US cities are not medically prepared for a nuclear attack: Bulletin of the Atomic Scientists. (
BAS). HT:
Crof.
The abstract:
The
United States is not prepared to deal with an attack by a terrorist
group using an improvised nuclear device, the author says. It should get
prepared, because the risk is real even if the probability is low, and
doing so could save a great many lives.
The
author explores the potential impact of a 10–15-kt improvised nuclear
device set off in New York City. The initial blast would kill between
75,000 and 100,000 people in seconds. Another 100,000–200,000 people
would be injured, many of them dying within weeks or months, some with
burns, others with impact injuries, and some with acute radiation
syndrome.
The
demands on the medical system would be vast and overwhelming, all the
more so because the bomb would have destroyed much of the capacity to
respond. Current planning efforts are not sufficient to manage the
carnage.
What we’re up against.
There
are four types of potential nuclear incidents that require some level
of preparation: an accident or attack at a nuclear power plant, a dirty
bomb, terrorist use of an improvised nuclear device, and an attack using
a nuclear weapon executed by a foreign nation.
The
first two types of events – an incident at a nuclear power plant and a
dirty bomb – have received a greater level of planning attention than
the others. An attack on a nuclear power plant or a catastrophic
accident like the ones that occurred at Chernobyl in 1986 and Fukushima
in 2011 would have devastating short- and long-term effects. With that
in mind, the Federal Emergency Management Agency (FEMA) and Department
of Energy require that states with nuclear power plants practice
notification, response, and evacuation plans. Zones requiring specific
actions have been designated depending on communities’ proximity to
nuclear power plants. Fortunately, the track record of the US nuclear power industry has been reassuring in terms of planning for accidents.
The
possibility of a dirty bomb attack has also received planning attention
from US authorities, in part because it is seen as relatively likely on
the spectrum of nuclear disasters. A dirty bomb is a rather simple
device composed of a conventional explosive – much like the one used to
blow up Oklahoma City’s Alfred P. Murrah building in 1995 – laced with
radiological materials called isotopes. Gaining access to radioactive
isotopes is not as challenging as one might expect. Medical facilities
use various types for diagnostic testing, and several industries require
them. Certain isotopes, while difficult to come by, have a long
half-life, and if used in a dirty bomb would contaminate the blast area
and that around it with residual radioactive material for months or
years. This would create a “hot zone” too dangerous to enter for any
type of firefighting, rescue, or reconstruction activity. Additionally,
radioactive particles dispersed in the air can be carried downwind in a
“plume” and deposited far from the explosion. Planning for the aftermath
of a dirty bomb will vary from city to city. Most cities have some
level of preparedness for managing
a mass-casualty event, but the problem of radiation contamination adds
complexity. The majority of contamination can be handled by removing
clothing and washing victims’ skin. Once victims are removed from the
area, the residual ground and building contamination is a less urgent
problem, and decisions about clearing the area will likely be made by
city authorities in conjunction with federal agencies.
The
most devastating kind of incident would involve a nuclear weapon:
Terrorists could acquire or build and detonate an improvised nuclear
device in a major city, or – worse because the bomb would be bigger – a
foreign nation could launch a nuclear attack.
In
the first scenario, the device would likely be between 5 and 10 kt. A
10-kt bomb would release the same amount of energy as 10,000 tons of
TNT. The kind of improvised nuclear device we are most likely to see is a
“gun” type of bomb that would use an explosive to fire a mass of HEU
through a tube at another mass of HEU, causing fission and the release
of energy in an eruption of pressure, light, and heat. A 10-kt
improvised nuclear device would destroy or significantly damage
everything within a half-mile radius.
An
attack by a government with a long-standing nuclear weapons program
could be orders of magnitude worse.
The strength of the explosion could
range from something around 10 kt – the size of a nuclear bomb North
Korea tested in 2013 – to measurements in the megatons, or hundreds of
times greater. In a nuclear attack, the bomb will be dropped from an
aircraft or delivered via missle. Unlike a bomb carried into a city on a
truck, a bomb delivered by air can be detonated above a city rather
than at ground level, causing a larger area of destruction and loss of
life.
In
the discussion that follows, I make the assumption – based on
information from open-source material – that terrorists are unlikely to
construct a device greater than 10 kt, and that a missile launched by
North Korea would carry a warhead in the 10–15 kt range. These scenarios
are both more likely than a multimegaton nuclear warhead being launched
at the United States.
What to expect
For
those who must think about planning for the aftermath, one of the
starkest facts about a nuclear bomb attack is that on top of killing
people on a vast scale, it will thoroughly destroy the capacity to
respond.
