Because of these memos, millions of people have been denied even rudimentary medical care. But the triage has also guaranteed that those who can be helped are given what they need.
During the flu, twenty percent of the population needed emergency help. This occurred against a background of chaotic supply problems, high doctor mortality in affected areas, and a tremen-
78 WARDAY
dous demand for drugs at a time when the industry was having trouble even maintaining normal production levels.
Perhaps one in ten of the flu victims saw a doctor, one in a hundred entered a hospital.
There is no way to tell if triage saves lives. Not only the triage, but so many other things that we now take for granted—home care for the dying, euthanasia, black market and alternate medicine, the British Relief—came about because the demand for care simply overwhelmed the nation's medical system.
The existence of the triage means different things to different people. For me it means the constant, niggling fear that my lifedose will creep up and I'll find myself suddenly denied medicine for some small ailment that will therefore become large and Anally kill. For Whitley, the triage means a shortened life. He cannot legally enter a hospital or consult a licensed physician.
Like so many triaged people, he has learned a great deal of medicine. Doctors who can't treat a triaged person can and do organize seminars for ten or twenty such individuals at a time. And then there are the underground medicals—the witches and the doctors who practice illegally.
And there is always the balance of hope.
These three short memoranda seem innocent enough. But they are not innocent. They are the foundations of postwar American medicine.
THE WEST 79
ATCEN/DC/35A.1038
VOICE TRANSMISSION FROM CENTERS FOR DISEASE CONTROL/ATLANTA TO ALL REGIONAL OFFICES [CONFIRMATION BY COURIER]
FOR IMMEDIATE DISTRIBUTION TO STATE/MUNICIPAL GOVERNMENTS
30 OCTOBER 1988
Recent Soviet bombing of U.S. cities of San Antonio, Washington, D.C., New York area, and Upper Central and Western states creates unprecedented numbers of dead and whole-body radiation-induced injuries.
Immediate burial and/or destruction of dead is imperative in order to contain spread of disease. Wherever possible, mass burial with suitable chemical agents is recommended. Civilian populations should be warned of disease potential.
Triage procedures must be implemented to assist individuals with radiation-related injuries. First-degree thermal radiation burns, i.e., ''flash burns,'' are likely to occur to exposed individuals within 3 0 miles of detonation point given estimated Soviet weapon yield of 9-10 Megatons. Second- and third-degree burns are likely in unprotected individuals in 15-25-mile range. Appropriate medical treatments should be as prescribed for injuries of this type.
Nuclear radiation injuries caused by gamma rays and neutrons are most serious, and high dosage can be life-terminating.
Populations in two-mile radii from detonation points might have received 1,000+ rems. Critical level is 400-500 rems where radiation symptoms are strongly evident and casualty rate is 50
percent or higher. Exposures below 2 0 0 are not believed life-threatening and little treatment is recommended. Death rate at 1000+ is almost 100 percent.
You are requested to provide every assistance possible to medical authorities to facilitate treatment of victims. Further triage instructions will follow.
William T. Adcock, M.D.
Director
ATCEN/DC
80
WARDAY
TO:
ALL MUNICIPAL GOVERNMENTS. SOUTHWEST AREA
FROM:
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES/CENTERS
FOR DISEASE CONTROL/EMERGENCY TASK FORCE ON RADIATION
INJURIES
DATE:
VOICE TRANSMISSION 15 JANUARY 1989
COURIER DELIVERY 16 JANUARY 1989
SUBJECT: EMERGENCY MEMORANDUM ON ACUTE WHOLE-BODY RADIATION
INJURIES
You are being provided herein with guidelines for the identification of suspected radiation dosages based on readily observable physical symptoms. These guidelines are intended for municipal and/or county representatives enlisted to screen civilian populations for subsequent medical treatment or attention. The severe drain on surviving medical facilities requires operating knowledge by all government personnel in order to d i -
rect individuals or groups to appropriate medical services.
Most urban centers sufficiently distant from radioactive or zoned areas have created several ''screening areas'' to process incoming refugees and native citizens: Level One areas are for those with no apparent radiation symptoms ; Level Two areas are for those with limited hematopoietic or gastrointestinal symptoms ; Level Three areas are for highly traumatized and atax-ic victims. Some version of this system is urgently recommended to all municipalities. Refugee movement rates are still inordinately high and unpredictable; virtually all communities in this region have reported high levels of influxing populations.
Similarly, these populations are demonstrating varying levels of whole-body radiation injuries. You have been notified previously of emergency steps necessary to screen physical objects and food supplies for potential radioactivity.
Because trained medical staff are limited and generally u n -
available outside of central medical facilities, it is imperative that municipal staff, including police, fire department, civil servants, and temporaries, be aware of radiation-related illnesses. Because of many factors, but particularly because of proximity to bombed area and total radiation exposure, individuals may or may not be viable candidates for medial treatment.
THE WEST 81
Large emergency treatment centers have been set up in key cities such as Lubbock, El Paso, Beaumont, Baton Rouge, Little Rock, Oklahoma City, New Orleans, and Albuquerque to treat individuals with medium to high levels of radiation dosages. Guidelines for treatment are under preparation and will be distributed to you as soon as available and approved by the Emergency War Recovery Administration.
