Once again, the politically volatile Middle East and accompanying rhetoric has escalated the risk of a major nuclear exchange. Diplomatic efforts have failed to make the medical consequences of such an exchange a leading element in negotiations. The medical and academic communities share this denial. Without exaggeration, the harsh reality of the enormous consequences of an imminently conceivable nuclear war between Iran and Israel will encompass an unprecedented millions of dead and an unavoidable decline in public health and environmental devastation that would impact major populations in the Middle East for decades to come. Nuclear deterrence and the uncomfortable but real medical and public health consequences must become an integral part of a broader global health diplomacy that emphasizes health security along with poverty reduction and good governance.