medical consequences o f nuclear war. 11. the physician's role in the post attack period. N Engl J Med 1962; 266:1137-44.

35. Gellhorn A, Janeway P. The immediate medical response. In: Chivian E, Chivian S, Lifton RJ, Mack JE, eds, Last aid: the medical dimensions of nuclear war. San Francisco: WH Freeman, 1982: 181-201. 36. Constable JD. Surgical problems among suwivors. Hull Atom Sci 1981; 37:22-25. 3% Preventing the last epidemic. JAMA (Editorial) 1980; 244:2314-15. 38. British Medical Association. Board of Science and Edu cation. The medical effects of nuclear war. The repot o f the British Medical Association's Board of Science and Edu. cation. New York: John Wiley, 1983. 39. World Health Organization. Effects of nuclear war on health and health services. Report of the International Corn- mittee of Experts in Medical Science and Public Health t o Implement Resolution WHA 34.38. Geneva: World Health Organization, 1983. 40. Geiger HJ. The illusion of survival. Bull Atom Sci 1981; 37:16-19.

NEAL 31

41. Office of Technology Assessment. Clnited States Con- gress. The effects of nuclear war. Washington D.C.: Govern- ment Printing Office, 1979. 42. Galbraith JK. The economics of the arms race-and after. Bull Atom Sci 1981; 37:13-15. 43. Laulan Y Economic consequences: hack to the dark ages. In: Peterson J, ed. The aftermath: the human and ecological consequences of nuclear war. New York: pan^

theon, 1983:141-46. 44. Royal Swedish Academy of Sciences. Nuclear war: the aftermath. Ambio 1982; 11:2,3. 45. National Academy of Sciences. Long term world wide effects of multiple nuclear weapons detonations. Washing- ton, D.C.: National Academy of Sciences, 1975. 46. Lipton JE. The last traffic jam: psychologic consequences of nuclear war. West J Med 1983; 138:222-26. 47 Abrams HL. Surviving a nuclear war is hardly surviving. New York Times 1983; Feb 2% 48. Cassel C. An epistemology of nuclear weapons effects. West J Med 1983; 138:213-18. 49. Leaning J, Keys L, eds. Civil defense: the counterfeit ark. Lexington, MA: Ballinger Press, 1983. 50. Programs for surviving nuclear war: a critique. Special supplement. Bull Atom Sci 1983; 39(6). 51. Leaning J. Civil defense in the nuclear age: what purpose does it serve and what survival does it promise? Cam- bridge, MA: Physicians for Social Responsibility, 1982. 52. Physicians for Social Responsibility. Civil defense in the 80’s: aspects of the debate on civil defense. Cambridge, MA: Physicians for Social Responsibility, 1982. 53. The civilian-military contingency hospital system (CMC- HS): pro and con. N Engl J Med 1982; 306:730-36. 54. Bermel J. Should physicians prepare for war. The Hast- ings Center Report 1982; 12:15-21. 55. Abrams HL. Civilian-military contingency hospital system: preparing for “the highest rate of casualties in history.” Bull Atom Sci 1983; 39:supplement 11s-16s. 56. Geiger HJ. Should physicians prepare for war? 2. Why survival plans are meaningless. The Hastings Center Report

5% Leaning J, Leighton M. Federal Emergency Management 1982; 12:17-19.

Agency: the world according to FEMA. Bull Atom Sci 1983; 39:2S-7S. 58. Biscard JC. Should physicians prepare for war? 1. The obligation to care for casualties. The Hastings Center Re-

59. Johnson JT. Should physicians prepare for war? 3. The moral bases of contingenq planning. The Hastings Center Report 1982; 12:19-20. 60. Doctors defend nuke-war readiness. Medical World News 1983; 2466. 61. Beaty JF, BigRard JC, Armstron PC. The civilian-military contingency hospital system. N Engl J Med 1982; 306:738-40. 62. The civilianmilitary contingency hospital system. Med- ical planning for nuclear war. N Engl J Med (Letters) 1982;

port 1982; 12:15.17

307:751- 52.