Guidelines to be employed by municipal authorities in screening war victims are as follows:
LEVEL ONE SYMPTOMS: 0 to 100 REMS
No apparent symptoms in this range. Internal blood
changes will occur but are not apparent with superficial inspection. Care should be taken, however, to query all victims in order to determine point of origin, proximity to hit areas, and exposure to contaminated foodstuffs and objects from contaminated areas.
LEVEL TWO SYMPTOMS: 100 to 200 REMS
Short-term effects include fatigue and general malaise.
Gastrointestinal effects may include nausea and vomiting on the first day. A two-week ''latent period'' may ensue in which symptoms disappear but then reappear in milder form. Generally, the more severe the symptoms in the beginning, the slower the process of recovery. Individuals with these levels of radiation dosages are excellent candidates for recovery.
LEVEL THREE SYMPTOMS: 200 to 6 00 REMS
Individuals with dosages in this range can display symptoms ranging from mild to severe. Nausea, vomiting, diarrhea, lack of appetite, etc., are the most obvious
characteristics. The more severe the symptoms, the higher the radiation dosage absorbed may be assumed. Again, there may be a latent period of a week or perhaps only several days. Higher dosages produce skin hemorrhages, bleeding in the mouth and urine, and, with dosages above 200 rems, a loss of hair. A swelling of the throat is not uncommon. In the G00+ rem stage, high uncontrollable fe-
82 WARDAY
vers may be present, as well as emaciation. Death in these cases is probable in 80 to 100 percent of the cases; Judgments as to the extent of medical services to be provided are therefore advised.
LEVEL FOUR SYMPTOMS: 600 to 1000+ REMS
Gastrointestinal symptoms are the most obvious: extreme vomiting, diarrhea, nausea, prostration, ataxia (loss of m
otor control) , and difficulty in breathing. Individuals displaying these symptoms will almost certainly die within several days to two weeks. You are not likely to see individuals with such severe symptoms. All subjects arriving in a coma or comalike state should immediately be referred to medical authorities for handling.
Undoubtedly, these guidelines are not complete, nor are they intended to be inflexible. However, the immediate need to process large numbers of incoming civilians is crucial in order to assure adequate distribution of medical supplies and attention, food and clothing, shelter, and relocation services.
THE WEST 83
MESSAGE BY COURIER
SIGNED RECEIPT MANDATORY
TO ALL DIRECTORS, CIVILIAN AND MILITARY MEDICAL FACILITIES
IN THE CONTINENTAL UNITED STATES
FROM U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, CENTERS
FOR DISEASE CONTROL (CDCHDQ) ATLANTA
REGARDING IMPLEMENTATION OF WAR EMERGENCY ACT AND
EXECUTIVE ORDER 15
10 FEBRUARY 1989
Pursuant to the War Emergency Act (23 CFR 586, Sections 18-35) and Executive Order 15, you are hereby instructed to implement at once the emergency triage procedures necessary for the treatment of war victims. This action is taken in view of the catastrophic numbers of victims requiring medical attention and the overall burden on existing facilities. The unavailability of adequate numbers of trained personnel and supplies, presently and for the immediate future, poses a major health hazard. The unprecedented nature of the emergency facing this nation mandates the immediate implementation of selection procedures for treatment. Communities can expect severe resistance, but you are reminded that the first task facing this nation is that of survival; existing facilities, personnel, and supplies must be directed to those populations with the greatest probability of survival.
Therefore, as of 1200 hours, 10 February 1989, you are instructed to triage victims according to the following requirements :
1.0 GENERAL INJURIES (Non-radiation-induced) Mild to Severe: Injuries of this nature, such as
burns, fractures, contusions, etc.,
may be treated as conditions allow.
Severe to
Treatment should be limited to
Critical:
victims with greatest possibilities
of recovery. Medical supplies should
be limited accordingly.
84 WARDAY
Severely
No treatment desirable.
Critical:
2.0 RADIATION-INDUCED INJURIES
Treatment should be accorded on the basis of radiation d o s -
age absorbed. Whole-body measurements should be taken whenever possible: in cases where this cannot be done, interviews should attempt to ascertain proximity to radiation zones and duration of exposure. The following schedule should then be utilized:
0 to 100 REMS No treatment necessary.
100 to 200 REMS Treatment limited to radiation symptoms such as flash burns, nausea,
vomiting, etc. No other treatment
desirable.
200 to 450 REMS
Medical assistance most valuable
here. At upper levels (350+), chances of recovery with medical attention
are 50 percent.
450+ REMS
No treatment desirable.
It is not known at this time whether radiation injuries are more severe in cases where radiation is absorbed all at once or cumulatively.
Your government is aware of the implications of this order.
Steps are being taken by appropriate military authorities to provide assistance to you in implementation of triage instructions. You will be provided with further information as soon as it is available. You will be instructed as soon as possible regarding the cessation of triage requirements.
Signed: William T. Adcock, M . D .
