War! What is it good for?
War! What is it good for? In this episode of Discovery Matters, Dr Smith explains how military medicine first shaped state medicine and how wartime creates an opportunity to innovate. From advances in prosthetics, psychology, and cosmetic surgery to the mass production of penicillin during World War II, this episode dives deep into the life-saving innovations brought over the line due to conflicts.
Show notes
Protecting maternal health in Rwanda | MIT News | Massachusetts Institute of Technology
CONOR: Dodi, if I asked you war: what is it good for? What comes to mind?
DODI: Only that song and I would try to sing back to you 'absolutely nothing!', which is how Edwin Starr's song from the ‘70s goes.
CONOR: Yeah, but this is not karaoke.
DODI: Okay, not this time.
CONOR: That's a different episode. Actually, I want to dig into this popular trope that war drives innovation in medicine.
DODI: Not just innovation in medicine, innovation everywhere.
CONOR: Exactly. But is it really true that in the harsh reality of war, humans being bad at being humans, create conditions that bring about life saving medical discoveries?
DODI: Okay, and that's a deep question. So, alleged war-derived medical innovations are what matters in today's episode of Discovery Matters.
CONOR: I spoke with Dr. Elisa Smith, historian of Medicine at the University of Warwick and a specialist in British imperial medicine in the nineteenth and twentieth centuries, she's an expert on many of the wrongs in the history of medicine.
ELISE: I came through as a global historian. I was very interested in studying the scientific foundations of race and how racial ideology was used to justify colonial rule. A big part of that was all about measuring skulls, measuring people's heads to determine their state of intelligence or their state of evolutionary development.
DODI: Oh, my!
CONOR: Yes, there it is. As we know, there's as much history that shames us as there is history that makes us hopeful and true. But from this horrible hypothesis, a perceived need to measure the physiques of sailors started to change things.
ELISE: Naval doctors who started creating growth charts in the nineteenth century, as the Navy is obviously recruiting young boys, and they were trying to figure out how tall they were going to grow and if they were going to meet the standards for enlisting to the Navy by the time they reached the age of 15. From that kind of research, I moved over to working on health in the Navy in the nineteenth century.
DODI: Well, medicine in the military is by definition different from medicine for the general population, isn't it?
CONOR: Yes, of course, and not always in the obvious ways. Military medicine is better funded, yes. And there's occasionally a lot more urgency to it. The idea, of course, is to get your patient fighting again. So, the question is, how did military medicine evolve differently from civilian medicine?
ELISE: Military medicine is interesting, because it's actually the first form of state medicine, right? So, we think of state medicine as really coming out of the NHS in the post-World War II period. But a medical provider that is funded by the government goes back centuries. Military medicine is really the foundation of state medicine. It's not a kind of medicine that's generally applicable. So specifically, for a long time, of course, it was concerned with battlefield wounds and injuries. Civilians aren't normally faced with being stood next to exploding bombs or being shot at.
DODI: Okay, I get it. It's a specific set of conditions and injuries that military medicine is dealing with.
CONOR: Yes, and it's not just the horrors that humans inflict on each other, military medicine is really interested in infectious diseases as well. You only have to think about the colonial expansion by European powers. One of the great obstacles in tropical latitudes was diseases such as yellow fever and malaria. They were a major factor in determining the colonial expansion in the Caribbean for example. It was established as the major sugar plantation of the world because of fewer diseases, rather than West Africa, which is much closer and easier to get to from Europe.
DODI: Wow.
ELISE: So, you have military and naval physicians really trying to get a handle on those kinds of diseases. And so, a lot of research has actually been at the forefront of these military campaigns. The other thing is that military medicine is a very limited demographic, so it tends to be for healthy men. So, this is not a medicine that deals with children, women, or older people.
DODI: So, focusing on military circumstances slows down medicine for women, the elderly, and children.
CONOR: Perhaps, yes. It certainly diverts investment. But the military’s goal was not the preservation of life into old age. It's triage, who's going to die? Whom can we save? Who can we patch up and send back out there? In fact, they invented triage. So, it's brutal. And it has quite a different dynamic between doctor and patient than civilian medicine.
DODI: It's seeming incredibly logical. I'm curious about the relationship between the patient and the doctor in the military. What's the human part of it? And how is that different from what it's like for us to go into the doctor's office or the hospital? Is there a catch?
ELISE: When we go to the hospital, we generally think that the doctors are on our side. And that tends not to be the relationship that especially men in the ranks have with doctors in a military context. So, doctors are charged with detecting malingering, which means that they're constantly suspicious if their patients are genuinely sick. Or are they milking things? There's this real sense that doctors are trying to get them patched up as quickly as possible so that there's not a real care for holistic health as it were, right? It's just about getting people back on their feet so that they can go back to the frontlines.
DODI: Thinking about the medical innovations, this doctor patient dynamic really affects the way in which innovation comes about.
ELISE: War obviously creates a lot of pressure. A really good example of this during the First World War is shell shock, which we now think of as PTSD. We have lots and lots of people having mental breakdowns. This really gives the young field of psychology and psychiatry a huge boost. When you think about orthopedics, you've got lots of people losing their limbs simultaneously. So that allows for the development of better prosthetics. With facial injuries, you get the advent of cosmetic surgery out of that. So again, in many cases simultaneously, it really becomes a spur to that kind of investment and observation.
