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VIEWPOINT

Viewpoint

Nuclear weapons, a continuing threat to health

Douglas Holdstock, Lis Waterston

32 000 nuclear weapons, with a destructive force equivalent to several thousand megatons of conventional explosive,
are still deployed. The risk of nuclear war by accident may have increased and new threats include war between newly
declared nuclear-weapon-states and the construction by terrorist groups of crude but effective devices. Health workers
have drawn attention in the past to the likely major health consequences of the use of nuclear weapons. An opportunity
for their global elimination under a nuclear weapons convention arises with the current review conference in New York of
the nuclear Non-Proliferation Treatya crucial event for efforts to bring about a world free of nuclear weapons.

Nuclear weapons have been used in war only twice, over
Hiroshima and Nagasaki, Japan, in August, 1945. The
energy yields were equivalent to 12 500 tonnes and 20 000
tonnes of high explosive. Yields from thermonuclear
weapons (H-bombs) range up to several megatons (Mt).
Between 1945 and the signing of the Comprehensive Test
Ban Treaty in 1996, over 2000 nuclear tests were carried
out by the USA, USSR, Britain, France and China, plus
one by India. More than 500 of these were above-ground
tests; the largest, by the USSR, had a yield of over 50 Mt.
Concern about radioactive fallout led to the Partial Test
Ban Treaty of 1963 which only drove testing underground.
Stockpiles rose to over 69 000 in 1985, but have fallen to
around 32 000 today.1 Nevertheless, there will still be over
20 000 in about 2007, with a combined yield of some
10 000 Mt.2 Many missiles can be launched within
minutes of an alert, which could be an errorindeed
accidental nuclear war remains a serious risk.3 The
economic crisis facing the Russian military undermines the
Russian system of command and control, with more
danger of an unauthorised military strike. In January,
1996, a rocket was launched from Norway to explore the
aurora borealis. Notification of the launch was given but
the information was not passed on, and President Yeltsins
aides opened the football containing Russias nuclear airburst would cause lethal burns out-of-doors over about
launch codes. If a single Russian submarine had been
ordered to fire its missiles, nearly 7 million people in US
cities might have died from the resulting firestorms.3
The Non-Proliferation Treaty of 1970 obligates nuclear
weapon states to achieve nuclear disarmament by negotiation,
though their commitment is questionnable. April 24 saw the
start, in New York, of a review of this treaty and many non-
nuclear states and non-governmental organisations will be
pressing for genuine progress. This is the best, and perhaps
the final, chance to advance to a nuclear-weapon-free world.
The review ends on May 15, 2000.
Effects of nuclear weapons
Although todays weapons can be accurately aimed at
military targets these targets are often close to major
population centres (eg, Faslane and Glasgow in the UK),
Lancet 2000; 355: 154447
Medact, 601 Holloway Road, London N19 4DJ, UK
(D Holdstock FRCP, E Waterston MRCGP)
Correspondence to: Dr Douglas Holdstock
(e-mail: info@medact.org)
so that any use of nuclear weapons would result in civilian
casualties.
Information on the effects of nuclear weapons48 has
been obtained from Hiroshima and Nagasaki and from
animal experiments during the atmospheric tests of the
1950s. Effects depend upon the size of the explosion and
its distance from ground zero, and whether the
detonation takes place at ground level (when aimed at
hardened military targets) or 6001000 m up to maximise
blast and thermal damage. Immediately after detonation
the temperature at the centre of the fireball is several
million C, producing a shock wave travelling at
supersonic speeds, followed by hurricane-force afterwinds,
and an intense flash of heat radiation.
Most deaths from blast would result from indirect
effects such as the collapse of buildings or being blown into
objects. The human body can withstand direct
overpressures of more than 200 kPa (2 atmospheres) but
nuclear explosions create transient overpressures of up to
35 kPa. A lethal area is defined as the area within which
the number of survivors is equal to the number of blast
fatalities outside it. For a 100 kt explosion this area, if
circular, has a radius of 24 km; for 1 Mt the lethal area is
71 km2 (panel 1, figure). The heat flash from a 100 kt
75 km2.9 Flash blindness would occur over many
kilometres.
Prompt radiation (neutrons and -rays) contributed
to the deaths in Hiroshima and Nagasaki but direct
radiation from the fireball of a large nuclear explosion
Panel 1: Blast damage to buildings
Peak Peak Typical blast effects
overpressure wind
(kPa) velocity
(km/h)
140 750 Reinforced concrete structures levelled
70 460 Factories and commercial buildings
collapsed; brick buildings scattered
as debris
35 260 Typical houses destroued; heavier
constructions severely damaged
21 150 Severe damage to houses; winds
sufficient
to kill people in the open
7 60 Structural damage; danger from flying
glass and debris
Source: ref 9, table 2.

