Thursday, March 3, 2011

If war is too important to be left to generals, then medicine is too important to be left to politicians. The US Marines and Afghanistan; DARPA and Serious Medicine: Are we fully mobilizing our national potential for Serious MILITARY Medicine?

Are we utilizing technology to the fullest extent possible to protect our service personnel in combat zones?  And to minimize fatalities and help the wounded to completely recover?  And by that I don't mean "fully recover as much possible within the constraints of current medical technology." Instead, we mean, "fully recover given the maximum mobilization of medical potential."  There's a huge difference between the present-day actual and the future-possible.   

And, as we shall see, the same idea--apply as much technology as possible--is as applicable to Serious Medicine as it is to the US military.  Indeed, counterintuitive as might seem to some, there's a robust common link between military technology and medicine.  In the end, what matters in both "miltech" and medicine is the application of science and technology.   And while war and medicine have much different purposes, in their technological dimension they share a common ancestor: The Industrial Revolution.    That is, the power to produce not just one, but millions.    Just as we can and should mass produce the tools we need for national security, so, too, should we mass produce the tools we need for medical security.  If we do mass produce them, they will be not only more abundant, but also better and cheaper.  
Unfortunately, we have fallen out of the habit of thinking that way, and that’s bad for both the military and for medicine. 

We can start by focusing on medicine.   Specifically, we illustrate the difference between the medical actual and the medical possible by considering a news article that appeared in the front page of The Washington Post this morning.  In a well-reported and also deeply moving story, reporter Greg Jaffe chronicles Marine Lieutenant General John F. Kelly, who lost his son, Marine Second Lieutenant Robert Kelly, in Afghanistan last November.   That's Gen. Kelly pictured above, awarding a Purple Heart to a comrade of his late son, Lance Corporal Sebastian Gallegos.  

After paying due respect to 2Lt. Kelly and LCpl. Gallegos--and all the other heroes who have sacrificed so much--we might next consider whether we are doing all we can to keep safe our armed services and their personnel as we put them in harm’s way.  

Here we should note that the US military has already made enormous progress in military medicine.   Back in January, The New York Times reported that the survival rate for American service personnel taken to hospitals in Afghanistan has improved dramatically, just in the past five years.  In 2005, according to the Times, 19.8 percent of those evacuated to military hospitals died.   By 2010, that death rate was down to 7.9 percent.  

To put it another way, that's a 60 percent decline in fatality in just five years.  It would be easy to go back further, to earlier wars, to the point where the death rate was half or more--and of course, it wasn't that long ago, that military hospitals were little more than amputation mills, or didn't exist at all.

Meanwhile, there's the additional issue of restorative and regenerative medicine.  Physical therapy is much improved; war has often been a catalyst for such advances, which then spin off. It’s worth remembering that plastic surgery emerged during World War One, as doctors started trying to give wounded troops at least the beginnings of a renewed post-war life.   And World War Two saw the mass production of penicillin, opening the door to a cornucopia of antibiotics.  

It’s heartening to see some f what the most forward-looking unit with the Defense Department is thinking up in terms of medicine;  Wired magazine recently cited some what the Defense Advanced Research Projects Agency has been working on.    It's quite a list, according to Wired's Madhumita Venkataramanan, including programs for battlefield diagnostics, improved tissue engineering and regeneration, and even improved eyes for soldiers.

We need all of this--and much more.  Whatever our opinion as to the wisdom of the Afghan war, we will always, of course, support the troops.  They are, in the most literal sense, our brothers and sisters, and they are doing what we, through our elected government, have asked them to do.  But our support should consist of more than admiration and compassion--and maybe chipping in to a USO fundraiser.  As a nation, our collective support should be not only the best available wisdom about true national security for America, but also the best available wisdom about military technology and military medicine.  If we do that, as we have seen, not only will we be doing right by our men and women, but we will also find the benefits feeding back to our own society.   

