Intended for healthcare professionals


Thinking the unthinkable!

BMJ 2002; 324 doi: (Published 15 June 2002) Cite this as: BMJ 2002;324:1405
  1. Zulfiqar Ahmed Bhutta (zulfiqar.bhutta{at}, Husein Lalji Dewraj professor of paediatrics and child health,
  2. Samiran Nundy, consultant gastrointestinal surgeon
  1. Aga Khan University, Karachi 74800, Pakistan
  2. Department of Gastrointestinal Surgery, Sir Ganga Ram Hospital, New Delhi 110016, India

    Preparing for Armageddon in South Asia

    News p 1412

    The unthinkable has actually happened. Over a span of barely four years, the subcontinent and its military and political leadership seem to have moved seamlessly from an obtuse nuclear capability and a doctrine of nuclear deterrence to the present state of nuclear weaponisation.1 As a million soldiers face each other across the volatile line of control and the border between India and Pakistan, the arguments have shifted from no use of nuclear weapons to their potential use in the event of conventional war, to the current state of actual deployment. To a large extent the numerical superiority of the Indian army and air force translates into a no win situation for Pakistan in the event of a conventional conflict. Faced with the potential of humiliation and dismemberment in such a scenario, a nuclear first strike becomes a frighteningly real possibility.2

    The debate and outcry on this reckless brinkmanship in South Asia has remained confined to the peace groups, and the vernacular press has largely been jingoistic and indifferent to the disastrous consequences of nuclear war. While one can understand that the illiterate masses in both countries may have no concept of the awesome power of nuclear weapons, the apparent resignation of the educated elite and intelligentsia to their fate and a possible nuclear conflagration is most surprising. In contrast to the nuclear disarmament appeals from a few years ago,3 most of the medical associations on both sides of the border have maintained an ominous silence (see also p 1412). This apparent apathy can be interpreted in one of several ways: one that there is widespread disbelief that a conflict will take place, the other that no level of preparedness can mitigate a nuclear conflagration. A third and more plausible explanation is that few among the health professionals are even remotely aware of the true meaning and consequences of a nuclear conflict. The fact remains that apart from a few calculations, 4 5 almost all the estimates of the human and material costs of a nuclear exchange between India and Pakistan, or even a nuclear accident, are from Western sources. It is entirely plausible that a nuclear exchange between these volatile neighbours will be neither surgical nor contained. A secret Pentagon study reveals that the immediate death toll in the case of a nuclear exchange can be as high as 12 million, with almost 7 million injuries.6 The widespread destruction of property, nuclear fallout, and environmental costs are almost impossible to compute, and may involve the entire south and central Asian region. The humanitarian crisis in the region and the impact on the global economy will be devastating.

    As the world braces itself for a possible terrorist nuclear attack, several projections and scenarios as to possible deaths from shock waves and thermal and ionising radiation injury have been made. 7 8 None of these estimates can apply to the Indian subcontinent, where urban congestion, tinderbox squatter settlements, and a dysfunctional health system make for a nightmare scenario in the aftermath of a nuclear exchange. A recent review of hospitals in the United States revealed that 73% were unprepared for a nuclear accident or attack.9 Poor disaster preparedness and health system performance in the subcontinent means that the number of late deaths due to burns, radiation, and infections will be considerably greater. To those potentially relying on the effectiveness of a limited nuclear strike over military targets, the unpredictability of wind directions and contiguous heavily populated border areas make containment almost impossible.10 The development and use of nuclear shelters by a select few only serves to highlight the abject lunacy surrounding nuclear weaponisation in the subcontinent.11

    The current nuclear imbroglio in India and Pakistan is a direct consequence of a lack of human and social development in the region. Malnutrition rates in the region are among the highest in the world, and successive generations have been fed a daily gruel of intolerance, jingoism, and religious fervour by political and military governments. The current military standoff must also be viewed in the context of the growth of religious intolerance and lack of social development in both countries.12 A conservative estimate of the costs of nuclear weaponisation in India placed it at well over $10bn (£6.8bn; €10.6bn),13 and although modest by comparison, it is sobering to note that Pakistan's recent ballistic missile tests alone could have funded the entire health budget of several districts.

    The current crisis also highlights why the doctrine of nuclear deterrence is a myth.14 As Bidwai and Vanaik have said, a state of deterrence is simply “a state of mind” and depends on the predictability of responses from either side.15 With Hindu extremists tugging at its sleeves and Islamic militants attempting to trigger an all out conflict, neither India nor Pakistan possesses stable command and control systems ensuring that an accidental conflict will not be triggered. Despite sophisticated systems and the advantage of early warning systems, the cold war era has left numerous examples of mishaps that could have triggered nuclear conflict.16 Neither Pakistan nor India has the luxury of distance and time in which to evaluate a false alarm, and thus the possibility of accidental nuclear conflict becomes frighteningly real. The only prudent way ahead for the leadership of the two countries is to step back from the brink and start substantive discussions and political dialogue. The large cadre of health professionals and societies in both countries, as indeed globally, must assume responsibility for the promotion of peace, and eventual nuclear disarmament.


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