The Soviet Gulags

 

For millions of Soviet citizens, a Gulag sentence represented a one-way journey to oblivion. Yet millions more went there and came back. This revolving door of Stalin’s Gulag presents historians with a number of challenges. First, it complicates the task of determining exactly how many Soviet citizens experienced Stalin’s Gulag. Any single annual figure on the number of prisoners provides only a snapshot and fails to capture the presence of a revolving door (Alexopoulos, 2006). Gulags were aimed at the physical destruction of enemies of the Bolshevik state and system (Supady, 2000). One of the main goals of the Soviet leadership was to destroy personal ties among private citizens and create an atmosphere of distrust and fear. Ordinary citizens were bombarded by propaganda which provided a constant reminder that they were surrounded by enemies and that vigilance was needed by all. People were encouraged to denounce enemies whenever they felt there was a threat (Hosford et al., 2007). According to Applebaum (2004), nearly 30 million prisoners passed through the Soviet Union’s labor camps in their more than 60 years of operation. 

In his famous book “The Gulag Archipelago” Aleksandr Solzhenitsyn writes…

...........  “In keeping silent about evil, in burying it so deep within us that no sign of it appears on the surface, we are implanting it, and it will rise up a thousandfold in the future. When we neither punish nor reproach evildoers, we are not simply protecting their trivial old age, we are thereby ripping the foundations of justice from beneath new generations.”

 Tchernavin (1935) disclosed the horrifying nature of the Soviet Gulag system in the following manner.

...  ……Picture a group of about forty prisoners, men, and women, all worn out, hungry, eaten by lice, suffering from swollen legs from long-standing—people who have not slept for many nights. Single file we were led into a big room with three or four desks, and at each desk was an examining officer. Then comes another room and more examining officers, a corridor, stairs, and more rooms with more examining officers. At the command “at a run” we had to run from one desk to another. And as we approached each desk the examining officer would start shouting at us in the vilest language imaginable …This sort of torture lasts from ten to twelve hours. Examining officers go away and rest; they get tired of sitting and shouting obscenities and so are relieved by others, but the prisoners have to keep on running.

 Dougherty (2001) interviewed Seven Russians who survived Stalin’s purges. They did exhibit symptoms sufficient to qualify as partial PTSD and those exposed to human remains suffer more symptoms of PTSD.

( From the book " PTSD in the Soviet Union " by Dr Ruwan M Jayatunge) 

Case Management in Substance Use Disorders

 

Ruwan M Jayatunge M.D. 

Abstract: This article discusses case management in substance use disorders. Substance use disorders have devastating physical, mental, spiritual, and socio-economic consequences for users and their families.  It causes an enormous burden to the health care system. Individuals with Substance use disorders have multiple social, physical, and mental health treatment needs. To provide more effective treatment for substance use disorders, case management has been introduced. Numerous studies have shown that case management is effective in treating substance use disorders.

Key Words: Substance Use Disorders, Addictions, Case Management

Alcoholism, drug dependence, and addiction are known as substance use disorders (USDHHS, 2004). Substance abuse is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress (APA, 1994). Substance use disorders affect millions of individuals and the problems associated with these disorders are pervasive and destructive (Caravella, 2008). Substance use disorders are major contributors to morbidity and premature mortality.

Substance abuse is increasingly recognized as a chronic and relapsing disorder (McLellan, 2002) Compton and colleagues (2005) found poor social adjustment and psychosocial burdens connected with substance use disorders. Hesse and colleagues (2007) highlight that Substance use disorders are associated with a wide range of serious health, social, and economic complications. 

Substance use disorders are often presented with co-occurring disorders—the use of more than one substance and/or one or more psychiatric disorders simultaneously. A co-occurring disorder may also be a medical condition. Clients with SUDs may also display polysubstance patterns, in which they experience physical or psychological effects from more than one substance. (NASW, 2013).

Individuals with substance use disorders have complex, multiple problems, and disabilities. Surveys indicate that substance abuse and other mental illnesses are often comorbid. Depression, Bipolar Affective Disorder, PTSD, Schizophrenia Personality Disorders, etc are comorbid with substance use disorders.  Comorbidity is often associated with a more severe illness course.

