Objectives: Advancements in North Korean nuclear weapons have heightened tensions and increased risk for nuclear war. U.S. public health agencies are investing resources in nuclear attack preparation. Analyses assess the impact and value of existing protective public health strategies for limited nuclear exchange.

Methods: Projections of fatality/injury from a North Korean nuclear strike within North Asia and explosive impact mapping are used to assess the potential impact of an attack on major U.S. urban centers.

Results: A nuclear strike on the 20 largest U.S. urban centers would place 38.1% of Americans at risk. With 1-3 missiles of 250 kiloton yield deployed to each, 9.7 million fatalities and 16.8 million injuries would result, impacting 8.2% of the population. Extrapolation of Seoul-Tokyo impact data, assuming public sheltering reduces mortality 50%, indicates 4.7-9.4 million Americans could be killed. Local medical-public health personnel/infrastructure to care for survivors would be destroyed.

Conclusions: Public health measures may not meaningfully decrease U.S. mortality/injury from a limited nuclear strike. Medical-public health leaders must ensure U.S. leaders comprehend the public health disaster resulting after even limited nuclear attack, and advocate against current shifts in U.S. nuclear policy toward first use and expanded nuclear scenarios with lower use thresholds.



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