Not since 1945 has the world experienced nuclear warfare, although there has been the threat of nuclear terrorism and a large number of nuclear/radiological accidents. Most people fear a nuclear/radiological threat even more than a conventional explosion due both to their inability to perceive the presence of radiation with the ordinary human senses and to concerns about perceived long-lasting radiation effects. Studies of radiological accidents have found that for every actually contaminated casualty, there may be as many as 500 people who are concerned, eager to be screened for contamination, sometimes panicked, and showing psychosomatic reactions mimicking actual radiation effects. Data from the Hiroshima and Nagasaki attacks revealed widespread acute reactions such as psychic numbing, severe anxiety, and disorganized behavior, and there were later chronic effects such as survivor guilt and psychosomatic reactions. Such responses would likely be common in any future nuclear/radiological accident, terrorist attack, or warfare.
As of this writing, the only nuclear devices used in war have been the Hiroshima and Nagasaki bombs of 1945. In addition to nuclear explosives, terrorists and other potential enemies could use radiological dispersal devices (RDD). These are weapons that spread a radioactive source material, either mechanically or by a conventional explosive but without generating a supercritical fission reaction. To date, a small number of RDDs have been produced and deployed, but their contents were not actually detonated or released. Therefore, a discussion of the psychological effects of such weapons depends heavily upon extrapolating from conventional weapons effects and from radiation-related accidents.
Conventional Weapons Effects
In the 1991 Gulf War, Iraq rained Scud missiles on coalition forces and on civilian areas in Israel. A study of all admissions to the emergency rooms in the Israeli area hospitals within 8 hours following each missile blast found that only 22% had actual physical injuries related to the blast. Another 22% had used their atropine auto-injectors in the mistaken belief that they had been exposed to nerve gas. In a sense, these casualties were psychologically based, although their strong physical reactions to the atropine were quite real. A full 51% were pure stress casualties, people who were unable to cope with their panic attacks and anxiety.1
Other examples have been provided by conventional terrorism involving guns and/or explosives. For instance, a French study of victims of such terrorism found post-traumatic stress disorder among only 11% of those who were uninjured, 8% among those moderately injured, but 31% among those severely injured.2 An Israeli study3 found similar results even 17 years after a terrorist incident at one of their kibbutzim.
How much worse might the psychological consequences be if, in addition to explosive effects, radiation were also released? Radiation cannot be detected by the ordinary human senses, for it is odorless, colorless, and cannot be felt directly. Yet people generally know radiation can cause severe harm or even kill. Thus, when there is any known possibility of exposure, however remote, many people will imagine the worst until it is proven otherwise. Some even suffer from the morbid and persistent anxiety about radioactive materials, which has often been termed radiophobia. For example, after the 1986 major accident at the Chernobyl nuclear power reactor in the Ukraine, people around the world were concerned when they learned that a radioactive fallout cloud might be headed their way. Even in areas where the actual exposure was just a little over the normal background radiation levels, some people refused to go outdoors unless it was absolutely necessary, they ate only canned food, and generally based their lives on avoiding what they perceived as a terrible threat. Some were so terrified of contracting a horrible and painful radiation-caused disease that they committed suicide rather than face that prospect.4
Other nuclear accidents have also caused widespread alarm and related psychological disturbances. In the 1979 Three Mile Island nuclear power plant accident in Pennsylvania, there were actually no injuries or deaths and only a minor release of radioactive gas to the environment. Few people received a detectable dose of radiation above the general background level, and even of those, the largest possible exposures were only equivalent to the dose of ordinary X-rays. Yet the concern and anxiety was very real. Psychosomatic reactions were common among the citizens of the area, and many fled the region in the mistaken belief that a major nuclear detonation might occur at any moment.5 There were anecdotal reports of medical personnel also leaving the region in the belief that staying might expose them to radiologically contaminated casualties they did not want to deal with.