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29.04 2nd Half 15/12/00 11:15 am Page 1545
Uninjured
Injuries
Fatalities
100
90
80
70
Population (%)
60
50
40
30
20
10
0 central Europe, but also in France and Argentina. The link
84 3584 1435 714
Peak overpressure (kPa)
Vulnerability of populations in various overpressure zones
Source: Ref 9, table 3.
would only be lethal in the area of total destruction from
blast and heat. However, after a ground detonation, debris
would be drawn into the fireball, irradiated, and deposited
in a cigar-shaped area down-wind; approximate distances
of radiation doses after one week, and their effects, are
given in panel 2. Effective sheltering reduces exposure, but
toxic levels of radiation persist for a long time. In the
medium term, immunosuppression would decrease
resistance to infection, and in the longer term leukaemia
and other cancer rates would increase.
A single nuclear explosion over a medium-sized city
would overwhelm the health services of even a developed
country, and an attack with multiple weapons would
disrupt the whole countrys economic and social
structure.12
Attacks on or near cities, oilfields and refineries, and
weapons silos in forest areas could produce intense fires
burning unchecked for weeks, the nuclear winter.13
Whereas large-scale nuclear war could directly cause up to
a billion deaths, its indirect effects on food availability and
production could kill many more in its aftermath. The end
of the cold war makes this risk less likely but remaining
stockpiles are sufficient for the possibility to remain.
Nuclear terrorism
There are currently about 500 tonnes of separated
plutonium available, of which 250 tonnes is military
plutonium and 220 tonnes is reprocessed from civil
nuclear reactors.14 Up to 14 kg (35 kg of the dioxide) is
needed to make a nuclear weapon. Reactor-grade
plutonium can be used to make an explosive device, and
one has been tested.15 The collapse of the Soviet Union has
been followed by illicit trafficking of fissile material by
people who often have no concept of the danger of the
material they are handling. In Kiise, Estonia in January,
1995, caesium-137 stolen from the Saku Nuclear Waste
Facility was kept in a kitchen cupboard; the thief died from
radiation sickness.
THE LANCET Vol 355 April 29, 2000
VIEWPOINT
Panel 2: Radiation doses and effects after 1 Mt surface burst
Distance 7-day Effects
downwind accumulated
(km) doses (Sv)*
50 30 Acute neurological syndrome
90 9 Severe gastrointestinal syndrome
160 3 Severe haematological syndrome
240 09 Milder haematological syndrome;
many later cancers and leukaemias
*Without shielding; LD50=45 Sv (survival impossible above about 10 Sv).
Sources: ref 10, figure 2, and ref 11 page 59.
A terrorist organisation could explode a crude weapon
made of stolen plutonium with a yield of 0120 kt.16 The
largest 193945 bombs were only 001 kt.
Health hazards of nuclear cycle
There is a risk to health due to exposure to ionising
radiation at all stages of both nuclear weapon manufacture
and deployment and the civil nuclear cycle.17,18
Uranium is mined mainly in the USA, Australia, and
between uranium mining and lung cancer has been well
known for centuries in the areas in central Europe, where
pitchblende has been mined since the fifteenth century.
The death rate from lung cancer is five times higher in
uranium miners than in the general population.19
Almost all the worlds plutonium, the key component of
modern nuclear weapons, has been produced in nuclear
reactors since 1945. The reactor produces plutonium-239
from uranium-238 in a controlled nuclear reaction and the
reprocessing plant separates chemically plutonium from
the irradiated reactor fuel. After separation from residual
uranium and fission products (highly radioactive and
needing special storage), the plutonium is processed and
assembled into weapons which are deployed at military
bases.
The toxicity of plutonium arises mainly from its
radiological effect.20 Plutonium delivers a negligible
external radiation dose to the skin because it emits mainly
alpha particles. Inhaled plutonium will irradiate the lung,
ingested plutonium the walls of the gastrointestinal tract.
Weight for weight, inhaled plutonium is more toxic than
ingested and reactor grade plutonium more toxic than
military.21 By extrapolation from experiments in dogs,
inhalation of 100 mg weapons-grade plutonium might
cause deaths in humans from acute respiratory failure
within a week, and 3 mg could result in fatal pulmonary
fibrosis within months. Inhalation of a few micrograms
leads to lung cancer several years later.
The experiences of early radiation workers suggested
that ionising radiation is a cause of cancer, and this is now
generally agreed. Follow-up of survivors from Hiroshima
and Nagasaki in 1945 showed an increase in leukaemia
and later solid tumours, and an excess of thyroid cancers in
children was observed unexpectedly soon after the
Chernobyl accident of 1986. Epidemiological studies have
revealed clusters of childhood leukaemia and non-
Hodgkins lymphoma around some nuclear sites in the
UK, but not all.22 A study of over 14 000 workers at a
nuclear site in north-west England found an overall cancer
rate of 5% lower than in England and Wales, but a small
excess of cancers of the pleura and the thyroid in radiation
workers.23 There were also significant increases in risk
with cumulative plutonium plus external radiation doses
for all lymphatic and haematopoietic neoplasms.
1545
29.04 2nd Half 15/12/00 11:15 am Page 1546
VIEWPOINT
Radioactive materials have been released from some at
least of these sites. Furthermore, information about
releases has not always been reliable;24 and standards of
handling waste have been ignored at Dounreay (where
reprocessing has now ceased) and have been appalling at
the Russian complex at Mayak,25 where Lake Karachay
may be the most radioactively contaminated site on earth.
