Course Authors

Robert Gould, M.D.

Dr. Gould is Associate Pathologist, Santa Teresa Community Hospital (Kaiser Hospital San Jose) and President-Elect, Physicians for Social Responsibility. Dr. Gould reports no commercial conflict of interest.

Estimated course time: 1 hour(s).

Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 

Learning Objectives

Upon completion of this Cyberounds^®, you should be able to:

• Describe the health effects that could be associated with terrorist use of nuclear or radiological weapons

• Discuss the guidelines regarding the mitigation of health consequences stemming from the release of radiation from a nuclear power plant or weapon

• List the steps that could be taken to prevent nuclear terrorism and its potential health consequences.

 

In the wake of the events of September 11, 2001 and the heightened Indian-Pakistani tensions of 2002, greater attention is now being focused on the potential use of nuclear or radiologic weapons by terrorists or state actors linked to the global complex of nuclear weapons and power facilities. Indeed, the New England Journal of Medicinerecently published guidelines to the diagnosis and management of potential sequelae to major radiation exposure.(1)

While the effects of low-level attacks may be appropriately managed, the significant toll that could result from the detonation of a nuclear weapon or an attack on a nuclear power plant requires serious, coordinated global efforts to prevent such disasters from ever occurring. However, such prevention measures need to move well beyond law enforcement and military action and must include the strengthening of stable, long-term global mechanisms to safeguard nuclear weapons and materials. At the same time, concrete plans need to be developed to eliminate all nuclear weapons.

Nuclear Weapons

Nuclear weapons achieve their destructive power by suddenly releasing vast quantities of energy through the splitting of the nucleus of an atom (fission) and/or by fusing the nuclei of two atoms (fusion). Nuclear weapons contain fissile materials compressed into a "supercritical mass" so that the number of fissions will escalate very rapidly and create a nuclear explosion.(2) The two principal fissile materials used in making nuclear weapons are uranium-235 and plutonium-239.

Uranium found in nature contains less than one percent uranium-235.(3) To produce the supercritical mass required for nuclear weapons, uranium must be "enriched" chemically to increase the percentage of uranium-235 to 90 percent or more. Uranium enriched to more than 90 percent is considered weapons-grade "highly-enriched uranium" (HEU), but uranium enriched to significantly lower percentages is also weapons-usable.(4) Virtually all plutonium-239 is produced by bombarding uranium-238 with neutrons in nuclear reactors.(5)

Even crude nuclear weapons have potential explosive force at least 1,000 times higher than the most powerful conventional explosives ever deployed.(6) A nuclear weapon was first used in warfare on August 6, 1945, when the U.S. military exploded a nuclear weapon over Hiroshima. The bomb had an explosive force equivalent to 15,000 tons of TNT. Three days later, the U.S. military exploded a bomb equivalent to 21,000 tons of TNT over Nagasaki.(7)

Terrorists could acquire a nuclear weapon by:

1. stealing or gaining control of a weapon already made by a nation with nuclear weapons; or
2. stealing, or otherwise illegally acquiring, military or civilian weapons-usable fissile material and fabricating an explosive device for detonating it.(8)

As of early 2002, the International Atomic Energy Agency (IAEA) had recorded 16 cases involving illicit trafficking of plutonium or enriched uranium since 1993.(9) A non-state actor could construct a crude, highly-enriched uranium bomb, with the explosive power of several hundred to a few thousand tons of TNT, that could be transported by and detonated in an ordinary van.(10)

Radiologic Weapons ("Dirty Bombs")

Radiologic weapons ("dirty bombs") disperse radioactive materials with a "conventional" device, rather than with an atomic explosion. During World War II, the United States initiated a research program to determine the feasibility of dispersing radioactive material with the use of conventional weapons.(11) In 2001, Iraq acknowledged that it explored the use of radiologic weapons against Iran in 1987. Iraq reportedly tested a radiological bomb meant to weaken enemy forces by inducing radiation sickness, but abandoned these weapons because the radiation levels were not sufficiently high.(12)

Radioactive materials in wide use in the United States, such as certain isotopes of cesium, as well as cobalt rods used for food irradiation, have also been implicated as possible source material for radiologic weapons.(13) In early 2002, the U.S. government was reported as interested in developing the capability to use radiological weapons in order to destroy stockpiles of chemical or biological agents.(14)