63. Kornfeld H. Nuclear weapons and civil defense: The influence of the medical profession in 1955 and 1983. West J Med 1983; 138:207-12. 64. Geiger HJ. The medicine and morality of civil defense. In: Prescription for prevention: nuclear war, our greatest health hazard. Stanford: PSR, in press. 65. Peny KW. The social psychology of civil defense. Lex- ington, MA: Lexington Books, 1982. 66. Murray TM. Should physicians prepare for war? 4. The physician as moral leader. The Hastings Center report 1982; 12:20~2 1 . 6% Myers B. To plan for a hoax is a disservice to the people. Remarks before the Joint Legislative Forum on Nu- clear War Preparedness in California, March 17, 1982. J Pub H Pol (Guest editorial) 1982; 3:119-21. 68. Side1 W. The health and social costs o f the weapons race. Mobius 1984; (Jan) 1:63. 69. Anderson JR. Bankrupting America: the impact of Pres- ident Reagan’s military budget. Intl J Health Sen. 1981; 11: 623-29. 70. Yankauer A. The pseudo-environment o f national defense. Special issue. Am J Pub Health 1980; 70:949-50. 71. Hiatt HH. The physician and national security. N Engl J Med 1982; 307:1142-45. 72. Sivard R. World mil i tq and social expenditures. Lees- burg, VA: World Priorities, 1983. 73. Beardslee W, Mack JE. The impact on children and adolescents o f nuclear developments. In: American Psy- chiatric Association. Psychosocial aspects o f nuclear devel~ opments 1980. 74. Schwebel M. Effects of the nuclear threat on children and teenagers: implications for professionals. Amer J Ortho- psychiat 1982; 52:608-18. 75. Escalona SI. Growing up with the threat of nuclear war: some indirect effects on personality development. h e r J Orthopsychiat 1982; 52:600-607. 76. Carey MJ. Psychological fallout. Bull Atom Sci 1982; 38: 20-24. 77. Halfon N. Growing up in the nuclear age: psychological development in the face of uncertainty. MBbius 1984; (Jan) 1:35-45. 78. Fogarty J. Bay girl’s nuclear fears. San Francisco Chron- icle 1983 Sep. 21:lO(coI.1). 79. Pollis MF. Perspectives o f a clinical practitioner: The indirect and direct consequences of the nuclear arms race. In: Natl kssoc ofSocial Workers. Bread, not hombs: a role for social workers in the peace movement. Silver Spring, MD:

80. Ahearn FL, Jr. Psychological effects o f the nuclear threat: an issue for clinicians. In: Natl Assoc of Social Workers. Bread, not bombs. Silver Spring, MI): NASW, 1982:20-33. 81. Wasserman H, Solomon N. Killing our om: the disaster of America’s experience with atomic radiation New York: Dell Pub Co, 1982. 82. Saffer TH, Kelly OE. Countdown zero: GI victims of U.S. atomic testing. New York: Penguin Books, 1982.

NMW, 1982:10-19.

32 MOBIUS

83. Irving, J. The making o f Dark Circle. MObius 1984; (Jan)

84. Nelkin I). Native Americans and nuclear power. Sci Tech and Human Values 1981; 6:2-8. 85. Kalven J. The legal quandary. Bull Atom Sci 1983; 39: 26-29. 86. Goffman .w. Radiation and human health. San Fran- cisco: Sierra Cltih l3ooks, 1981. 87. Vyner IIM. The psychological effects o f ionizing radiation. Culture. Medicine, and Psychiatry in press. XX. H;inckel F, Faden R. Health professionals in a nuclear age: professional obligations and continuing education needs. Mnbius 1984; (Jan) 1:70.74. 89. Physicians for Strial Responsibility. Medical statement on nuclear power. N Engl J Med (Advertisement) 1979; 300: xxxix. 90. MacLeod GK. A role for public health in the nuclear

91. American College o f Physicians. Ilealth Policy Commit- tee. The medical consequences o f radiation accidents and nuclear war. Ann Int Med 1982; 97:447-50. 92. Groom AJR, Mitchell CR, eds. International relations theory: a bibliography. New York: Nichols Pub Co, 1978. 93. Katz D. Current and needed psychological research in international relations. J Soc Issues 1961; 17:69-78. 94. Kelman H, ed. International behavior: a social psycho- kigical analysis. New York: Holt Rinehart and Winston, 1965. 95. Branison L, Goethals GW, eds. War: studies from psy- cholohy, socioki&y and anthropology. Revised edition. New York: I h i c Iwoks, 1968. 96. Frank JI). Prevention of a nuclear niilitaly catastrophe. In: Prescription for prcvention: nuclcar war, our greatest health hazard. Stanford, CA: PSR, in press. 97. Frank JD. Sanity and survival: psychological aspects of wu and peace. New York: Randoni House. 1982 (orig. 1962). 98. Frank JD. Prenuclear age leaders and the nuclear arms race. Amer J Onhopsychiat 1982; 52630-37. 99. Cunningham S. Questions dominate New York meeting. Amer I'sychol Assoc Monitor 1982; 13:8,1 1. 100. Clark MM. The cultural patterning of risk-seeking behavior: implication for armed conflict. Mobius 1984; (Jan) 1:97-107. 101. Mack JE. Psychosocial effects o f the nuclear arms race. HLIII Atom Sci 1981; 37:18~23. 102. Mack JE. The perception of L!.S.~Soviet intentions and other psychological diniensions o f the nuclear arms race. k i ie r J Orthopsychiat 1982; 52:590-99. 103. Hilgartner S, Bell RC, O'Connor R. Nukespeak: the selling o f nuclear technology in America. New York: Penguin Books, 1982. 104. Carson D1. Nuclear weapons and secrecy In: American Psychiatric Association, Psychosocial Aspects o f Nuclear De- velopments, 1980. 105. Manoff RK. The role of the media in war and peace. In: Prescription for prevention: nuclear war, otir greatest hc5alth hazard. Stanford, CA: PSR, in press.