Leaks of strontium-90 and caesium-137 are over five times
the combined releases of these isotopes from atmospheric
nuclear testing, Chernobyl, and Sellafield taken together.
In the 1957 Kyshtym accident in this region of the Urals
high-level waste was dispersed by a chemical explosion in a
storage tank, and a later report will describe environmental
and health effects around the Mayak site.
Epidemiological studies do not prove that the leukaemia
clusters are due to release of radioactivity. On conventional
models of radiation carcinogenesis the exposures seem too
small to account for the effects observed. It has been
suggested that preconceptual irradiation might be to
blame, but other studies have failed to confirm this, and
the finding is currently ascribed to chance.26 A large study
of cancer in the children of radiation workers found
increased cancer, but no correlation with parental
radiation dosage.27 Radiation doses in such studies are
generally expressed as effective whole-body dose, but
recent research raises the possibility that inhaled or
ingested radioisotopes, particularly alpha-emitters such as
plutonium, may have a disproprotionate effect. Irradiation
of human borne marrow with -particles (which have high
linear-energy-transfer) causes genomic instability
resulting in diverse aberrations inthe progeny of some stem
cells many cell divisions later.28 The UKs Committee on
Medical Aspect of Radiation inthe Environment remains
unconvinced of the relevance of this work to the Sellafield
cluster.29 If the relative biological effectiveness of absorbed
a-emitters is high enough to explain the excess leukaemia
around Sellafield, COMARE estimates that natural
background sources would induce more cases of leukaemia
and non-Hodgkin lymphoma than are actually observed,
but accepts that further research is needed on effects in the
embryo and fetus and on germ and stem cells. Since the
publication of the 1996 COMARE report, evidence has
appeared suggesting that genomic instability can be
transmitted to a later generation.30 Mice were treated
with plutonium-239 and the offspring were given a
carcinogen, methylnitrosourea. Significantly more of
the offspring of irradiated male parents developed
leukaemia and lymphoma, than those of untreated parents;
there are many more cell divisions in spermatogenesis
than ovogenesis. The pathological consequences of low-
level internal radiation, particularly from -emitters,
and the concept of genomic instability are beginning to
suggest that standard models of radiation effects need
updating.
Nuclear testing
One source of release of radioactivity should have ended
with the Comprehensive Test Ban Treaty but this treaty is
still not in force, and the legacy of atmospheric tests in the
1940s and 1950s will remain for centuries.19 Meanwhile,
two non-signatories to the treaty, India and Pakistan
carried out underground tests in May, 199831 and in April,
1999, both countries test-fired nuclear capable missiles
with ranges of over 2000 km.
The relation between leukaemia in Utah, USA, and
radioactive fallout from the Nevada test site was
1546
investigated in a case-control study of 1177 individuals
who died of leukaemia and 5330 controls.32 The risk
increased in subgroups defined by cell type, age, and time
after exposure. As a result of atmospheric tests in Nevada,
mainly between 1951 and 1958, American children were
exposed to 1579 times more radiation than previously
admitted.33 Some childrens thyroids received up to 11
Gy, and many millions more than 01 Gy. This will cause
between 10 000 and 75 000 excess thyroid cancers, only a
third of which will have been diagnosed to date.
Evidence of the effects of Pacific testing remains
anecdotal because of the official secrecy of the Ministries
of Defence of Britain and France, but armed forces
personnel and the local population may well have been
exposed to what are now considered to be unacceptably
high levels of radiation. The US government has awarded
compensation to US test veterans for certain cancers, but
similar requests from British nuclear test veterans have ben
refused. Anecdotal reports document the concerns of the
native population of the Pacific islands.34
Solutions
The only solution is preventionie, the elimination of all
nuclear weapons. This is a political issue but preventive
medicine often has a political dimension. Physicians
groups such as International Physicians for the Prevention
of Nuclear War have long been concerned with the threat
of nuclear war. Indeed the former USSRs Mikhail
Gorbachev was convinced by his contacts with IPPNW in
the need to bring about nuclear disarmament,35 and he
initiated the stepwise reduction in nuclear weapons
stockpiles.
The end of the cold war has provided a window of
opportunity for the elimination of nuclear weapons
indeed, according to 1996 advisory opinion of the
International Court of Justice (the World Court) this is
an obligation.36 IPPNW and its affiliates were active in
persuading governments to vote in the UN General
Assembly for the opinion to be obtained. The court stated
that any use of nuclear weapons must accord with
international humanitarian law limiting attacks on
civilians and neutrals and damage to the enviornment. The
Court could not agree on whether use would or would
not be legal when the very survival of a state was at
stake.