And yet at the same time, it would be nice to think that we are prosecuting our wars in the most cost-effective way possible.   Let’s take a look at this passage from Jaffe's article, describing the paternal concern of the elder Kelly, the general, in regard to his son, the lieutenant: 

Kelly knew that Robert went out on almost every patrol with his men through mine-filled fields. One of the Marines at Bethesda told him that Robert was "living on luck." [emphasis added] 

Now we might just step back and ask ourselves: Isn't it, er, interesting that the US military is still fighting in Afghanistan by sending Americans on patrol through fields of landmines?    Yes, boots on the ground are a good idea, but boots on landmines are a bad idea.   I understand the idea of counter-insurgency, or COIN, but surely we understand that we can't win hearts and minds by marching our people around so they get blown up.  Aside from the obvious humanitarian considerations, the Afghan hearts and minds we are trying to win are not impressed with us and our ways if we can't outsmart the handmade bombs that the Taliban are planting.  Meanwhile, US casualties drain away support for a war on our homefront.
As Clausewitz, patron saint of all military intellectuals, reminds us, wars occur within a political context.  That is, public opinion in both Afghanistan and America will be just as decisive as any military battle.   So COIN, without the proper strategic thinking--about not only military buildup and preparation, but also the politics of the countries involved--is unlikely to prove effective over the long run.   

Yes, of course, some might say, planning is nice.  But sometimes nations must react, and quickly.  

Perhaps we had no choice, therefore, in the War on Terror.   After all, as former Defense Secretary Donald Rumsfeld once put it, “You go to war with the Army you have. They're not the Army you might want or wish to have at a later time.”  So sure, we had to go to Afghanistan with what  we had.  But wait: Rumsfeld made that "you go to war" comment on December 8, 2004That is, he was making excuses for a lack of preparation more than three years after US forces first arrived in Afghanistan.  In other words, by the time Rumsfeld said those words, he had had plenty of time to think about what equipment our warriors needed and to ask for whatever resources he felt were necessary.  But perhaps, as I wrote at the time, Rumsfeld was too busy writing CYA memos to think cogently about the battlefield situation. 

So there should be a better way.  But what better way?  The answer is as old as the industrial revolution: Replace "labor"--that is, the lives and limbs of our young people--with capital, and the technology that capital + ingenuity can create.   

We've done it before.  Within four years of Pearl Harbor, the US government had totally transformed its warfighting.  A war that began with infantry and battleships ended--successfully, of course--with dozens of new aircraft carriers, effective radar, B-29s and, of course, A-bombs.  Yes, there were some fiascoes of inadequate technology during the course of that march to victory, but our ultimate victory speaks for itself.   

Indeed, we won WW2 suffering a tenth of the KIAs that the enemies that we defeated suffered fighting against us.  In a nutshell, that's the way to win a war.  As Gen. George Patton said, you don't win a war by dying for your country, you win a war by making the other s.o.b. die for his country.   Admittedly, we were spent close to 40 percent of our GDP on the military, but it was worth it.   America’s fighting men and women were worth it.   And if the Global War on Terror is worth it, then we should be willing to spend what it takes to fight it effectively. 

Instead, we tried to fight in Afghanistan and Iraq  on the cheap, at least financially.   That is, we scrimped on the sort of military R&D that could have saved lives--that’s why our men and women are still working their way through minefields. 

Perhaps politicians figured that it was too risky, politically, to ask for the resources needed to rapidly develop effective countermeasures to the insurgents, or perhaps the pols were too busy with other priorities.  

But we do know this: The result, on the ground, has been an inadequate hodgepodge of technological improvisations. As one Marine combat veteran of Iraq in 2004-5 recalled of the on-the-ground miltech that he saw in Al-Anbar province: 

Nothing more frustrating than sitting in the opened air rear of a Humvee without up-armor while watching anti-IED [improvised explosive devices, aka land mines] engineers roll along in a "Star Wars"-looking machine. The USMC has never had the funding to do much more than the basics and when we have been given $'s we have usually botched it.

In other words, more than a year after the US invasion of Iraq, Leathernecks were still riding around in the “opened air”--that is, our troops were fully exposed to enemy fire--Humvees.  Disgraceful.   And yet as we know, through grit and determination, the Marines made a magnificent accounting of themselves in Iraq, anyway. 