1 : 139 ~ 140.

age. AmJ Pub Health 1982; 72:237-39.

106. Duman LE Human fallibility and weapons. BuU Atom Sci 1980; 36:15.20. 107. Eggertson PF. The dilemma of power: nuclear weapons and human reliability. Psychiatry 1964; 27:211-18. 108. Quoted in the film, The Last Epidemic. 109. Bronfenbrenner LJ. The mirror image in Soviet-Ameri can relations. J Soc Issues 1961; 17:45.56. 110. Eribon E. A developmental crisis of mankind? In: Prescription for prevention: nuclear war, our grf2dteSt health hazard. Stanford, CA: PSR, in press. 11 1. Shea S , Muller J. The work of the International Phy- sicians for the Prevention o f Nuclear War (IPPNW). Mobius 1984; (Jan) 1:89-95. 1 12. Fellowship o f Reconciliation. Directory o f initiatives for U.S.-L1.S.S.R. reconciliation. Nyack, New York: Fellowship of Reconciliation, 1983. 113. Grtiund Zero. What about the Russians- and nuclear war. New York: Pocket Books, 1983. 114. International Physicians for the Prevention of Nuclear War. The Soviet response t o medical efforts for the prevention o f nuclear war. Cambridge, MA: I P P W , 1982. 11 5. Kennan CF. The nuclear delusion. Soviet-American re lations in the atomic age. N e w York: Pantheon Books, 1983. 116. CraCrah J, ed. The Soviet Union today: an inexpensive guide. Chicago: Bulletin of the Atomic Scientists, 1983. 117. Gaylor N. Nuclear weapons vs security: a strategic anal^ ysis. In: Prescription for prevention: nuclear war, oi ir greatest health hazard. Stanford, CA: PSR, in press. 118. Kornfeld H. Human health and global security. Mobius 1984; (Jan) 1:132-134. 119. De Boer C. The polls: our commitment to world war 111. Public Opinion Quarterly 1981; 45:126-34. 120. Smith W. The polls: American attitudes toward the Soviet llnion and Communism. Public Opinion Quarterly

121. Thiermann I. The making ofThe Last Epidemic. Mijhius 1984; (Jan) 1:136-137. 122. The road away from nuclear war. Ann Int Med (Edi- torial) 1982; 97:445-46. 123. Christ Smith J. O n the nuclear arms rxc. Amer 1 Psychiat (Letter) 1983; 140:661-62. 124. Orient JM. Nuclear weapons: surrender or defense. J Amer Med Women's Assoc 1982; 37:260-62. 125. Colby WE. Verification. In: Prescription C)r prevention: nuclear war, otir greatest health hazard. Stanford, CA: PSII, in press. 126. Poeter JN. Conflict and conEict resolution: a historical bibliography. New York: Garland Pub Co, 1982. 12% Kelman t ic . Problem-solving in conflict resolution: a contribution to unofficial diplomacy. In: Prescription for prevention: nuclear war, our greatest health hazard. Stanford, CA: PSR, in press. 128. Quinn JR. The vision ofpeace in a nuclear age. Miibius 1984; (Jan) 1:109-111. 129. Caldirott H. Dr. Helen Caldicott o n the medical con-

1983; 47:277-92.

