Medical Preparedness for Nuclear Disaster

A Conversation With Robert Peter Gale, MD, PhD, DSc (hc)

Get Permission

Robert Peter Gale, MD, PhD, DSc (hc).
©Patricia Williams.

Robert Peter Gale, MD, PhD, DSc (hc). ©Patricia Williams.

ROBERT PETER GALE, MD, PhD, DSc (hc), was on the faculty of the University of California, Los Angeles, School of Medicine for 20 years and has served as Chairman of the Scientific Advisory Committee of the Center for International Blood and Marrow Transplant Research. In 1986, he was asked by the government of the Soviet Union to coordinate medical relief among first responders to the victims of the Chernobyl disaster. He is an internationally recognized expert in radiation injury and also offered his services after the Goiânia radioactive contamination accident in Brazil and the 1999 Tokaimura and 2011 Fukushima accidents in Japan. 

Dr. Gale and James O. Armitage, MD, have worked together on projects discussing our nation’s medical preparedness for nuclear terrorism, recently penning an article in The New England Journal of Medicine on that subject. They believe physicians should be educated to recognize the symptoms indicative of radiation exposure, allowing early detection and management of the syndrome. 


For more on medical preparedness for nuclear events, see Gale RP, Armitage JO: N Engl J Med 378: 1246-1254, 2018.

Radiation exposure can manifest in a number of nonspecific signs, including gastrointestinal symptoms, low counts of blood granulocytes, lymphocytes, and platelets—all symptoms of bone marrow injury and hair loss. Resources for information about recognizing radiation exposure are provided herein (see sidebar). In the event of a nuclear accident or attack, oncology and hematology specialists would likely be called on to identify, diagnose, and treat radiation syndrome, especially bone marrow failure, in exposed individuals. 

The ASCO Post spoke with Dr. Gale about preparedness for and consequences of nuclear accidents or acts of terrorism involving nuclear weapons. 

Crucial Subject 

What generated your interest in nuclear terrorism? 

I’m usually the first person called on for medical support coordination after a nuclear disaster such as Chernobyl, and I’m always preparing for the next phone call, hoping it won’t come. These events are not as infrequent as you might believe. 

So the interest in how to respond to a nuclear catastrophe, whether by accident or by a terrorist act, is similar. Dr. Armitage and I discussed this issue when we met in Omaha recently. Jim has been on expert panels that look at what drugs should be stockpiled in the event of nuclear terrorism. We shared knowledge and ideas on this very crucial subject—one that doesn’t get enough open discussion. 

How is nuclear terrorism different from other acts of terrorism? 

The goal of terrorism is massive social disruption, even above the act of killing. Large metropolitan areas have been targets of past acts of terror, including New York and Washington, DC, not only because they are densely populated, but also for the psychological effect on the nation as a whole. 


  • National Council on Radiation Protection and Measurements (NCRP)
  • International Atomic Energy Agency (IAEA)
  • World Health Organization
  • Federal Emergency Management Agency (FEMA)
  • U.S. Department of Health and Human Services SALT Mass Casualty Triage Algorithm

The fact that nuclear terrorism would involve radioactive material vastly increases the effect of the psychological distraction and social disorder. People have a natural fear of radiation, which is based on ignorance. For instance, people have voiced concern over radiation exposure in airport security scanners, not realizing that they are getting more radiation exposure during their flight on the airplane than from the scanner. So although terrorists could accomplish their goals by other means, a nuclear device causes much more fear and large-scale emotional panic and disruption. 

Targeting a Nuclear Facility 

What would be the effect of using a plane as a weapon to crash into a nuclear power plant? 

Intelligence reports showed that the 9/11 terrorists had considered attacking a nuclear power plant as one of their scenarios. In the 1970s, when commercial airlines were more commonly hijacked, there was a threat made to crash a jetliner into the Oak Ridge nuclear weapons facility, where the atomic bombs dropped during WWII were made. And there have been many other military strikes on nuclear facilities around the world. 

Interestingly, when nuclear power first came about, President Eisenhower gave an “Atoms for Peace”–themed speech that was used to enlighten people about the hope of a nuclear future, one in which all electrical power to our citizens would be free. No one at that point really thought about targeting a nuclear power plant, especially since the concept of international terrorism wasn’t yet a threat. 

There are two aspects to that issue. One is the question of whether you could actually destroy the reactor itself. And there’s a bit of controversy here on whether a reactor could withstand a direct hit on its core from a commercial airliner. Jim and I received different responses from engineers on this question, so there is no real consensus. 

But terrorists wouldn’t need to tackle the reactor’s core; they could assault and commandeer the plant and penetrate the defenses of the reactor itself. For example, they could disrupt the reactor’s water-cooling system. In fact, environmental groups aiming to prove how vulnerable these nuclear reactors are have conducted this very kind of operation. 