The International Court of Justice could find nothing in
international law specifically either authorising or
forbidding the use of nuclear weapons but it interpreted
Article VI of the 1968 Nuclear Non-Proliferation Treaty as
an obligation on the part of the nuclear-weapon states to
achieve nuclear disarmament at an early date under strict
and effective international control. A nuclear weapons
convention, analogous to the conventions on biological
(1972) and chemical (1994) weapons, which would outlaw
the testing, production, stockpiling, or use of all nuclear
weapons is required. Through Abolition 2000, a coalition
of over 700 medical and other peace groups worldwide,37 a
draft version is available.38
Making such a convention effective is not easy and
verification of the final stage of destruction of nuclear
stockpiles will present problems.39 The knowledge of how
to make nuclear weapons will always be with us but as
familiarity with them becomes more remote, the military
would increasingly distrust them (as might the patients of a
surgeon advising an operation he had never performed
before).40
THE LANCET Vol 355 April 29, 2000
29.04 2nd Half 15/12/00 11:15 am Page 1547
Highly enriched uranium or plutonium is essential for
nuclear weapons, so a country with a civil nuclear energy
programme that is prepared to refuse International Atomic
Energy Agency inspection could rapidly acquire such
weapons. An end to reprocessing is thus essential if we are
to have a world permanently free of nuclear weapons, and
that means phasing out all nuclear power plants.
The problem of safe disposal of waste from the civil nuclear
industry will remain; of the various options, vitrification
offers the least likelihood of plutonium being made
available for weapons at a later date.
We thank Frank Barnaby and David Sumner for comments on earlier
drafts, and the librarians at Ashford Hospital, Middlesex, for help in
obtaining material.
References
1 Norris RS, Arkin WM. Global nuclear stockpiles, 19452000.
Bull Atomic Sci 2000; 56: 79.
2 Cochran TB, Norris RS, Paine CE. Progress in nuclear weapons
reduction. In: Rotblat J, ed. Nuclear weapons: the road to zero.
Oxford: Westview, 1998: 15789.
3 Forrow L, Blair BG, Helfand I, et al. Accidental nuclear war: a post-
cold-war assessment. N Engl J Med 1998; 328: 132631.
4 Special Study Section, Physicians for Social Responsibility. The
medical consequences of thermonuclear war. N Engl J Med 1962; 266:
112655.
5 Glasstone S, Dolan PJ. The effects of nuclear weapons, 3rd ed.
Washington, DC: US Department of Defense and US Department of
Energy, 1977.
6 Chivian E, Chivian S, Lifton RJ, Mack JE, eds. Last aid: the medical
dimensions of nuclear war. San Francisco: W H Freeman, 1981.
7 Rotblat J. Nuclear radiation in warfare. London: Taylor and Francis,
1981.
8 Smith J, Smith T. Medicine and the bomb. BMJ 1981; 283: 77174,
84446, 90708, 96365.
9 Rotblat J. Physical effects of nuclear weapons. In: Effects of nuclear war
on health and health services. Geneva: WHO, 1983; 2648.
10 Office of Technology Assessment, Congress of the United States. The
effects of nuclear war. London: Croom Helm, 1980.
11 Sumner D, Whelton T, Watson W. Radiation risks: an evaluation, 4th
ed. Whithorn: Tarragon Press, 1994.
12 Report of the WHO Management Group on follow-up of resolution
WHA 36.28. Effect of nuclear war on health and health services.
Geneva: WHO, 1987.
13 Pittock AB, Ackerman TP, Crutzen PJ, et al. Environmental
consequences of nuclear war. Chichester: John Wiley, 1985.
14 Allbright D, Berkhout F, Walker W. Plutonium and highly enriched
uranium 1996. New York: Oxford University Press, 1997.
15 Mark JC. Reactor-grade plutoniums explosive properties. Washington
DC: Nuclear Control Institute, 1990.
16 International Physicians for the Prevention of Nuclear War. Crude
nuclear weapons: proliferation and the terrorist threat. Boston:
International Physicians for Prevention of Nuclear War, 1996.
17 Roff SR. Chronological bibliography of studies relating to human
exposures to ionising radiation in the course of nuclear weapons
developent, 194090. Med Confl Surviv 1997; 13 (suppl 1): 156.
18 Godlee F. Environmental radiation: a cause for concern? BMJ 1992;
304: 299304.
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19 Makhijani A, Hu H, Yih K, eds. Nuclear wastelands. Cambridge,
Mass: MIT Press, 1995.
20 Clark RH, Dunster J, Nemot J-C, Smith H, Voeltz G. The
environmental safety and health implications of plutonium. J Radiol
Prot 1996; 16: 91105.
21 Barnaby F. The radiological hazards of plutonium. Med Confl Surviv
1997; 13: 195206.
22 Bithell JF, Dutton SJ, Draper GJ, Neary NM. Distribution of
childhood leukaemias and non-Hodgkins lymphomas near nuclear
installations in England and Wales. BMJ 1994; 309: 50105.
23 Omar RZ, Barber JA, Smith PG. Cancer mortality and morbidity
among plutonium workers at the Sellafield plant of British Nuclear
Fuels. Br J Cancer 1999; 79: 1288301.
24 Committee on Medical Aspects of Radiation in the Environment. First
report: the implications of the new data on the releases from Sellafield
in teh 1950s for the conclusions of the Report on the Investigation of
the Possible Increased Incidence of Cancer in West Cumbria. London:
HMSO, 1986.