There is a high level of comorbidity of PTSD and substance use disorders (Saladin et al. 1995). The comorbidity of PTSD with substance use disorders is complex because while a substance use disorder may often develop as an attempt to self-medicate the painful symptoms of PTSD, withdrawal states exaggerate these symptoms (Brady et al. 2000).

Comorbidity of substance use disorders with mood and anxiety disorders has been found in many studies. Mirin, Weiss & Michael (1988) hypothesized that up to 70 percent of individuals treated for substance abuse have a lifetime history of depression.   

Substance use could trigger psychotic symptoms in vulnerable individuals (Green, 2006). Co-occurring substance use disorders including alcohol are common in schizophrenia and are associated with poor outcomes (Mesholam-Gately et al. 2014).

People with substance use disorders are heterogeneous, with wide variations across groups in terms of substances used, comorbid disorders, and their strengths and resources (McGovern  & Carroll, 2003). The multiplicity of social, familial, and economic problems associated with substance use disorders make the treatment process challenging and sometimes prolongs the recovery. In substance use disorders multiple needs of the individual should be considered and a multimodal approach is recommended. The goals of treatment include the achievement of abstinence or reduction in the use and effects of substances, reduction in the frequency and severity of relapse to substance use, and improvement in psychological and social functioning (APA, 2006).

 

Providing Case Management   Services in Substance Use Disorders

Addiction is a chronic disease for which multiple episodes of treatment, remission, relapse, and retreatment frequently occur before achieving stable recovery (Tai &Volkow, 2013).  People with substance use disorders have a wide variety of needs across the range of symptom severity (Reif et al. 2014). Substance abuse can have a devastating effect on the social support networks of individuals (Sarrazin & Hall, 2004). They need effective and uninterrupted support to combat their addictions. In substance use disorders multiple aspects of a patient’s care ought to be addressed. To coordinate the treatment and support services case management has been recommended in numerous therapeutic modalities. 

Since the 1970s, case management has been introduced in various countries to improve the accessibility, accountability, coordination, and continuity of services provided to diverse at-risk populations with multi-faceted problems, such as persons with mental illness, the elderly, homeless persons, and multi-problem families (Hall et al., 2002; Holloway & Carson, 2001; Moxley, 1989; Sargent et al., 2007; Kolind et al., 2009). Case management has a long and relatively successful history for the treatment and support of several mental health populations in the United States, Australia, Canada, and several European countries  (Burns, Fioritti, Holloway, Malm, & Rössler, 2001; Hesse et al, 2007).

Case management is regarded as one of the most important innovations in mental health and community care of the past decades (Holloway et al., 2001; Vanderplasschen et al., 2004). Case management has been widely used as an intervention in the treatment of substance abuse problems (Rapp et al., 2014).

In general terms, Case Management is defined as a multi-step process that ensures coordination of medical and specialty care and access to a range of appropriate medical, psychosocial, and social services for the client and family and which promotes and supports the independent functioning of the client and family. A case manager is the person who takes responsibility for coordinating various forms of support to achieve the objectives of the case plan. They have a strong relationship with the client and are the key liaison between all services involved.

According to the Ontario Addiction Services Advisory Council (2000), Case Management services are defined as a process that includes the designation of a primary worker whose responsibilities include the ongoing assessment of the client and his/her problems, ongoing adjustment of the treatment plan, linking to and coordination of required services, monitoring and support, developing and implementing the discharge plan, and advocating for the client. Case management services are offered regardless of where the individual is in the system.

The National Case Management Standards Network of Canada (2009) defines case management as a collaborative, client-driven process for the provision of quality health and support services through the effective and efficient use of resources. Case management supports the clients’ achievement of safe, realistic, and reasonable goals within a complex health, social, and fiscal environment.

Case management is flexible and consists of a broad range of activities.  Case management is a client-centered strategy to improve coordination and continuity of care, especially for persons who have multiple needs (Moxley, 1989).  Hall et al (2002) describe case management as a coordinated and integrated approach to service delivery, intended to provide ongoing supportive care and to help people access the resources they need for living and functioning in the community. The core functions of case management—assessment, linking, monitoring, and advocacy—remain constant across almost all applications of case management (Rapp et al. 2008). Case management is also viewed as a tool or service to help clients maintain their autonomy while achieving positive health outcomes (MacNeil Vroomen et al., 2012).