The radiation accident in Goiania, Brazil in 1987 was one of the worst to date in the Western Hemisphere and perhaps sheds the clearest light on what might happen following a possible future terrorist use of an RDD. In this case, two scavengers broke into an abandoned medical clinic and stole a radiotherapy device, not knowing what it was, for its scrap metal value. Eventually the device was broken open and sold to a junk dealer. The latter observed that the powder within glowed in the dark and began to share it with family and friends. People were initially quite fascinated with the "magical" powder, but soon flu-like symptoms (anorexia, nausea, vomiting, diarrhea) appeared among those playing with it. Eventually the junk dealer's wife alerted the authorities who quickly established that the material was Cesium 137, a radioactive isotope. The authorities set up a radiological screening post in the soccer stadium and announced that anyone concerned about contamination could come in for a free screening. Although the screening was voluntary, and not a public health mandate, a total of 125,800 people in a city of about 1.2 million, came forward to be screened. Of those, only 249 were actually contaminated, 20 required hospitalization, and four eventually died.6 The ratio of concerned, anxious, and even panicky people requiring attention to those actually contaminated was approximately 500 to 1. Complicating the picture is the fact that of the first 60,000, who were monitored, 5,000 had psychosomatic reactions, which mimicked symptoms of radiation exposure. Imagine how much worse the panic might be if such a radiological dispersal were known to be the deliberate work of terrorists who might strike again at any moment!
Data from the atomic bomb attacks in Hiroshima and Nagasaki in 1945 are somewhat dated and the applicability to today may be questioned on the grounds that no one in those cities initially realized or understood what an atomic bomb was, whereas people today would have all sorts of preconceived notions, some erroneous, about the impact of nuclear weapons if they were subject to attack by them. Nevertheless, since that is the only data available so far concerning a nuclear attack on a human population, it is worth discussion. Among the survivors, acute reactions such as apathetic withdrawal, psychic numbing, and severe fear reactions (e.g., helpless or disorganized behavior, overwhelming anxiety, and even hysteria) were common. Later psychological effects included survivor guilt, psychosomatic symptoms, and post-traumatic stress disorder.7 Psychological effects such as these would likely be common among any population exposed to nuclear/radiological accidents, terrorist attacks, or warfare.
1. Karsenty D, Shemer J, Alshech I, et al: Medical aspects of the Iraqi missile attacks on Israel. Israel J Med Sci 1991; 27: 603-7.
2. Abenhaim L, Dab W, Salmi LR: Study of civilian victims of terrorist attacks (France 1982-1987). J Clin Epidemiol 1992; 45: 103-9.
3. Desivilya HS, Gal R, Ayalon O: Extent of victimization, traumatic stress symptoms, and adjustment of terrorist assault survivors: a long-term follow-up. J Trauma Stress 1996; 9: 881-9.
4. Drottz-Sjoberg B-M, Persson L: Public reaction to radiation: fear, anxiety, or phobia? Health Phys 1993; 64: 223-31.
5. Collins DL: Stress at Three Mile Island: altered perceptions, behaviors, and neuroendocrine measures. In: Ricks RC, Berger ME, O'Hara FM (editors), The Medical Basis for Radiation-Accident Preparedness. New York: Elsevier, 1991, pp 71-9.
6. Petterson JS: Perception vs. reality of radiological impact: the Goiania model. Nuclear News 1988; 31: 84-90.
7. Mickley GA: Psychological factors in nuclear warfare. In: Zajtchuk R (editor), Medical Consequences of Nuclear Warfare. Office of the Surgeon General, U.S. Army, 1989, pp 153-69.
Guarantor: LTC Charles A. Salter, MSC USA
Contributor: LTC Charles A. Salter, MSC USA
Medical Service Corps, USA, Military Medical Operations Department, Armed Forces Radiobiology Research Institute, Bethesda, Maryland 20889.
Presented at The Operational Impact of Psychological Casualties from Weapons of Mass Destruction (WMD), Bethesda, Maryland, July 25-27, 2000.
Reprints: LTC Charles A. Salter, Medical Service Corps, USA, Military Medical Operations Department, Armed Forces Radiobiology Research Institute, Bethesda, Maryland 20889; e-mail: firstname.lastname@example.org.
This manuscript was received for review in August 2001. The revised manuscript was accepted for publication in October 2001.
Copyright Association of Military Surgeons of the United States Dec 2001
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