When
a nuclear bomb made with HEU detonates, it releases an enormous amount
of energy of four different types. The blast releases 50 percent of its
energy in the form of a pressure wave so powerful that it levels
buildings. There is little chance for human survival within a quarter
mile, and as the wave travels farther out and weakens, it can shatter
glass within half to three quarters of a mile. Thirty-five percent of
energy from the blast creates the blinding flash, emitting heat that
incinerates all but concrete buildings (and melting glass and burning
the contents even in those). Fires will be so numerous and radiation
levels so high that firefighting will be impossible. Initial (or
“prompt”) radiation accounts for 5 percent of the energy. The remaining
10 percent is released in long-term fallout or residual radiation, which
can, when carried by wind, travel over long distances.
Should
an improvised nuclear device detonate in New York City’s Times Square,
the initial blast will kill between 75,000 and 100,000 people in
seconds. They will be incinerated so thoroughly that their ashes will be
indistinguishable from the ashes of the buildings around them. Others
will be crushed by falling buildings, struck by flying debris, or thrown
by the pressure wave against buildings, the ground, or each other.
Another
100,000–200,000 people will be injured, some with burns from the heat
of the blast, others by objects hurtling through the air. Many will be
exposed to various levels of radiation that will cause suffering or
death over weeks and months.
The loss of city government, fire and
police departments, and other emergency responders, coupled with
demolished hospitals and destroyed water, sewage, power, and gas lines,
means that repairs will take months or years even outside the
contaminated “hot zone” and be impossible within it. The city will
become a ghost town. As a result of the plume carrying radioactive
particles downwind, hundreds of square miles may be unusable and need
decontaminaion.
People
will leave their homes in search of safe havens. With no radios to give
them instructions, some will move into the path of the plume and be
exposed to a higher dose of radiation than they would have received had
they stayed home. Many of these evacuees will die from radiation
exposure.
Chaos
will prevail as millions of people try to evacuate the city without aid
of communications systems, which will have been destroyed. They won’t
know where to go or where to receive medical care. Following a
hurricane, people can reach shelters, medical teams, and sources of food
and water that were deployed in advance. Following a nuclear attack,
none of these assets will have been prepositioned prior to the
explosion.
In
the early 1980s, while living outside of Boston, I received a pamphlet
in the mail instructing me to evacuate to a specific town should the
worst happen. A reporter following this effort to prepare citizens
traveled to several of the “host” towns to determine their readiness to
receive all the evacuees.
The reporter was startled to find townspeople
who said the new arrivals wouldn’t be welcome. Where would city evacuees
go if an attack occurred today?
From
2009 to 2010, as part of research I was doing for the Defence Academy
of the United Kingdom, I conducted an end-to-end assessment of the
medical capabilities of several countries and cities to respond to
terrorist use of an improvised nuclear device. (It was similar to one I
completed while serving as director of the Mayor’s Office of Emergency
Management in New York City, looking at the aftermath of biological and
chemical attacks.) No city or country visited during this assessment was
prepared to manage the aftermath of a nuclear detonation. Even taking
into account just the medical needs of a large city following a nuclear
attack, the results clearly showed that current planning efforts were
not sufficient to manage the carnage.
Using
New York City as a model, it’s anticipated that several hundred
thousand people will require some sort of medical evaluation or care.
With the loss of hospitals and 35–50 percent of first responders, and
health care personnel unable or unwilling to go to work, surviving
hospitals will need to use every inch of space to treat only the most
critically injured. Makeshift treatment centers or casualty collection
points near the blast will be required to triage the injured. Ethical
and moral issues will arise as the overwhelmed staff, short on supplies,
is forced to decide who should receive treatment and who should be
moved to end-of-life care, receiving morphine to ease their pain. The
profound psychological impact on these healthcare workers and first
responders cannot be overstated. Their task is essential, though: The
ability to make some order out of the chaotic wave of people with
different levels of injuries, from those with various kinds of physical
trauma to those with psychological trauma to the “worried well,” is a
key to reducing morbidity and mortality.
Certain
characteristics of nuclear attacks make them especially hard to prepare
for. A nuclear blast causes an electromagnetic pulse that knocks out
communication systems, some irreversably. Without the ability to
communicate, coordination among medical personnel and other first
responders will become nearly impossible.
Assuming medical staff can get
to where they need to be, demand for them will be extraordinary, but
managers will have to rotate them to prevent exhaustion and reduce the
psychological impact.
There
will be an overwhelming number of patients. After triage, some will
have to be transported. Hospitals will have to not only care for the
injured but also control security and coordinate the flow of information
to victims’ families. Local, state, and federal governments will have
to rapidly set up alternate-care facilities close to the “hot zone.”
They will have to have plans for alternate standards of care, so that,
for example, emergency medical technicians are allowed to perform tasks
ordinarily reserved for paramedics or nurses, freeing paramedics and
nurses to perform more advanced medical treatment than normally
permitted. This last issue, the focus of numerous studies and reports,
presents both legal and ethical challenges, many of which need to be
resolved in state capitals, where the scope of practice for health care
professionals is typically controlled. And planners should remember that
just because an ethical issue is resolved in advance, doesn’t mean that
the decision will be followed in practice in the aftermath of a
disaster.