According to Annicka and colleagues (2012), case management is a heterogeneous concept of care that consists of assessment, planning, implementing, coordinating, monitoring, and evaluating the options and services required to meet the client's health and service needs.  Case management was developed to address fragmentation in service delivery and is rooted in the social casework tradition (Weiss, 1998; Lillquist, 2008).  Case management is pragmatic as well as culturally sensitive. CM servicers help to recover from a substance abuse problem more effectively.

According to Vanderplasschen et al. (2004), four models of case management are usually distinguished for working with substance abusers: the brokerage/generalist model, assertive community treatment / intensive case management, the clinical / rehabilitation model, and strengths-based case management. Case management could reduce attrition from treatment and improve both psychosocial and drug and alcohol outcomes among persons with substance use disorders (Lightfoot et al. 1982; Vanderplasschen et al, 2004). The main objective of case management is to keep the individual with substance use disorder engaged in treatment, preventing relapses and helping the client to move towards recovery.

The Efficacy of Case Management Services

Case management in mental health services has been a positive initiative (Ziguras & Stuart, 2000). As indicated by Zwarenstein and colleagues (2005) in case management, an individual or a small team is responsible for navigating the patient through a complex process in the most efficient, effective, and acceptable way. Case management has been suggested as an innovative strategy that facilitates the improvement of a patient's quality of life, the reduction of hospital length of stay, the optimization of self-care, and improvement in the satisfaction of the patient and the professionals involved (Lee et al., 1998).

Willenbring and colleagues (1991) demonstrated the effectiveness of case management as it helped keep public inebriates engaged in treatment, stabilize their situation, improve access to service providers, reduce clinical deterioration, and provide continuity of care.  Rapp and colleagues (2008) state that the effectiveness of case management is largely based on improving linkage with treatment. Vanderplasschen et al (2007) are of the view that strengths-based and generalist case management have proven to be relatively effective for substance abusers in general. Intensive case management is associated with reduced healthcare costs and increased client satisfaction with services received (Vanderplasschen et al., 2007).  Fukui et al (2012) report positive outcomes with strengths-based case management – especially for people with psychiatric disabilities and in the areas of hospitalization, housing, employment, symptoms, leisure time, social support, and family burden.

Through case management clients with complex, multiple problems, and disabilities receive all the services they need in a timely, effective, and appropriate fashion (Rubin   1992;   Caravella, 2008). Evidence suggests that case management has been a powerful intervention to assist people with psychosocial problems (Cowger, 1994). Although case management may seem a radical intervention relative to clients’ situations, appreciation by clients is consistently high (Vanderplasschen, 2006).

 

Conclusion

A significant burden of disease has been reported in substance use disorders. Individuals with substance use disorders have complex, multiple problems, and disabilities and a wide variety of needs across the range of symptom severity. They need effective and uninterrupted support to combat their addictions. To provide optimal support and care case management services have been recommended. Case management is a pragmatic intervention that helps in treatment, stabilizes the situation, improves access to service providers, reduces clinical deterioration, and provides continuity of care.  Case management promotes recovery and enables the substance abuse client to fully integrate into society as a healthy, substance-free individual. 

 

 

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. Washington, DC: American Psychiatric Association, 1994.

American Psychiatric Association. Practice guideline for the treatment of patients with substance use disorders, 2nd edition. In American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2006. Arlington, VA: American Psychiatric Association, 2006 (pp. 291–563).

Annicka, G. M., van der Plas Bregje, D., Onwuteaka-Philipsen, Marlies van de Watering, Wim, J. J. Jansen, Kris C Vissers, Luc Deliens. (2012). BMC Health Serv Res.  ; 12: 163. Published online 2012 June 18. doi: 10.1186/1472-6963-12-163.

Brady, K.T., Killeen, T.K., Brewerton, T., Lucerini, S. (2000).Comorbidity of psychiatric disorders and posttraumatic stress disorder.J Clin Psychiatry;61 Suppl 7:22-32.

Burns, T., Fioritti, A., Holloway, F., Malm, U., & Rössler, W. (2001). Case management and  assertive community treatment in europe. Psychiatric Services, 52(5), 631-636.

Caravella, K. (2008). The use of intervention and case management models in maximizing recovery and reducing relapse risks in substance abuser. Policy and Practice, 2(2), 1-7.