Although characterized as "conventional" weapons by the United States and the North Atlantic Treaty Organization (NATO), and not strictly intended as a radiologic weapon, the use of depleted uranium weapons, according to the World Health Organization (WHO), may pose a radiation and chemical exposure hazard for military personnel, children and others who may be exposed if the depleted uranium enters the body through inhalation, ingestion or through open wounds.(15) Depleted uranium weapons were used by the United States in 1991 during the Persian Gulf war and, again, in 1999, in the war in the Balkans.(16)

Targets as Weapons: Nuclear Power Facilities and Transportation Routes

Nuclear power plants are also possible terrorist targets. Concerns have been raised that the containment structures around nuclear reactors may be breached by attacks such as occurred at the World Trade Center on September 11, 2001.(17) In addition, areas outside of the containment structure are equally, if not more, vulnerable to terrorist attacks.(18)

Transporting highly-radioactive materials away from nuclear power plants presents additional opportunities for the intentional or unintentional release of radioactive materials into the environment. If implemented, recently authorized plans for the transport of highly radioactive waste from nuclear power plants across the United States to a proposed long-term storage site at Yucca Mountain, Nevada, would involve tens of thousands of shipments of highly-radioactive waste by train and truck across 43 states over the next 30 years; 50 million people would be living within one-half mile of the projected routes.

Proliferation of Nuclear and Related Weapons

The proliferation of nuclear weapons and related technologies over the past half-century has resulted in the wide distribution of vast quantities of nuclear weapons and fissile and other radioactive materials throughout the world.(20) However, according to some authorities, recent U.S. government decisions -- to abrogate the Anti-Ballistic Missile Treaty, to deploy a national missile defense system (which would be ineffective against most scenarios of nuclear terrorism), and to develop a new generation of nuclear weapons -- may stimulate additional global proliferation.(21)

Plutonium from civilian nuclear reactors can be used to make nuclear and radiologic weapons. The proliferation potential from civilian power programs has been illustrated by:

1. reactor-grade plutonium being used to fabricate a nuclear weapon exploded by the U.S. military in 1962; and
2. civilian nuclear power and research programs being integrally involved with the nuclear weapons programs of both India and Pakistan.(22)

Civilian plutonium is contained in an irradiated form (spent fuel) or in a separated, non-irradiated form. In order to be used in nuclear weapons, plutonium must be chemically extracted from the spent fuel at "reprocessing" plants. Worldwide, approximately five times more total plutonium exists in civilian stores than in military stockpiles. However, because the overwhelming majority of civilian plutonium is in the form of irradiated fuel, civilian (205 tons) and military (225 tons) stockpiles of separated plutonium are almost equal. The amount of separated plutonium from civilian nuclear power plants will rapidly increase as more reprocessing capacity becomes operational.

Adverse Consequences of the Use of Nuclear and Radiological Weapons

Detonation of a nuclear weapon results in blast heat and the release of radiation. The U.S. bombing of Hiroshima is believed to have caused approximately 40,000 deaths instantly or later that day. It also provided a grim illustration of how individuals exposed to radiation at levels sufficient to cause acute radiation sickness may die in a few hours, days or weeks.(24)

Use of a nuclear or radiologic weapon, or an attack on a nuclear facility that results in the release of radiation, would lead to exposure to ionizing radiation. How ionizing radiation enters the body depends on its form. Beta particles and gamma rays penetrate the human body; in contrast, alpha particles do not penetrate human skin. Radiation also enters the body through inhalation and ingestion of contaminated food and water, and through wounds.(25)

Localized exposure to radiation will most likely produce a burn similar to a thermal injury and may, depending on the severity, require pain management, prophylaxis against infection and, if severe, skin grafting or even more invasive surgical procedures. Exposure to a large dose of penetrating radiation will produce within the first 12 hours acute radiation sickness, presenting as nausea and vomiting. Larger and longer exposures to radiation result in more significant damage to CNS, gastrointestinal and hematopoietic systems and usually death, as there is no effective therapy after such exposures.(1)

For individuals who do not receive doses high enough to cause acute illness, the primary health impacts of radiation exposure are cancer and inheritable genetic damage. Most of these health impacts will appear years later, making causal inferences difficult. Studies of community members living near, or working at, nuclear facilities indicate that even "low-level" exposures may result in increased rates of childhood cancer, leukemia, non-Hodgkin's lymphoma, thyroid cancer and multiple myeloma.(26)

The explosive yields of crude nuclear devices that might be produced or used by terrorists is likely to be more unpredictable than the expected yields of weapons developed through rigorous testing protocols in nation-state weapons programs.(27) The size of the radiation release, types and chemical form of the isotopes involved, explosive device used, heat generated, weather conditions, population density and location will determine estimated health risk of exposure to radiation and risk of other non-cancer health impacts.