Director
ATCEN/DC
Interview
Hector Espinoza, Aztlan Leader
[ E N T R Y I N T O AZTLAN: R U M O R T O R E A L I T Y . Officially, Aztlan starts in Monahans. The actual border, however, was not encountered until we reached the former town of Van Horn, now called Ciudad de Reforma.
The Texas & Western Bus Company stops on this side of the big white gate that has been erected across 1-20. When we arrived at the border, we found that we were expected. Governor Parker had sent a special message to the Foreign Minister of Aztlan, apparently right after our interview.
Despite the differences between Texas and the new country, this letter smoothed our passage and enabled us to gain access to the highest Aztlan authorities. Once in El Paso, Aztlan's capital, we found that the real power in the country is centered around the Foreign Minister, who has obtained recognition from most of Latin America, Spain, and a number of African countries. Even more important, he has obtained much friendly help from Japan.
There is no reason, really, to introduce Senior Espinoza. He speaks very well for himself.]
We in Aztlan have created a new nation, stretching from Texas to the California border. There is a constitution, and a national government, the only one presently active in the former United States.
86 WARDAY
Aztlan is recognized by many countries. We have here in El Paso ambassadors from Mexico, Brazil, Chile, Paraguay, Nicaragua, El Salvador, Guatemala, Cuba, and Japan. Many other nations are favorably inclined toward Aztlan. We have received an agricultural team from the People's Republic of China. Great Britain is providing medical help. Officially, Britain, France, and Germany have not recognized Aztlan. But we are confident that they will one day do so.
Aztlan is a Hispanic country. The official language is Spanish.
This must be understood. As U.S. citizens, you have the right to enter and leave without showing a passport, but you do not have the right to vote in our elections, or remain here more than thirty days without a visa.
We have an army of four divisions, nearly forty thousand men.
We have a national police force, which is why, when you crossed the border, there were suddenly no more bandits on the roads.
Also, the Japanese have sent road-repair teams to Aztlan, so we have no more potholes in our interstates. And Japanese medicine has kept our disease rate low. We have not been affected by fallout. In fact, we drew the border through Fort Stockton rather than including San Angelo and San Antonio, because of the destruction and the radiation.
You must understand that, as a new nation, Aztlan has had its share of growing pains. We have had to relocate many Anglos across the border in Texas, and there has been a certain very small amount of violence, inevitable when a new nation is formed.
Aztlan is a strong, civilized, and free country. We have no political prisoners in our prisons, and nobody has ever been tortured in Aztlan. We do have a policy of encouraging Hispanic and Indian settlement of the territory. We are very frank about that. For five generations this land belonged to the Anglos, and look at the result. For ten generations before that it was Hispanic land, and before that, Indian for twenty generations.
We practice the same sort of enlightened socialism that is found in progressive countries across the world. We follow the Chinese example to some extent, but we also guarantee personal freedom as the Swedes do. And we do not keep people in prison THE WEST 87
because of their political views. There are many cooperative concerns in Aztlan, farms and factories and power establishments.
When a farmer sells his holdings to the cooperative, he gets in return lifetime free medical care with no triage, an income based on his production capabilities, and the support that comes from being a part of our wonderful cooperative farm and ranch system.
The Japanese have provided us with millions of dollars' worth of advanced trickle-irrigation equipment, so we have been able to add many thousands of acres to the area cultivated in Aztlan. This acreage is planted with soybeans, which has become our largest export crop. We also sell oil and peanuts and
wheat and corn and, of course, beef. Aztlan is a prosperous country. There is no unemployment here. If you want to work, you can work. If you don't want to work, you can go to Texas or California.
Officially, both of those states are part of Aztlan. But we do not want the part of Texas we don't already have, and we would have to fight a war to get California. We are not yet prepared to do that.
If we were ever to gain California, Aztlan would become one of the most powerful countries in the world. Not a superpower—we don't want that. But a great power, perhaps as economically powerful as, say, Sweden.
Do you know that we gave foreign aid last year? Can you imagine it? We sent five hundred thousand bushels of soybeans and two hundred thousand of corn to Mexico. Of course, you know that they are all dying down there. Officially, the border between Aztlan and Mexico is open. And in the past three years, perhaps a million immigrants have come here. Now we have an agreement with Mexico. They get our food aid, and in return they process all potential emigrants to Aztlan. Since we cannot take the sick and they will not let the able-bodied leave, the immigration from Mexico is presently very small. If they wish to enter North America, the Mexicans must cross the Rio Grande into Texas, not Aztlan.
I am myself the Foreign Minister and official spokesman for Aztlan. We have a full portfolio of ministers. Our present capital is the Marriott here in El Paso. It has been renamed La Capitola, and contains our administrative apparatus. Our government is not or-
88 WARDAY
ganized around a president or prime minister. Instead, the two parties run against one another, and the party that gets a simple majority forms the governing committee for the next four years.
We have the State Socialists and the Social Democrats. The SD is part of the International Social Democratic Movement, and is the less radical of the two parties, as they believe that private ownership of national industries, such as power and transport, should be allowed. At the present time, my party, the State Socialists, is in power.
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