Compton, M.T., Weiss, P.S., West, J.C., Kaslow, N.J.,(2005).The associations between substance use disorders, schizophrenia-spectrum disorders, and Axis IV psychosocial problems.Soc Psychiatry Psychiatr Epidemiol. 40(12):939-46.  

Cowger, C.D. (1994).Assessing client strengths: Clinical assessment for client empowerment. SocWork .40:755-82. 

Fukui, S., Goscha, R., Rapp, C.A., Mabry,A., Liddy, P., Marty, D.(2012). Strengths model case management fidelity scores  and client outcomes. Psychiatric Services.63 (7):708-10. 

Green, A.I.J.(2006). Clin Psychiatry.67 Suppl 7:31-5; quiz 36-7.Treatment of schizophrenia and comorbid substance abuse: pharmacologic approaches.

Hall, J.A., Carswell, C., Walsh, E., Huber, D.L, Jampoler, J.S.(2002). Soc Work. 47(2):132-41.

Hesse, M., Vanderplasschen, W., Rapp, R., Broekaert, E., Fridell, M.(2007). Case management for persons with substance use disorders. In: The Cochrane Collaboration. Cochrane database of systematic reviews. Wiley.

Holloway, F., Carson, J.(2001). Case management: an update. International Journal of Social Psychiatry. 47(3):21–31. 

Kolind, T., Vanderplasschen, W. and De Maeyer, J. (2009) Dilemmas when working with substance abusers with multiple and complex problems: The case manager’s perspective. International Journal of Social Welfare 18 (3): 270–280.       

Lee, D.T.F., Mackenzie, A.E., Dudley-Brown, S, Chin, T.M.(1998). Case management: a review of the definitions and practices. J Adv Nurs.27:933–939. doi: 10.1046/j.1365-2648.1998.t01-1-00566.x

Lightfoot, L., Rosenbaum, P., Ogurzsoff, S, et al.(1982). Final Report of the Kingston Treatment Programmed Development Research Project. Department of Health and Welfare, Health Promotion Directorate; Ottawa, Ontario, Canada.

Lillquist, P.P. (2008). Implementing case management in New York State’s partnerships for publicly funded breast cancer screening. Preventing Chronic Disease, 5(2), A45.

McGovern, M. P., & Carroll, K. M. (2003). Evidence-based practices for substance use disorders. Psychiatric Clinics of North America, 26, 991–1010.

McLellan, A. T. (2002). Have we evaluated addiction treatment correctly? Implications from a chronic care perspective. Addiction, 97(3), 249-252.

MacNeil Vroomen J., Van Mierlo LD,  van de Ven PM, Bosmans JE, van den Dungen P., Meiland FJ et al.  Comparing Dutch case management care models for people with dementia and their caregivers: The design of the COMPAS study. BMC  Health Services Research  2012;12:132.

 

Mesholam-Gately, R., Gibson, L.E., Seidman, L.J., Green, A.I. (2014).Schizophr Res.Schizophrenia and co-occurring substance use disorder: reward, olfaction and clozapine. (1-3):45-51. doi: 10.1016/j.schres.2014.03.002.

Mirin, S.M.; Weiss, R.D., Michael, J.(1988). Psychopathology in substance abusers: Diagnosis and treatment.American Journal of Drug and Alcohol Abuse.  14(2):139–157.

Moxley, D. (1989).The Practice of Case Management: Sage Human Services Guides.Vol. 58. Sage; Newbury Park, Calif.

NASW ( 2013). Clients with Substance Use Disorders. Retrieved  From https://www.socialworkers.org/practice/standards/NASWATODStatndards.pdf

Ontario Addiction Services Advisory Council. (2000). Admission and Discharge Criteria for Ontario’s Substance Abuse Services. Toronto: Ontario Substance Abuse Bureau, Ministry of Health and Long-Term Care.

Rapp, R.C., Otto, A.L., Lane, D.T., Redko, C., McGatha, S., Carlson, R.G.(2008).Improving linkage with substance abuse treatment using brief case management and motivational interviewing.Drug Alcohol Depend. 94(1-3):172-82. doi: 10.1016/j.drugalcdep.2007.11.012.