25 Joint Norwegian-Russian Expert Group. Sources contributing to
contamination of the Techa River and area surrounding the Mayak
production association, Urals, Russia. sters: Norwegian Radiation
Protection Authority, 1997.
26 Doll R, Evans HJ, Darby SC. Paternal exposure not to blame. Nature
1994; 367: 67880.
27 Draper GJ, Little MP, Sorahan T, et al. Cancer in the offspring of
radiation workers: a record linkage study. BMJ 1997; 315: 118188.
28 Kadhim MA, Lorimore SA, Townsend KMS, Goodhead DT,
Buckle VJ, Wright EG. Radiation-induced genomic instability: delayed
cytogenic aberrations and apoptosis in primary human bone marrow
cells. Int J Radiat Biol 1995; 67: 28793.
29 Committee on Medical Aspects of Radiation in the Environment.
Fourth report: the incidence of cancer and leukaemia in young people
in the vicinity of the Sellafield site, West Cumbria: Further studies and
an update of the situation since the publication of the report of the
Black Advisory Group in 1984. London: HMSO, 1996.
30 Lord BI, Woolford LB, Wang L, et al. Tumour induction by methyl-
nitroso-urea following preconceptual paternal contamination with
plutonium-239. Br J Cancer 1998; 78: 30111.
31 Lown B, Chazov EI, Foege WH, Ul-Majeed S, Reddy RJ. An appeal
for nuclear sanity. JAMA 1998; 280: 467.
32 Stephens W, Thomas DC, Lyon JL, et al. Leukemia in Utah and
radioactive fallout from the Nevada test strip. JAMA 1990; 264:
58591.
33 National Cancer Institute. Study estimating thyroid doses of I-131
received by Americans from Nevada atmospheric nuclear bomb tests.
Washington DC: National Cancer Institute, 1997.
34 de Vries P, Seur H. Moruroa and us. Lyon: Centre de Documentation
et de Recherche sur la Paix et les Conflits, 1997.
35 Gorbachev M. Perestroika: new thinking for our country and the world.
London: Collins, 1987: 154.
36 International Court of Justice. Advisory opinion: legality of the threat
or use of nuclear weapons (UN document A/51/218). New York:
United Nations, 1996.
37 Forrow L, Sidel VW. Medicine and nuclear war: from Hiroshima to
Mutual Assured Destruction to Abolition 2000. JAMA 1998; 280:
45661.
38 Datan M, Ware A. Security and survival: the case for a nuclear
weapons convention. Cambridge, MA: International Physicians for
Prevention of Nuclear War, 1999.
39 Fetter S. Verifying nuclear disarmament. In: Rotblat J, ed. Nuclear
weapons: the road to zero. Oxford: Westview, 1998: 71100.
40 Mackenzie D. Uninventing the bomb. Med Confl Surv 1996; 12:
20211.
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HEALTH AND HUMAN RIGHTS

Health and human rights

The rights of the severely mentally ill in post-conflict societies
ebate continues about the value
D of implementing mental health
and psychosocial programmes in the
early reconstruction phase of societies
that have undergone humanitarian
emergencies. We are concerned that
theoretical polarisations that have
emerged in the field could undermine
efforts to provide legitimate mental-
health services to high-risk subgroups,
especially those with severe mental
illnesses.
Disagreement among experts in the
field seems to stem mainly from
an either-or fallacy, with
some authorities implying that
entire populations exposed to
war are traumatised. Critics,
however, have argued that nor-
mative social responses to
extreme human-rights abuses
should not be medicalised by
labelling them as post-traumatic
stress disorder (PTSD).1 It
seems important, therefore, to
identify separate if overlapping
subpopulations with distinctive
needs: those with disabling psy-
chiatric illnesses; those with
severe psychological reactions Rehabilitation clinic in Kakuma Refugee Camp, 1998
to trauma; and the majority who
are able to adapt once peace and order
are restored.
Neglect of the issue of severe mental mothers may be at high risk of death
disorder in these contexts means that
there are limited data on psychosis
and neuro-organic disorders in post-
conflict populations. Questions
remain about the transcultural validity
of western diagnostic categories in
classifying these disorders and about
the effectiveness of indigenous meth-
ods for treating them. Nevertheless,
psychoses and severe mood disorders
rank high as causes of disability world- unit from achieving some degree of
wide, and it is clear that these disor-
ders are found across post-conflict
societies, even if there may be cultural ruptive social behaviour by a few
differences in conceptualising and
dealing with such problems.
Indeed, certain risk factors to severe refugee camp, it can have an erosive
mental illness are accentuated in popu-
lations exposed to conflict and dis-
placement. These factors include: poor
antenatal health and nutrition; subop-
timum perinatal care; increased risk of
birth injuries; infantile malnutrition;
early separation from care givers; neg-
lect and understimulation of children;
exposure to chronic communicable
diseases that affect the brain; the risk often at a loss as to how to deal with
of traumatic epilepsy; and exposure to
extreme and repeated stress.