Some models of consequences may provide a sense of the potential toll from terrorist attacks. Ira Helfand and colleagues estimated that the detonation of a 12.5-kiloton nuclear weapon in New York City by a terrorist would cause more than 250,000 deaths from blast, heat and exposure to radiation directly and through fallout.(28) Another study, by Lachlan Forrow and colleagues, indicates the potential toll of a terrorist takeover of a nuclear submarine. The launch of a single submarine's missiles bearing nuclear weapons could result in approximately 7 million fatalities.(29)

Peter Taylor and David Sumner have estimated the consequences of the use of a radiologic weapon to disperse plutonium in a large city. According to their model, such a weapon is unlikely to result in short-term doses sufficient to cause radiation sickness or other acute effects of plutonium exposure. However, fear and other social impacts would likely be large, and cancer risk would be increased, although delayed for many years.(30)

Hundreds to tens of thousands of casualties could result from a terrorist attack on a nuclear power reactor, depending on the size of the reactor, as suggested by government assessments of unintentional large releases from nuclear power plants.(31) A study by Matthew Lamb and Marvin Resnikoff of an unintentional release of radiation during the transport of spent fuel demonstrates that, if such an incident were initiated by terrorists, it could result in thousands of fatalities from cancer and widespread environmental contamination.(32)

Together, these examples indicate that the magnitude of the health consequences of the intentional release of radiation by a non-state actor, beyond large-scale fear and panic, could range in scale from a few thousand deaths from cancer to millions of immediate and long-term fatalities from the detonation of a nuclear weapon. Depending on the isotopes released, vast areas of land could become contaminated for thousands of years.

Responding to Attacks and Mitigation of Health Consequences

Evaluation of the sequelae to the 1986 Chernobyl releases of radiation indicates that a plan for mitigation measures in the event of a release of radiation from a nuclear power plant or radiological weapon should include:

1. Keeping populations indoors prior to subsequent evacuation. Initial restriction of populations to indoor areas may reduce exposure to radioactive hazards. As Fred Mettler Jr. and George Voelz recently indicated in their review article in the New England Journal of Medicine, it is recommended that people stay indoors for up to two days if a dose of 1 rem may be reached and that people should be evacuated for up to one week if the expected dose is 5 rem or higher.(1)

   However, even with thoughtful preparation, mass evacuation of a large urban area affected by any variety of larger-scale nuclear terrorist scenarios would be a daunting challenge. As underscored by testimony given during public hearings regarding the potential evacuation of the densely populated area around the Indian Point nuclear reactor located 30 miles north of New York City, the local roads -- jammed at rush hour even on ordinary days -- would be clogged with panicking families.(33)

2. Restricting consumption of locally produced milk and foodstuffs: The absorbed dose from inhalation of external exposure to radioiodines is negligible compared to that from ingestion of milk or dairy products. For example, individuals receiving the highest doses of radioactive iodine-131 from Nevada Test Site fallout during open-air tests of nuclear weapons by the U.S. government between 1951 and 1962 were young children who consumed large amounts of milk from backyard goats and cows after the tests. The National Academy of Sciences has estimated that exposure of the public in the United States to radioactive iodine-131 through this and other pathways from U.S. nuclear weapons testing in Nevada will ultimately result in a total of 11,300 to 212,000 excess cases of thyroid cancer.(34)
3. Providing potassium iodide prophylaxis: In the event of a radiologic emergency at a nuclear power plant, federal and international agencies recommend rapid iodine prophylaxis of at-risk populations in order to reduce the radiation dose to the thyroid.(35) After September 11, 2001, the U.S. government purchased one million adult-strength tablets and 600,000 children's doses of potassium iodide for $180,000, with plans to spend $1 million to buy another 5 to 10 million doses in 2002.(36) Because of heightened concerns about the vulnerabilities posed by the Indian Point reactor, located in the New York suburbs, Westchester County officials began distributing potassium iodide pills to all residents living within 10 miles of the plant.(37) Despite universal acceptance of potassium iodide as an effective thyroid-protective agent, proper implementation of such a policy remains a matter of significant debate.(38)
4. Worker protection, medical treatment, environmental sampling and illness tracking: Planning must also include: protection of emergency responders; identification of treatment facilities where highly-contaminated patients can receive definitive medical treatment, with safeguards for attending medical personnel; and environmental sampling and radiological monitoring.(39) An additional public health challenge would be the follow-up surveillance, diagnosis and management of chronic adverse health effects of radiation, including cancer among survivors of the exposure, emergency responders and other occupationally exposed individuals.