Rapp, R.C., Van Den Noortgate, W., Broekaert, E., Vanderplasschen, W.(2014). The efficacy of case management with persons who have substance abuse problems: A three-level meta-analysis of outcomes.J Consult Clin Psychol. 

Reif S, George P, Braude L, Dougherty RH, Daniels AS, Ghose SS, Delphin-Rittmon ME. (2014) Residential Treatment for Individuals With Substance Use Disorders: Assessing the Evidence. Psychiatric Services, 65(3):301 doi:10.1176/appi.ps.201300242.

Rubin, A.(1992). Is case management effective for people with serious mental illness? A research review. Health &Social Work.17(2): 138-150.

Saladin, M.E., Brady, K.T., Dansky, B.S., Kilpatrick, D.G. (1995).Addict Behav. Understanding comorbidity between PTSD and substance use disorders: two preliminary investigations. 20(5):643-55.

Sarrazin, M.V., Hall, J.A.(2004).Impact of Iowa case management on provisions of social support for substance abuse clients. Care Manag J. 5(1):3-11.

Tai B., Volkow, N.D.(2013). Treatment for substance use disorder: opportunities and challenges under the Affordable Care Act. Soc Work Public Health.28:165–174.

Vanderplasschen, W., Rapp, R. C., Wolf, J. & Broekaert, E. (2004) ‘Comparative review of the development and implementation of case management for substance use disorders in North America and Europe’, Psychiatric Services, vol. 55, no. 8, pp. 913-922.

Vanderplasschen, W., Rapp, R., et al.  (2004).  The development and implementation of case management for substance abuse disorders in North America and Europe.  Psychiatric Services, 55, 913-922.

Vanderplasschen, W. (2006). Implementation and evaluation of case management for substance abusers with complex and multiple problems.European Journal of Social Work 9:259-61.

Vanderplasschen, W., Wolf, J., Rapp, R.C. & Broekaert, E. (2007). Effectiveness of different models of case management for substance-abusing populations. Journal of Psychoactive Drugs, 39(1), 81-93.

What is Substance Abuse  Treatment? (2004). U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment. Retrieved from http://store.samhsa.gov/shin/content/SMA08-4126/SMA08-4126.pdf 

Weiss M. (1998).Case management as a tool for clinical integration. Adv Pract Nurs Q. 4(1):9–15.

Willenbring, M.L., Ridgely, M.S, Stinchfield, R., Rose, R.(1991). Application of Case Management in Alcohol and Drug Dependence: Matching Techniques and Populations. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

Ziguras, S. & Stuart, G. W. (2000) A meta-analysis of the effectiveness of mental health case management over 20 years. Psychiatric Services, 51,1410 -1421.

Zwarenstein, M., Stephenson, B., Johnston, L..(2005). Case management: effects on professional practice and health care outcomes. (Protocol)The Cochrane Database of Systematic Reviews.  

 

Rafah Crossing

 

We just realize that life has no value

Perhaps life  has no meaning either 

We see only the sand and blazing sky

No hope and no tomorrow for us 

Death  in abundance 

Death is inevitable 

Dead bodies on roads

Dead Bodies in gutters  

Children cry for their parents 

Mothers cry for their dead babies 

I see humans but no humanity 

Death and destruction everywhere 

Incoming rockets and death from above   

Obliterating everything around us 

Who are we and what are we? 

We are humanoids or human waste

Caught between two aggressive powers 

Nobody gives adamn

As we witnessed 

Truth and innocence 

Became the first casualties of this conflict 

There is no escape for us 

If you are lucky 

If you a chosen one 

You go through Rafah crossing 

The rest of us 

painfully waiting for our destiny 

Ruwan M Jayatunge 

Tattoos -a window to the psyche?

Ruwan M Jayatunge M.D. PhD ( in progress) 

The word “tattoo” derives from a Polynesian word. Tattooing is an ancient, ritualized practice and a decorative form of body modification.  Tattoos are defined as the introduction of exogenous pigments into the dermis in order to produce a permanent design (Islam et al.,2016).

Tattoos are a form of self-expression. Mostly tattoos are applied for the sake of fashion. tattooed people consider themselves more adventurous, creative, artistic, and individualistic. Sometimes tattooing indicates sexual identity, masculinity, and sexual orientation.  Tattooing represents a bodily expression of uniqueness. In Sri Lanka there is an upward trend in the practice of tattooing. Tattooing has become popular among the X and Millennial Generations.

