The detonation of an improvised nuclear device in a U.S. city would be among the most catastrophic events public health systems have ever faced — not only in the immediate aftermath, but across the decades of medical monitoring that survivors would require. Radiation exposure can trigger solid tumors, leukemias, and lasting mental health disorders years or even generations after an event. Yet as nuclear threats have grown more acute globally, no state public health agency or academic institution has attempted to operationalize a concrete plan for the long-term health surveillance program such a disaster would demand. A new study published in Disaster Medicine and Public Health Preparedness by researchers from Emory University’s Department of Emergency Medicine and the Radiation Emergency Assistance Center and Training Site (REAC/TS) at Oak Ridge Institute for Science and Education — aims to change that.
The study builds directly on a 2019 National Academies of Sciences, Engineering, and Medicine (NASEM) workshop report that outlined seven broad categories of concern for post-IND health monitoring, from stakeholder engagement and registry design to long-term communication and disease screening. That report provided a conceptual framework; the new study subjects it to expert scrutiny and generates an operationally grounded consensus on what matters most — and what will be hardest to accomplish.
High Stakes, High Difficulty: Where Consensus Holds and Where It Fractures
On the question of importance, the expert panel reached formal consensus on 59 of the 79 items, with median scores of six or seven out of seven — placing them in the “very important” to “extremely important” range. The remaining 20 items also received high median importance scores despite not meeting the IQR threshold for consensus, a pattern the authors attribute to disciplinary heterogeneity among panelists rather than disagreement about the items’ fundamental value.
Consensus on difficulty proved far more elusive: the panel reached agreement on only 13 of 79 items for this dimension. That disparity is itself informative. Items that did achieve difficulty consensus and carried high importance scores represent the clearest priorities for pre-event planning investment. Among the most challenging and highest-priority tasks: securing and defining resources for registry creation before a disaster occurs, ensuring adequate long-term financing for staffing and data analysis, and enacting enabling legislation that would allow a rapid-response registry to stand up quickly in the acute phase.
Beyond resource and legislative barriers, the panel flagged a cluster of items with high difficulty scores that reflect equity and operational complexity: identifying and reaching vulnerable, underserved, and non-English-speaking populations; tracing registry participants across state lines over time; countering disinformation; ensuring data governance and privacy protections over a decades-long program; and providing wraparound support for survivors who screen positive for disease. These items underscore that a technically sound registry design is necessary but not sufficient — social trust, sustained institutional commitment, and intergovernmental coordination are equally foundational.
Preparedness Implications
The authors explicitly note that federal, state, local, tribal, and territorial government agencies could use these results to guide preparedness planning now, before any nuclear emergency occurs. The consensus matrix the authors provide — mapping items by their combined importance and difficulty ratings — gives planners a practical triage tool for allocating limited preparedness resources. Items rated both highly important and highly difficult, such as pre-event resource securing and legislative authorization, are precisely the ones that cannot be improvised in an emergency and must be addressed in peacetime.
Sources and further reading:
Kazzi Z, Kiernan E, Goldstein L, Iddins C. Expert Consensus on the Elements Needed for the Design of a Long-Term Population Health Study After the Detonation of an Improvised Nuclear Device. Disaster Medicine and Public Health Preparedness. 10 June 2026