During the Cold War, physicians and others described the potential medical consequences of thermonuclear war and concluded that health care personnel and facilities would be unable to provide effective care to the vast number of victims of a nuclear attack. (1,2,3) In 1987, a report by the World Health Organization concluded, "The only approach to the treatment of health effects of nuclear warfare is primary prevention, that is, the prevention of nuclear war." (4) Many physicians and medical organizations have argued that the prevention of nuclear war should be one of the medical profession's most important goals. (5,6,7,8,9) Although many people believe that the threat of a nuclear attack largely disappeared with the end of the Cold War, there is considerable evidence to the contrary. (10) The United States and Russia no longer confront the daily danger of a deliberate, massive nuclear attack, but both nations continue to operate nuclear forces as though this danger still existed. Each side routinely maintains thousands of nuclear warheads on high alert. Furthermore, to compensate for its weakened conventional armed forces, Russia has abandoned its "no first use" policy. (11) Even though both countries declared in 1994 that they would not aim strategic missiles at each other, not even one second has been added to the time required to launch a nuclear attack: providing actual targeting (or retargeting) instructions is simply a component of normal launch procedures. (12,13,14) The default targets of U.S. land-based missiles are now the oceans, but Russian missiles launched without specific targeting commands automatically revert to previously programmed military targets. (13) There have been numerous "broken arrows" (major nuclear-weapons accidents) in the past, including at least five instances of U.S. missiles that are capable of carrying nuclear devices flying over or crashing in or near the territories of other nations. (15,16) From 1975 to 1990, 66,000 military personnel involved in the operational aspects of U.S. nuclear forces were removed from their positions. Of these 66,000, 41 percent were removed because of alcohol or other drug abuse and 20 percent because of psychiatric problems. (17,18) General George Lee Butler, who as commander of the U.S. Strategic Command from 1991 to 1994 was responsible for all U.S. strategic nuclear forces, recently reported that he had "investigated a dismaying array of accidents and incidents involving strategic weapons and forces." (19) Any nuclear arsenal is susceptible to accidental, inadvertent, or unauthorized use. (20,21) This is true both in countries declared to possess nuclear weapons (the United States, Russia, France, the United Kingdom, and China) and in other countries widely believed to possess nuclear weapons (Israel, India, and Pakistan). The combination of the massive size of the Russian nuclear arsenal (almost 6000 strategic warheads) and growing problems in Russian control systems makes Russia the focus of greatest current concern. Since the end of the Cold War, Russia's nuclear command system has steadily deteriorated. Aging nuclear communications and computer networks are malfunctioning more frequently, and deficient early-warning satellites and ground radar are more prone to reporting false alarms. (10,22,23,24) The saga of the Mir space station bears witness to the problems of aging Russian technical systems. In addition, budget cuts have reduced the training of nuclear commanders and thus their proficiency in operating nuclear weapons safely. Elite nuclear units suffer pay arrears and housing and food shortages, which contribute to low morale and disaffection. New offices have recently been established at Strategic Rocket Forces bases to address the problem of suicide (25) (and unpublished data). Safeguards against a nuclear attack will be further degraded if the Russian government implements its current plan to distribute both the unlock codes and conditional launch authority down the chain of command. Indeed, a recent report by the Central Intelligence Agency, which was leaked to the press, warned that some Russian submarine crews may already be capable of authorizing a launch. (26) As then Russian Defense Minister Igor Rodionov warned last year, "No one today can guarantee the reliability of our control systems.... Russia might soon reach the threshold beyond which its rockets and nuclear systems cannot be controlled." (24) A particular danger stems from the reliance by both Russia and the United States on the strategy of "launch on warning" -- the launching of strategic missiles after a missile attack by the enemy has been detected but before the missiles actually arrive. Each country's procedures allow a total response time of only 15 minutes: a few minutes for detecting an enemy attack, another several minutes for top-level decision making, and a couple of minutes to disseminate the authorization to launch a response. (27,28) Possible scenarios of an accidental or otherwise unauthorized nuclear attack range from the launch of a single missile due to a technical malfunction to the launch of a massive salvo due to a false warning. A strictly mechanical or electrical event as the cause of an accidental launch, such as a stray spark during missile maintenance, ranks low on the scale of plausibility. (29) Analysts also worry about whether computer defects in the year 2000 may compromise the control of strategic missiles in Russia, but the extent of this danger is not known. Several authorities consider a launch based on a false warning to be the most plausible scenario of an accidental attack. (20,29) This danger is not merely theoretical. Serious false alarms occurred in the U.S. system in 1979 and 1980, when human error and computer-chip failures resulted in indications of a massive Soviet missile strike. (10,30) On January 25, 1995, a warning related to a U.S. scientific rocket launched from Norway led to the activation, for the first time in the nuclear era, of the "nuclear suitcases" carried by the top Russian leaders and initiated an emergency nuclear-decision-making conference involving the leaders and their top nuclear advisors. It took about eight minutes to conclude that the launch was not part of a surprise nuclear strike by Western submarines -- less than four minutes before the deadline for ordering a nuclear response under standard Russian launch-on-warning protocols. (10,24,27) A missile launch activated by false warning is thus possible in both U.S. and Russian arsenals. For the reasons noted above, an accidental Russian launch is currently considered the greater risk. Several specific scenarios have been considered by the Ballistic Missile Defense Organization of the Department of Defense. (31) We have chosen to analyze a scenario that falls in the middle range of the danger posed by an accidental attack: the launch against the United States of the weapons on board a single Russian Delta-IV ballistic-missile submarine, for two reasons. First, the safeguards against the unauthorized launch of Russian submarine-based missiles are weaker than those against either silo-based or mobile land-based rockets, because the Russian general staff cannot continuously monitor the status of the crew and missiles or use electronic links to override unauthorized launches by the crews. Second, the Delta-IV is and will remain the mainstay of the Russian strategic submarine fleet. (27,32,33) Delta-IV submarines carry 16 missiles. Each missile is armed with four 100-kt warheads and has a range of 8300 km, which is sufficient to reach almost any part of the continental United States from typical launch stations in the Barents Sea. (34,35) These missiles are believed to be aimed at "soft" targets, usually in or near American cities, whereas the more accurate silo-based missiles would attack U.S. military installations. (36) Although a number of targeting strategies are possible for any particular Delta-IV, it is plausible that two of its missiles are assigned to attack war-supporting targets in each of eight U.S. urban areas. If 4 of the 16 missiles failed to reach their destinations because of malfunctions before or after the launch, then 12 missiles carrying a total of 48 warheads would reach their targets. Click here for the remainder of the report. 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