In the early 60s and 70s tattoos represented a cultural taboo in Sri Lanka. The most tattooed people were criminal elements.  During that era, tattooed people were considered as gangsters and social outcasts.   Many incarcerated criminals, gang members, and counter-cultural groups (unorthodox artists) had skin tattoos. With tattoos on their body, they looked more aggressive and rebellious.  For long years tattoos carried negative associations.  However, this trend changed significantly after 2000. Although stigma associated with tattoos appears to still exist tattoos have evolved into a mainstream phenomenon.  

Tattoos are symbolic marks.  What are the psychological and psychiatric aspects of tattoos? Can tattoos provide a valuable window into the psyche? Demographic and behavioral correlates of getting tattooed indicate psychosocial health. Some experts speculate that tattoos appear to be a marker of risk-taking behavior in adults.

According to the psychoanalytic perspective, tattoos have implicit meanings and suggest that tattoos may also serve a defensive function when associated with themes of destruction. Tattoos have psychological meaning and symbolism. For Psychoanalysts skin represents the fragile border of the self. Sigmund Freud in his Totem and Taboo (1913) narrates how tattoos were used as totem clans in the ancient tribes.  Tattoos have metaphorical symbolism. As Freud commented people carve the image of a totem animal into themselves by tattoos. The totem animal must not be killed or consumed, and this taboo forms the core of totemism. Lacan underlines the drive of erotogenic masochism in tattooing. 

Pozgain and collogues (2004) examined the association between the tattoo(s) and human personality traits and concluded that tattooed subjects have less social conformity. Mortensen and team (2019) suggest that individuals with tattoos are more likely to engage in risky behaviors relative to their non-tattooed counterparts. Raspa and Cusack (1990) highlight those psychiatric disorders, such as antisocial personality disorder, drug or alcohol abuse, and borderline personality disorder, are frequently associated with tattoos. However, Roggenkamp et al., (2017) elucidate that tattoos should be viewed not as signs of pathology, but as opportunities to explore core aspects of self-identity. Pajor and the team (2015) emphasize that tattoos and piercings should not be considered indicators of psychopathology.

References 

Islam PS, Chang C, Selmi C, Generali E, Huntley A, Teuber SS, Gershwin ME. Medical Complications of Tattoos: A Comprehensive Review. Clin Rev Allergy Immunol. 2016 Apr;50(2):273-86. doi: 10.1007/s12016-016-8532-0. PMID: 26940693.

Mortensen K, French MT, Timming AR. Are tattoos associated with negative health-related outcomes and risky behaviors? Int J Dermatol. 2019 Jul;58(7):816-824. doi: 10.1111/ijd.14372. Epub 2019 Jan 24. PMID: 30677140.

Pajor AJ, Broniarczyk-Dyła G, Świtalska J. Satisfaction with life, self-esteem and evaluation of mental health in people with tattoos or piercings. Psychiatr Pol. 2015 May-Jun;49(3):559-73. English, Polish. doi: 10.12740/PP/27266. PMID: 26276922.

Pozgain I, Barkic J, Filakovic P et al. Tattoo and personality traits in Croatian veterans. Yonsei Med J 2004; 45: 300 – 5.

Raspa RF, Cusack J. Psychiatric implications of tattoos. Am Fam Physician. 1990 May;41(5):1481-6. PMID: 2333825.

Roggenkamp H, Nicholls A, Pierre JM. Tattoos as a window to the psyche: How talking about skin art can inform psychiatric practice. World J Psychiatry. 2017 Sep 22;7(3):148-158. doi: 10.5498/wjp.v7.i3.148. PMID: 29043152; PMCID: PMC5632599.

The Nightmare of Robert Oppenheimer

 

 

I saw the skies lightning up

Red and green colors with enormous heat 

The giant mushroom with radiation 

Smoke from nuclear fires rises above 

Incinerating the living 

Thermal radiation everywhere 

Creating a hell on earth 

That signified mass destruction

It is   Armageddon - the end of days

Our destiny is marked by nuclear fusion

The survivors will live with radioactive fallout

He said;  I am become death, the destroyer of worlds

Nothing will remain at the end 

That is the  Nightmare of Robert Oppenheimer

Ruwan M Jayatunge