In times of civil war and mass dis-
placement, those with established
mental illnesses are vulnerable to
abuse, neglect, abandonment, and
exploitation. Institutions, including
psychiatric facilities, are usually
destroyed or abandoned, leaving
patients without protection, medica-
tion, or social support. Individuals
with overt psychosis may be found liv-
ing in states of gross dereliction, com-
monly falling prey to malnutrition,
stigma, ostracism, and even violence.
The mentally ill are at risk therefore of
life-threatening physical illness, death
from misadventure, or violence and
suicide. Children born to psychotic
from malnutrition and disease result-
ing from maternal neglect. In some
communities, people with mental ill-
ness are chained to trees or posts sim-
ply to prevent them from assaulting
family members, from wandering, or
from being attacked by neighbours or
strangers. Having to care for a person
with chronic mental illness may be the
critical element that prevents a family
self-sufficiency under already precari-
ous conditions. When bizarre and dis-
psychotic individuals occurs repeat-
edly in a confined situation such as a
impact on the fragile social fabric of
displaced communities.
Social networks and indigenous
healing practices that may assist in the
care of the mentally ill are usually dis-
rupted by war and displacement.
Emergency health services provided
by relief organisations rarely include
psychiatrists so that personnel are
those with severe mental illness, and
sufferers may be condemned to long
periods without access to appropriate
treatment.
What evidence is there that effi-
cient, low-technology mental-health
facilities can be effectively established
in these contexts? Models now exist in
Africa, Cambodia, and elsewhere that
demonstrate the effectiveness of estab-
lishing such programmes. In a refugee
camp in northern Kenya, the mental-
health service is led by two psychiatric
nurses and volunteer community
workers from the relevant ethnic com-
munities. In 1998, 600 people were
treated by the service, representing
about 1% of the total camp
population. In Cambodia, since
a community mental-health
service was established in 1995
in Siem Reap, patients have
travelled long distances from all
around the country to seek
treatment at the centre. In both
settings the number of patients
who attend the clinics has
grown dramatically during a
short period. Most of the early
attendees have been those with
severe mental illnesses. There
are fewer people with trauma-
related disorders, although the
numbers are increasing, which
suggests that the initial barriers
of stigma and suspicion tend to
decrease with time.
The impact of treatment can be
dramatic. Individuals respond rapidly
to the introduction of standard
antipsychotic medications and sup-
portive community follow-up. When
visited by a consultant team some
months after the initiation of treat-
ment, a psychotic man chained to a
tree for 8 months in Siem Reap,
Cambodia, was found to be working
in the rice fields with his family, appar-
ently restored fully to his usual mental
state. Traditional family structures
often provide a supportive environ-
ment for the rehabilitation of psy-
chotic patients. In refugee camps,
community volunteers can be trained
to provide outreach services, family
education and support, and links to
agencies that provide rehabilitation.
Efforts to destigmatise and reintegrate
people with psychiatric illness into
society may be pursued by commu-
nity-based awareness raising and edu-
cation programmes for the whole
population.
Critical issues in service develop-
ment for the severely mentally ill
remain. Psychotropic medications,
particularly the newer and more
expensive drugs, are scarce. Con-
troversy continues about imposing

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western models of mental illness on
other cultures, but this concern needs
to be balanced against the effects of
rapid cultural change. Excessive zeal
in protecting local cultures from
global trends in disciplines such as
mental health can be as patronising as
devaluing indigenous approaches to
healing. In Cambodia, one of us (RM)
and his Harvard-based group have
attempted to address these complex
issues by giving equal emphasis to
western and traditional systems of
diagnosis and treatment.
The second population subgroup
that warrants consideration are those
who experience extreme psychological
reactions to trauma. Research in the
field assists in clarifying some of the
ongoing controversies about applying
western concepts of trauma and
PTSD across diverse cultural settings.
Epidemiological evidence indicates
that PTSD can be identified in most
cultures, but only a minority of those
exposed to mass violence suffer from
the disorder; numbers vary from 4 to
20%. In addition, most people with
early symptoms of the disorder
undergo natural remission over time.
Consequently, there can be no justifi-
cation for the blanket application of
group-based early interventions such
as the widely practiced method of
debriefing. An important considera-
tion for service provision is that those
with severe PTSD are often the least
likely to seek treatment. In addition,
cultural, religious, and political factors
seem to exert an appreciable influence
on the outcome of PTSD, as does the
security of the recovery environment,
which indicates that part of the
response to the problem may be to
direct limited resources towards popu-
lation-based interventions rather than
to conventional one-to-one therapy.
PTSD is not the only psychiatric
outcome of trauma exposure. Other
disorders, such as drug and alcohol
abuse, somatisation, anxiety, and espe-
cially depression, are common seque-
lae. An important finding in a study of
Bosnian refugees2 is that comorbidity
of PTSD and depression, a common
clinical presentation, is associated with
high rates of psychosocial disability.
Thus, the available data suggest that
for the subgroup with disabling
psychological responses to trauma,
further work is needed to: refine selec-
tion criteria for treatment; define the
essential ingredients of therapy; ensure
cultural acceptability of interventions;
and to establish the appropriate
balance between population-based and
clinic-based interventions.