A number of previously-published assessments have provided extensive documentation on the inability to provide care for injured survivors of a nuclear attack.(40) Ira Helfand and colleagues have noted that casualties on the scale estimated by the terrorist use of a nuclear weapon would immediately overwhelm medical facilities, leading to a high mortality rate among those injured but not killed by the initial blast and thermal effects.(28)

It is our opinion, therefore, that while preparedness measures are important, they thus have inherent limitations with respect to nuclear weapons attacks. While health care providers and public health professionals should initiate and implement plans for mitigation measures (secondary and tertiary prevention), we believe health professionals should also support measures to limit the likelihood of a nuclear terrorist attack (primary prevention).

Prevention of Nuclear Terrorism

Since September 11, 2001, extensive resources have been dedicated towards combining law enforcement and military action against those individuals and networks that would presumably carry out terrorist actions.(41) In addition, the U.S. government has advocated an expansion of "anti-terrorist" responses, including the possible use of nuclear weapons, towards a number of states, specifically those described by President George W. Bush in January 2002 as constituting an "axis of evil." Such nations allegedly would directly carry out or support a terrorist action employing nuclear weapons or other weapons of mass destruction.(42) Notwithstanding the morbidity, mortality, social, political and economic costs of aggressive military "solutions" in a volatile, nuclear-armed world, exclusive focus on short-term suppression of the putative agents of nuclear terrorism can overlook the deeper, long-term threat posed by the persistence of the materials and methods of the global nuclear weapons and nuclear power infrastructure.

The threat of nuclear terrorism is related to the combined existence of nuclear weapons and a surfeit of weapons-usable material available to states and non-state actors who may be willing to use them for their own political agendas.(43) In order to address this threat, there is a need to develop a comprehensive primary prevention approach that includes:

1. concerted international safeguarding of nuclear weapons and/or their constituent materials that are already dispersed throughout the world in nuclear power facilities and nuclear weapons stockpiles;
2. utilizing and strengthening existing treaties aimed at curbing proliferation and promoting nuclear disarmament; and
3. moving beyond current treaty obligations to develop even stronger global agreements to drastically reduce and ultimately eliminate materials and weapons that could have catastrophic consequences for humankind.

Safeguarding Nuclear Facilities and Weapons Stockpiles

"Mock intruder" tests conducted by the Nuclear Regulatory Commission between 1991 and 1998 demonstrated that security regulations at nuclear power facilities are inadequate and need to be strengthened. Various short- to moderate-range measures have been proposed to address the vulnerabilities of nuclear facilities, including, but not limited to: increasing and strengthening the security regulations and security force capabilities at these facilities; increasing Coast Guard patrols around coastal nuclear reactors; establishing no-fly zones around nuclear facilities; placing caps on the amount of spent fuel produced at nuclear power plants; and moving spent fuel into dry cask storage onsite.(44)

While important deterrents, the most sophisticated safeguards on materials and facilities can never be fully protective. Global procedures and practices used to safeguard state-owned and stored fissile material are chaotic and ineffective, and permit leakage, theft and smuggling on the "nuclear black market," as exemplified by the situation in Russia and former Soviet republics. Currently, 603 metric tons of weapons-usable nuclear material are stored at 53 different sites in Russia-- enough to make 41,000 additional nuclear bombs.(45)

The United States is spending between $900 million and $1 billion annually on a number of related nuclear threat reduction programs in the former Soviet Union. The purpose of these programs includes securing these stockpiles and ensuring employment of weapons scientists, who might otherwise provide scientific and technical know-how for would-be nuclear terrorists or states. However, current funding, comprising less than 1 percent of U.S. defense spending, is inadequate to meet this challenge.(46)