NEAL 33

sequences of nuclear war. A speech given in Berkeley, April 20, 1981. Watertown MA: Women’s Party for Survival, 1981. 130. Thurlow S. Nuclear war in human perspective: a survivor’s report. Amer J Onhopsychiat 1982; 52:638-45. 131. Ohkita T. Delayed medical effects at Hiroshima and Nagasaki. In Chivian E, Chivian S, Lifton RJ, Mack JE, eds., Last aid: the medical dimensions of nuclear war. San Fran- cisco: WH Freeman, 1982:93-108. 132. Macy JR. Despair and personal power in the nuclear age. Philadelphia: New Society Publishers, 1983. 133. Kelly A. The spiritual imperative for peace. Mobius 1984; van) 1:112-124. 134. Cassel C, Jameton k Medical responsibility and thermonuclear war. Ann Int Med 1982; 97:426-32. 135. Smith AK Scientists and public issues. Bull Atom Sci 1982; 3838.45. 136. b w n B, Chivian C, Muller J, and Abrams H. The nuclear arms race and the physician. N Engl J Med (Reply to letters) 1981; 305:223. 13% Murray TH. The CMCHS: medical planning for war. N Engl J Med (Letter) 1982; 307:752. 138. Rozovsky LE, et al. Health services, law and war. Can J Pub Health 1982; 73:361-63. 139. Sidel W, Sidel M. Warfare: biomedical science and war. In: Reich Wr, ed, Encyclopedia of Bioethics, Vol. 4. New York: Free Press, 1978: 1699-1704. 140. Vastayan Ek Warfare: medicine and war. In: Reich W, ed, Encyclopedia of Bioethics, Vol. 4. New York: Free Press, 1978: 1695-99. 141. Sidel W, Goldwyn RM. Chemical and biological weapons-a primer. N Engl J Med 1966; 274:21-2% 142. Abrams HL. The medical consequences of nuclear war. Bull Atom Sci 1980; 36:15. 143. Porter ck The Lancet (Letter) 1980; II(8208/9):137% 144. Wasserstrom RA, ed. War and morality. Belmont, ck. Wadswonh, 1970. 145. Walzer M. Just and unjust wars: a moral argument with historical illustrations. New York: Basic Books, 1977. 146. Miller RB. Final draft of the pastoral letter. Bull Atom Sci 1983; 3955.56. 14% Bruwer k Nuclear war, patriotism and medical ethics. The Pharos 1982; 45:2-8. 148. Safire W. Bullies in the pulpit. New York Times 1983 Mar 14. 149. Hiatt HH. Preventing the last epidemic: 11. JAMA 1981;

150. Cassel C. Nuclear armaments. West J Med (Letter)

151. Cassel CK. War, peace and professional responsibility. Soc Sci Med 1983; 17:1199-1203. 152. b w n B. Nuclear war and the public health. J Pub Health Pol 1982; 31:12-19. 153. Relman AS. Physicians, nuclear war and politics. N Engl

246:2314-15.

1982; 137:437-38.

154. Redlener 1. Physicians and the nuclear arms race: how far should we go? PSR Newsletter (Editorial) 1983; 4(3):4. 155. PSR/West. 1983 program plan. PSWes t Newsletter 1983; Spring:3-4. 156. Specht H. An analysis of the roles, tasks and functions of social workers in a nuclear war: problems, process and policy recommendations. Social Work 1982; 27:372. 15% Greater Boston Physicians for Social Responsibility. Suggestions for running a speakers bureau. Cambridge, MA: Greater Boston PSR, 1983. 158. Greater Boston Physicians for Social Responsibility. Speaking out on the threat of nuclear war: a speakers training manual. Cambridge, MA: Greater Boston PSR, 1982. 159. Cassel CK, McCally M. Nuclear weapons, nuclear war and the health professions curriculum development in medical schools. Mobius 1984; (Jan) 1:126.131. 160. Freiberg E, Wolper M. Social workers for peace and nuclear disarmament an organizing model. In: NASW! Bread, not bombs. Silver Spring MD: NASW 1983:34-42.

~~

Mary Neal, M.S. Ms. Neal is a doctoral candidate in the Medical Anthropology Program, University of California, San Francisco and holds a master o f science degree in public health. She is currently conducting research on the dynamics of social movements and social change and adapting management training to the needs of volunteer organizations. She has also developed educational materials for the NuClYdr Weapons Freeze Campaign.

Requests for reprints: Mary Neal, Department of Medical Anthropology, LICSF, 1320 3rd Avenue, San Francisco, CA -

J Med (Editorial) 1982; 307:744-45. 94143.

Documents

Changing our ways of thinking. Health professionals and nuclear weapons