A key question is whether mental-
health professionals have any role in
THE LANCET Vol 355 April 29, 2000
offering interventions to most of the
population who undergo normative
adaptive responses to mass violence
and displacement.3 Opinions are
divided on this issue. Where there is a
growing consensus, however, is that a
community-development approach is
most appropriate to the needs of the
whole population because it aims to
restore the capacity of communities to
reconstruct and develop their own
societies. From a psychosocial per-
spective, community programmes
might focus on strengthening family
and kinship ties, promoting indigenous
healing methods, facilitating commu-
nity participation in decision-making,
fostering leadership structures, and re-
establishing spiritual, religious, social,
and cultural institutions and practices
that restore a framework of cohesion
and purpose for the whole
community.3
Events of the past decade have pro-
vided us with stark reminders of the
health costs of mass violence. The
problem is too grave to allow theoreti-
cal polarisations to paralyse humani-
tarian action. There is a risk that a
singular focus on the psychological
impact of trauma will obscure the mul-
tiplicity of psychosocial needs that
require attention in the reconstruction
phase. Mental-health programmes
attract a small portion of total aid
funding provided worldwide for soci-
eties emerging from humanitarian
crises, yet individuals with severe men-
tal illness are at particular risk of neg-
lect, abuse, and disability. Lack of
treatment for affected individuals
undermines the capacity of families to
attend to basic survival needs, and fur-
ther erodes the fabric of the commu-
Tools to measure landmine incidents and injuries
espite an international treaty
D banning the use of landmines,
tens of thousands of people are killed
or injured by these weapons every
year. The pain and suffering for
countless victims of landmines
around the world is staggering. In
Cambodia, one out of every 236 peo-
ple is an amputee and in Afghanistan,
almost one out of every 50 is a land-
mine victim. Studies show that 48%
of victims may die before receiving
assistance and most will ultimately
need extensive rehabilitation. In
many of these countries, the loss of a
limb severely disables a person and
impedes their ability to function as a
productive member of society.
Epidemiological surveys are essen-
tial for properly quantifying the pub-
lic-health consequences. The results
of such studies facilitate the alloca-
HEALTH AND HUMAN RIGHTS
nity as a whole. At the same time, the
either-or fallacy alluded to earlier
should be avoided, and strategies to
assist people severely disabled by psy-
chic trauma need to be developed in
parallel with programmes for the
severely mentally ill. The risk of ideo-
logical rigidity as to which subpopula-
tion (and hence which set of
interventions) should be given priority,
risks confusing donors, relief organisa-
tions, and international agencies
charged with setting priorities for
humanitarian relief programmes in a
field where competition for funds is
intense. The risk of excessive dissent
among mental-health experts in the
field is that the casualties of mass con-
flict may become the unintended vic-
tims of our neglect.
*Derrick Silove, Solvig Ekblad, Richard
Mollica
*Psychiatry Research and Teaching Unit,
School of Psychiatry, University of New South
Wales, Sydney, Australia; Division of
Psychosocial Factors and Health, Department
of Public Health Sciences, Karolinska
Institute, Stockholm, Sweden; and Harvard
Program in Refugee Trauma, Harvard Medical
School, Boston, MA, USA
1 Summerfield D. A critique of seven
assumptions behind psychological trauma
programmes in war-affected areas. Soc Sci
Med 1999; 48:144962.
2 Mollica RF, McInnes K, Sarajlic N, Lavelle J,
Massagli MP. Disability associated with
psychiatric comorbidity and health status in
Bosnian refugees living in Croatia. JAMA
1999; 282: 43339.
3 Silove D. The psychosocial effects of torture,
mass human rights violations, and refugee
trauma: toward an integrated conceptual
framework. J Nerv Ment Dis 1999; 187:
20007.
tion of resources and aid in evaluat-
ing the impact of interventions.
Physicians for Human Rights (PHR)
has coordinated the development of
standardised survey tools to ensure
that data collection proceeds accord-
ing to appropriate scientific methods
and allows for the comparison of data
between differing regions and coun-
tries. An instrument for hospital-
based surveillance and a community
survey tool were developed by PHR,
WHO, the International Committee
of the Red Cross, Injury Center
Uganda, and the London School for
Hygiene and Tropical Medicine. The
goal of this tool is to establish a
global reporting system so that injury
data are collected and then transmit-
ted to centres in ministries of health
or to international organisations
responsible for the analysis and dis-
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HEALTH AND HUMAN RIGHTS

semination of the data. It integrates
easily into the WHO injury-surveil-
lance systems with con-
tinuous data collection.
In addition, this tool
can be used as a short
survey to establish
baseline information,
which allows for meas-
uring trends over time.
The tools were pre-
sented at the
Intersessional meeting
of the Committee of
Experts for Mine
PHR and other members of the
international Campaign to Ban
Landmines have devel-
oped additional tools
to measure prehospital
care and hospital
capabilities, prosthetic
capabilities, and reha-
bilitation and social
reintegration of land-
mine victims. These
measure the effective-
ness of the resources
of hospitals and
orthopaedic/rehabilita-
Management System for Mine
Action have refined the hospital data
tool so that it is standardised and
universally accepted.