Paradoxically, while many aspects of current U.S.-Russia initiatives could have a positive impact on reducing terrorist threats, some agreements, such as those providing for the disposition of excess weapons-grade plutonium at mixed-oxide (MOX) fuel plants, create their own terrorist risk. This risk reflects the vulnerabilities of increased transport and storage of weapons-capable materials, and the subsequent generation of additional fissile materials in the reactors.(47) Simply put, the more that weapons-usable and weapons-grade materials are available, the greater the risk will be that some of these materials will be acquired illegally and used to produce nuclear explosives.(48)

Op-Ed Epilogue -- A Plan for Prevention

International concerns about the proliferation potential inherent in all nuclear facilities led to the signing, ratification and unlimited extension of the Non-Proliferation Treaty (NPT). As part of the NPT, the International Atomic Energy Agency (IAEA) monitors more than 900 facilities throughout the world in order to ensure that no nuclear materials at these facilities are diverted to military use.(49)

Unfortunately, the NPT, even if stringently enforced, cannot adequately cope with the persistence of highly-concentrated sources of nuclear fuel and nuclear waste in nuclear reactors that are globally distributed and may serve as targets and sites of unintentional releases. Moreover, by virtue of the Non-Proliferation Treaty's inherent support for the development of nuclear power, the IAEA simultaneously plays two apparently conflicting roles -- discouraging active proliferation while encouraging "latent" proliferation.(50) Indeed, if one were to examine the relationship between nuclear power and the proliferation of nuclear and radiologic weapons, one might logically champion, as a key element in the prevention of nuclear terrorism, the phasing-out of nuclear power.

As long as the global nuclear economy persists, there will be a continued need for vigorous enforcement of the NPT in order to stem the diversion of materials and technical knowledge from civilian nuclear programs to military programs of state or non-state actors. However, the necessary global political will to apply the force of the NPT steadfastly is itself contingent on the need for the nuclear-weapons states to uphold their clear obligations, under Article VI of the NPT, to formulate concrete steps towards global disarmament.

A key demonstration of support by the nuclear powers for carrying out their disarmament obligations would be for all of them to ratify the Comprehensive Test Ban Treaty (CTBT). However, in 1999 the U.S. Senate rejected ratification, and in 2002 the Bush administration announced that it might resume nuclear testing.(51) Renewed testing would facilitate U.S. plans, as reflected in its recent Nuclear Posture Review, that call for developing and deploying new nuclear weapons -- steps that could well unravel the entire treaty-based non-proliferation system.(52)

Even U.S. proposals to reduce the number of deployed strategic warheads -- from the current level of approximately 6,000 to a level between 1,700 and 2,200 within 10 years -- involve placing the warheads in storage, from which they could be reactivated, instead of destroying them.(53) Under the Department of Energy's "Stockpile Stewardship" program, the U.S. government is currently spending $5.3 billion a year on nuclear weapons research, development, testing and production.(54)

The Nuclear Posture Review's explicit discussion of contingencies for U.S. use of its proposed improved "nuclear strike capabilities" constitutes a significant legitimization of the utility of nuclear weapons.(14) This policy inevitably undermines global disarmament efforts and will, therefore, facilitate a new era of weapons proliferation by states and by terrorist groups.

Current U.S. policy embraces the potential use of nuclear weapons against states that allegedly either:

1. pose a threat of attack, or
2. support terrorists who would attack the United States with nuclear, chemical, or biological weapons.(14)

To this end, the United States is also actively pursuing the development of so-called "mini-nukes" ("low-yield" nuclear weapons) for use against hardened targets, such as caves and deep underground command centers.(55)

Primary prevention of the entwined threats of nuclear weapons proliferation and terrorism can ultimately only be achieved by universally sanctioned and verifiable programs that move towards the complete elimination of nuclear weapons.

Nuclear abolition has been supported by numerous global political and military leaders and has been endorsed by leading medical and public health organizations, including the American Medical Association, the American College of Physicians, the American Public Health Association, and the International Physicians for the Prevention of Nuclear War and its U.S. affiliate, Physicians for Social Responsibility.(56)

Only abolition of nuclear weapons (and all other weapons of mass destruction), together with other concerted measures to reduce the availability of deadly nuclear materials and technologies, will significantly reduce the dangers of nuclear terrorism well beyond what individual and collective preparedness efforts can accomplish.

Update: Letter to Editor and Reply