Sending an adult to end-of-life care may pull on the
heartstrings, but sending a child to the same fate could prove to be too
difficult for many medical personnel.
Beyond
the difficult front lines of triage, survivors of a nuclear explosion
will have a variety of injuries, some well known to modern hospitals but
others more difficult to diagnose and develop a plan for. Acute
radiation syndrome, in particular, results from exposure to radiation
and does not have to coincide with any other injury. It may be the only
effect a survivor suffers, and it may not manifest soon after exposure.
Acute radiation syndrome occurs when a significant portion of the body
is exposed to a large dose of penetrating radiation in a short period of
time. The nature of acute radiation syndrome depends on the dose. At
lower doses, the only effect may be on the gastrointestinal system and
bone marrow. At higher doses, bone marrow will stop producing
infection-fighting white blood cells, platelets that assist in blood
clotting, and red blood cells that carry oxygen. Larger doses also
destroy the lining of the gastrointestinal system, causing diarrhea,
vomiting, and an inability to swallow or digest food, requiring patients
to receive nutrition and fluids intravenously. At the highest levels of
exposure, the heart and nervous system are impacted and rapid progress
toward death is certain. Some of the most difficult patients to manage
are those with combined injuries – say, a penetrating wound from a shard
of glass, requiring rapid surgical intervention, and also acute
radiation syndrome.
Finally,
a great moral and societal challenge will be managing the dead. Many
victims will be in the “hot zone,” where responders can’t enter and
radiation levels may not be safe for years. Victims’ families, though,
will demand recovery of loved ones. Even where identifiable remains
exist, the number of dead will be so large that months may pass before a
family receives them. At some point in recovering bodies, a decision
may have to be made to bury victims in mass graves. The United States
has excellent systems in place to manage mass fatality incidents – but
they have never been tested with several hundred thousand dead at one
time.
Where do we stand?
These
issues have not received enough attention from FEMA, the US government
entity responsible for helping states plan for and respond to disasters.
FEMA takes what emergency planners call an “all hazards” approach,
meaning it addresses effects common to many different types of
disasters. This lack of planning to deal specifically with a nuclear
incident is a serious weakness.
That
makes it all the more important for states and cities to have their own
plans in place for worst-case scenarios. It’s far easier to scale back a
response if resources are not needed than to need them but not have
them. While serving as Commissioner of Homeland Security and Emergency
Services for New York State, I asked each of the 57 counties to plan for
what they thought to be a worst-case scenario. (Scenarios varied from
county to county.)
Where
FEMA has lagged, the US Department of Health and Human Services has
aggressively built up its capability to respond to a nuclear incident.
It has medical response teams that are staffed and equipped to mobilize
in response to an incident, support state and local governments, and,
depending on what is needed where, either provide comprehensive health
care infrastructure or augment existing hospitals and clinics. In the
aftermath of Hurricane Sandy in 2012, these teams provided the only
medical care available to some communities on Long Island, just east of
New York City. They provided invaluable aid in evacuating Manhattan
hospitals.
The
Department of Health and Human Services has also committed significant
resources to acquiring medical treatments for the survivors of a nuclear
detonation. The Strategic National Stockpile, composed of 12 separate
units at classified locations around the country, is also under the
department’s control, and capable of being dispatched to any city within
12 hours. In it are supplies to treat burn injuries, as well as
cutting-edge therapeutics to aid in reversing the effects of radiation
by stimulating bone marrow to produce platelets (which help stop
bleeding) and white blood cells (which help prevent infection). Should
respirators be needed, the Strategic National Stockpile can provide
them, along with antibiotics, vaccines, and massive quantities of
intravenous solutions. Many units from the stockpile will be needed to
support a city in the aftermath of a nuclear detonation.
Cities
far from the nuclear blast are also a potential resource. The federal
government is sure to ask for help from far afield as soon as demand for
medical resources exceeds local supply in a given area. Governors and
mayors may be reluctant to release personnel, though, either for
political reasons or out of concern that their cities and states may be
targeted next. I believe most elected officials will rise to the
occasion, and dispatch as much help as they can spare. But no number of
simulated incidents can predict how political dynamics will shift
following the real thing.
Over
the course of the study I conducted in 2009 and 2010, several
government officials said they were unable to take steps forward because
the elected officials they reported to were unwilling to discuss the
issue. Privately, many politicians used to worry that if they discussed
nuclear terrorism, they would likely be ridiculed for fearmongering. In
the last seven years, that concern has changed dramatically at the
national level, with President Obama and other world leaders convening
to address nuclear proliferation and nuclear terrorism. Silence at the
local level continues, though. Among city and state governments, the
only ones that I’m aware have some level of ongoing planning for nuclear
disaster are New York (city and state), Washington state, Los Angeles,
Boston, and Chicago. To a much lesser extent, several more cities are
engaged as well. The state of Hawaii has asked the federal government
for assistance in planning for a nuclear attack. Read the full story
here.