These core tools measure the mor-
bidity and mortality associated with
landmine injuries and collect infor-
mation on demographical features,
device-type, pre-hospital care, trans-
portation time, and treatment. WHO
is coordinating the pilot testing of
these tools in collaboration with the
participating organisations. PHR
field-tested the tools in Azerbaijan in
1999. The tools will help identify

AP
Victim Assistance in Landmine victim, Kabul, tion centres to treat areas where landmine injuries are a
Geneva at the end of Afghanistan mine victims, provide significant problem and thus target
March, 2000. surgical care, and regions where more intensive surveys
The community-survey tool include characteristics of the physical should be undertaken.
records data of mine-affected plant, personnel, operating theatres, The tools were designed to be easy
areas and provides information on blood-donation capability, and sani- to use, inexpensive to administer,
the effect landmine injuries have on tation. The data collected can help in and can be used collectively or indi-
communities. It is designed to the allocation of donor funding for vidually. Used as short surveys, they
collect data on all individuals, specific projects or to individual can be done quickly to determine
including those who either did or did facilities in need of necessary equip- need and can be repeated to measure
not seek hospital care or died before ment and supplies. These tools also change. A new manual available
attaining care. By calculating the measure the extent to which a vic- from PHR contains all seven tools
percentage of victims that were tims injuries are interfering with and instructions on their use.
missed in the hospital data, the re- their ability to lead stable and self-
gions true incidence of mine injuries sufficient lives and the degree to James Cobey, Barbara Ayotte
can be determined. Data can be used which they are receiving aid from the Physicians for Human Rights,
to prioritise resources, time, and government. The UNs Mine Action 100 Boylston Street, Suite 702,
money. Service and the Information Boston, MA 02116 USA

Torture and the scientific community

he United Nations and profes-
T sional umbrella organisations
have stressed the importance of the
prevention of torture and care for sur-
vivors, but also the duty of physicians
to avoid any acts of complicity.
Physicians in Turkey have been espe-
cially active not only in treatment, but
also in the development and publica-
tion of methods to diagnose sequelae
to torture.
Professor Veli Lok, an orthopaedic
surgeon who is active in the Human
Rights Foundation of Turkey, first
published in The Lancet on the use of
bone scintigraphy as a diagnostical
tool in torture.1,2 This technique has
become accepted world-wide as a
standard procedure in specialised cen-
tres. Professor Lok and several of his
co-workers, including psychiatrist Dr
Alp Ayan and Dr Zeki Uzun, have
now been targeted for acts of persecu-
tion in a campaign by Turkish govern-
ment forces, who have been widely
criticised for their extensive use of
torture.3,4
Lok is charged with having violated
section 2, article 30, of the Turkish
Press Act by having expressed his
opinion about court decisions about
detentions and criticised and influenced
the courts. The charges seem to refer
to concerns raised by Lok in regard to
dangers to professionals caring for vic-
tims of torture. Apart from the serious
doubts raised by international observers
about the fairness of allegations and
court procedures, physical violence,
threats, and torture have reportedly
been used in the context of those
actions, according to the International
Rehabilitation Council for Torture
Survivors5 and other sources.
New court sessions have been
scheduled for April 11 and April 13,
2000, and might lead to prison sen-
tences of several months and up to
3 years, as well as continued danger
for the life and physical health of the
medical professionals involved.
Observers from different embassies
and organisations are expected during
this hearing, as in the earlier sessions
of the court. Since Lok and colleagues
have been widely associated with pro-
grammes offering medical treatment
to torture survivors, many fear that the
action against him will frighten away
scientists, physicians, and their
patients from urgently needed treat-
ment and research.
Recent events seem to be in viola-
tion of international agreements, and
earlier pledges by the Turkish govern-
ment to comply with those standards.
The case highlights the need to ask not
only the health professionals to refuse
to collaborate with governments who
use torture and to take an active role
against human rights violations, but
also to ask the international commu-
nity to support those who have the
courage to follow this request.
*Thomas Wenzel, James Jaranson, Ingrid
Sibitz, Marianne Kastrup
*World Psychiatric Association Section on
Psychological Consequences of Torture and
Persecution, 1160 Vienna, Austria; University
Hospital, Department of Psychiatry, Vienna,
Austria; and Rehabilitation Centre for Torture
Survivors, Copenhagen, Denmark.
1 Tunca M, Lok V. Bone scintigraphy in
screening of torture survivors. Lancet 1998;
352: 1859.
2 Lok V, Tunca M, Kumanlio lu K, Kapkin E,
Dirik G Bone scintigraphy as clue to previous
torture Lancet 1991; 337: 846-47.
3 Salinsky M. Torture continues in Turkey:
findings of new report. Lancet 1998; 352:
1854.
4 Yuksel S. Torture in Turkey. Lancet 1989;
2: 866.
5 IRCT. International community urged to
denounce Turkeys persecution of doctors
working against torture. Torture (in press).

1550 THE LANCET Vol 355 April 29, 2000