After nine years, we should be doing better than marching young men and young women through mine-laden fields in Afghanistan.  Our fighting forces shouldn’t have to be “living on luck.”  If we had really wanted to, this past decade.  we could have figured out something completely different--something as radically innovative as that which emerges from Silicon Valley every few months.  I have no doubt that  DARPA has plenty of ideas for Iraq and Afghanistan--after all, DARPA's predecessor agency created the Internet.   Indeed, we recently learned that DARPA is experimenting with a “cheetah-bot” that would bound across the landscape like a fast cat.

If DARPA can do that in the future, it could have done it in the past, with enough resources.  Maybe, for example, DARPA could have made a "daddy long legs"-ish vehicle for COIN, so that human feet never touch the ground on patrol.  Or maybe some sort of hovercraft.  Or perhaps something altogether different.  At minimum, the Pentagon, properly resourced, should have been able to figure out how to disable every mechanical device in a given area--that is, landmine clearance on a vast scale.    

Speculative thinking?  Sure.  But that's how we win wars.  And as the French statesman Georges Clemenceau declared, "War is too important to be left to generals." 

Indeed, history shows us that generals are instinctively suspicious,  even mistrustful, of technology.   That's why, for example, Billy Mitchell--one of the most brilliant American officers ever, the visionary of American airpower--ended up being courtmartialed.  (Fortunately, President Franklin D. Roosevelt posthumously vindicated Mitchell.)

This is not the place to delve too far into military psychology, but suffice it to say that the record shows, over and over, that top brass have rejected new ideas more often than not.  The airplane was viewed with suspicion, as we have seen.  And so to another military innovation, the  tank--it took an outsider, Winston Churchill, to push armor on the British Army, which seemed perfectly satisfied with trench warfare. The trench warfare, of course, in which, as Churchill said, men fight machine guns with their chests.  

History will eventually show what DOD knew and didn’t know, and what it asked for and didn’t ask for.  But if generals weren’t getting what they thought they needed, they should have protested--or resigned.  A prominent resignation or two would have gotten America’s attention.

And all the same arguments apply to military medicine--and to Serious Medicine.  If war is too important to be left to generals, then medicine is too important to be left to politicians.  

We need everything DARPA is doing now, and 10 times more.   Our troops are worth it.  So we need someone in the military, or in the civilian leadership at DOD, or in the government somewhere to say that we will set as a goal repairing spinal cords, so that those wounded in war will regain their motor power.  And if we achieve that breakthrough, it will be a breakthrough for all of us.   And so that's where the medical discussion ought to lead--toward all of us getting the benefit of DARPA-like leadership, whether we are in the military or not.

One last point: I think that a similar deep problem runs through both our medical thinking and our military thinking.   And that is, a certain de-materialization of our approach to the world.  Instead of medicines and drugs, and nuts and bolts, we seem to think in terms of bailouts and finance and ideology.  We--or at least our leaders--think not in tangible realities, but intangibles of rhetoric and spin.   And yet it is real thing--real machines--fight wars.  And then it is other machines, and the products of machines, that save lives.  

UPDATE:  Another Washington Post reporter, David Brown, chronicles the rise of double-amputee and groin injuries among US personnel in Afghanistan.    As Brown notes, the number of amputations and genitourinary (GU) wounds is up sharply:

In 2009, 75 soldiers underwent amputation and 21 lost more than one limb. In 2010, 171 soldiers had amputations and 65 lost more than one limb. GU injuries increased from 52 to 142 over the same period.

Of the 142 soldiers with genitourinary wounds who arrived at Landstuhl last year, 40 percent — 58 men in all — suffered injury to the testicles. Body armor, which has greatly reduced fatalities, usually includes a triangular flap that protects the groin from projectiles coming from the front. It doesn't protect the area between the legs from direct upward blast. Various laboratories are reportedly working on forms of shielding that would provide such protection. Medical staff at Landstuhl also noticed a rise in severe genital injuries last fall.


  1. Some of the abilities that the military exhibits in technology and medicine has to do with the way the military does things. It's smooth, exempt from the same bureaucracy that taints the private sector and expediency.Up against medicine around the corner, the military is more logical,analytical and consequently things get done and by design with accuracy.Maybe 2012 will have a general in the running.

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  4. This is not too far away to study military psychology, but I just want to say records show that over and over again, executives rejected the new ideas more often than not. Aircraft is considered suspicious, as we have seen.