DODI: Well, then what is the impact on civilian medicine?
CONOR: So, it's the case that there's a lot of funding for certain types of medicine during wartime that advances the war effort and helps preserve manpower. For example, doctors discovered that wound shot is caused by acid in the blood. So that needed to be combated to save lives.
DODI: A Penicillin is also mentioned a lot and is important . Now, the mass production of penicillin is often associated with wartime.
ELISE: But whether these things would have been developed otherwise, wartime sometimes creates a mass demand for certain products and innovations that might not have existed otherwise. But in many of these cases, ambient research is already being done. A lot of the work has already been done by the time war gives it that extra push.
DODI: So clearly, many examples of war being a catalyst to pushing innovation over a threshold because of demand, just pure quantity, current timing, the rush, but would a battlefield be its own testbed?
ELISE: There is absolutely something to the idea that a crisis creates need and demands. And there's also - and it's also maybe controversial - in wartime, there's a lot more possibility for experimentation on soldiers, which would be unethical in peacetime because you can't treat civilian volunteers the way you treat military personnel. So, a lot of these kinds of innovations are the kind of trials that are being done, you wouldn't necessarily get away with in peacetime and the normal parameters of medical research and testing.
DODI: So, returning to the role of medical innovation in war overall, how does Elise reconcile the two disciplines of saving as many lives as possible, but for the enemy, you want to end as many of those lives as you can in war?
CONOR: Yeah, it's really, really tricky.
ELISE: Yeah, I think there's been a trend amongst historians about what's called a medical balance sheet of war. We question is war good for medicine. There is a commonly held belief that it is in part because we create these circumstances that lead to increased demand, that leads to increased funding, that leads to some innovations. But then you have to really weigh that against all the costs, you have to consider that some of the gains are very circumstantial, very limited to the context of the war itself, the types of injuries that are sustained in war, also to remember that a lot of the gains are quite short-lived.
CONOR: It is true that disciplines like psychiatry got a huge boost during and then after the First World War. We did an episode on PTSD and the mental impact on uniformed service people. But then demand recedes, and the funding starts to peter away. Veterans who are very well cared for during and maybe in the immediate aftermath of the war, their care has slowly eroded and neglected.
DODI: Things like nutritional standards go down in wartime. So, there are huge kinds of detrimental health consequences. And I guess we need to weigh those advances against some of the limited benefits.
CONOR: Yes. And there's certainly no utilitarian balance between any alleged good that's coming out of war and the impact on human health.
ELISE: We have a sense that there's always money for military operations. Whenever we improve a state budget, there seems to always be lots of money for war. And there are lots of cuts to other things, including health so we maybe don't prioritize health in a civilian setting the way we do in conjunction with war. We may need to consider preserving life outside of the context of war as just as important. I also think that if we weren't already ready for those crises - if we didn't already have vaccine programs and development, if we weren't already doing research on penicillin - then you wouldn't have been able to scale up that demand during wartime if the seeds of work weren't already there. So, I think our ability to meet these demands does require lots of investment outside of the context of war.
DODI: Well, it sounds like Elise was really interesting to talk to.
CONOR: 100%, and really put to bed the idea that war is a singular driver of innovation in medicine. It's not what drives innovation in medicine, frankly it is the very human response of trying to save human lives when there is real pressure and difficult things to be dealt with, irrespective of whether it's war, or famine, or plague, or what have you...
DODI: ...or whether it's medicine for your body or medicine for your mind. What have you learned this week?
CONOR: You're going to like this, because you're a language geek like me, the nature of English and the way that it uses words like add and enhance, and words like improve and create, means that when you start to try to improve something, you usually try to add things to a solution when the answer actually might be to take things away and make things simpler. Oh, that's interesting. But the nature of the English language is something that tends to make English speakers want to add things. And this is now showing up in machine learning-driven algorithms being applied in large language models for chatbots. Chatbots trained on English language tend to make things more complicated when they're trying to improve things.
DODI: It's the Rube Goldberg rule of speaking.
CONOR: That's it! I love that.
DODI: It's absolutely the most complex route to the destination.
CONOR: The paper is published in Cognitive Science in April, it is an international team from the University of Birmingham, Glasgow, Potsdam, and Northumbria University. So, there you go.
DODI: As long as we're on AI, there's a new story about caesarean deliveries, which are going up in Rwanda. But doctors are using a smartphone app with AI, that is helping them detect certain patients that might get post-surgery infections.
CONOR: Oh, wow.
DODI: Yeah.
CONOR: So, it used to be 'there's an app for that', it's now there's an 'AI for that'. Lord, where will it all end? I for one, welcome our new AI overlords.
DODI: I know you do. That brings us to the end of this episode of Discovery Matters. Our producer is Beth Armitt-Brewster. Editing, mixing and supervision by Enrique Swenson and Tom Henley from Banda Productions, music from Epidemic Sound. My name is still Dodi Axelson.
CONOR: And my name is Conor McKechnie. Make sure you rate us on Spotify or whichever platform you use. We'll see you when we come back with another episode of Discovery Matters.