We have three redundant systems to prevent what is called a loss-of-cooling accident. But in Fukushima, all three systems failed, causing catastrophic failure of the core. It would be possible for terrorists to knock out all three systems, which is something that needs to be addressed. In the United States, we have force-to-force exercises to prepare us for this kind of attack, but other countries may not be so prepared. There’s a lot of vulnerability out there. 

Need for Public Education 

We have heard the term “improvised nuclear device” used as a method for terrorists to strike a U.S. city. Please touch on that issue. 

That term is used to describe illegally obtained fissile material from a radioactive source. That’s why we get concerned about potential thefts of nuclear rods from nuclear power facilities. Now, you couldn’t smuggle the material in by air, because— and most people don’t know this—airports in the United States have radiation detection devices. So the material would have to be smuggled in by boat or across the Mexican or Canadian border. 

In an easier-to-realize scenario, a terrorist operative could steal radioactive material from a hospital and use it in a conventional bomb. As I mentioned, the aim is for mass disruption, and just the word “radiation” causes panic in the public. 

For example, if a device like this was detonated in a city such as New York, midtown Manhattan would have to be evacuated. Panic would spread across the island, causing chaos and fear. The only way to prevent that is through education, but it is an uphill battle. 

When the atomic bombs were dropped on Japan, killing an estimated 250,000 people, the deaths mainly occurred as a result of the percussive force and superfires; only about 5% of the deaths were due to radiation poisoning. Most people assume that radiation was the largest killer, and convincing them otherwise is difficult. We humans are programmed to fear what we can’t perceive. We can run away from fire or seek higher ground during a tsunami, but the invisible terror of radiation provokes irrational behavior. 

Medical Preparedness 

What should the medical community do to prepare for nuclear terrorism? 

The first necessity is to revamp education on radiation and how various scenarios could play out. The average physician has only a modest knowledge about radiation. One problem is that besides a lack of training in the curricula, we also don’t have enough people to teach about radiation in medical schools. Knowledgeable doctors are important, and oncologists and hematologists are the likely professionals who would be treating individuals affected by radiation. When you have one of these events, people put less faith in governmental sources than they do in their health-care providers. And if the providers don’t have the knowledge, they give incorrect advice. 

To identify how best to help individuals exposed to radiation, physicians must be able to obtain an accurate dose estimate to determine the level of radiation exposure, after which interventions to limit adverse events can be implemented. Dependent on the degree of exposure, some interventions include oral antibiotic or antiviral drugs, red-cell and platelet transfusions, and hematopoietic growth factors (ie, filgrastim and sargramostim [granulocyte and granulocyte-macrophage colony-stimulating factors]). 

We also need physicians with the knowledge to diagnose radiation sickness in the event of a terrorist secretly planting radioactive material on a train, for instance. People would slowly develop symptoms, such as skin rash and diarrhea, but unless you’re thinking about clinical radiation exposure, you’ll never make the diagnosis, and it will go untreated. 

And last, we need to make sure we have an adequate supply of drugs used to treat radiation sickness and the ability to adequately deploy those drugs, keeping in mind that many in the medical community might also be victims. 

Global Tensions and Nuclear Treaties 

It’s been about 25 years since the end of the Cold War, which was best characterized by the looming threat of nuclear war. Has that threat been greatly diminished? 

No. During the Cold War, it was the Soviet Union vs the United States, and despite the heated rhetoric, both countries knew a nuclear war would result in mutual destruction. Now there are a lot more players with various levels of nuclear capability. We have increased global tensions and the collapse and disarray of major nuclear treaties such as the Strategic Arms Limitations Treaty. 

The U.S. Air Force is able to develop stealth nuclear cruise missiles and smaller tactical nuclear weapons. Russia is increasing its nuclear capabilities. Smaller countries are moving their weapons to different locations within their country to avoid attack and disarmament. 

Key Recommendations 

Do you have any closing thoughts on education and medical preparedness in the event of a nuclear accident or casualty? 

Again, we need to increase our education on radiation and the possible consequences of a nuclear terrorist attack. National and international plans and guidelines exist, as do educational materials for health-care providers, with advice on triage, centers of excellence for treating bone marrow failure, and training exercises, but there is a knowledge gap that exists among policymakers, health-care professionals, and the public about the consequences of exposure to radiation. But more importantly, we need to get back to the drawing board and create policies that will prevent the intentional use of these weapons. Russia has a nuclear bomb that is 5,000 times more powerful than the A-bomb dropped on Hiroshima. There is no way to prepare for something like that. Prevention is the only course. 

DISCLOSURE: Dr. Gale is a part-time employee of Celgene Corp.