‘A searing, deeply humane collection of essays about medical practice that has all the makings of a modern classic’

Casualties of War
E
ach Tuesday, the U.S. Department of Defense provides
an online update of American military casualties from
the wars in Iraq and Afghanistan. According to this up-
date, as of December 8, 2006, a total of 26,547 service mem-
bers had suffered battle injuries. Of these, 2,662 died; 10,839
lived but could not return to duty; and 13,085 were less severely
wounded and returned to duty within seventy-two hours.
These figures represent, by a considerable margin, the largest
burden of casualties our military medical personnel have had
to cope with since the Vietnam War.
When U.S. combat deaths in Iraq reached the two-
thousand mark in September 2005, the event captured world-
wide attention. Combat deaths are seen as a measure of the
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Better
magnitude and dangerousness of war, just as murder rates are
seen as a measure of the magnitude and dangerousness of vi-
olence in our communities. Both, however, are weak proxies.
Little recognized is how fundamentally important the medical
system is—and not just the enemy’s weaponry—in determin-
ing whether or not someone dies. U.S. homicide rates, for ex-
ample, have dropped in recent years to levels unseen since the
mid-1960s. Yet aggravated assaults, particularly with firearms,
have more than tripled during that period. A key mitigating
factor appears to be the trauma care provided: more people
may be getting shot, but doctors are saving even more of
them. Mortality from gun assaults has fallen from 16 percent
in 1964 to 5 percent today.
We have seen a similar evolution in war. Though fire-
power has increased, lethality has decreased. In the Revolu-
tionary War, American soldiers faced bayonets and single-shot
rifles, and 42 percent of the battle wounded died. In World
War II, American soldiers were hit with grenades, bombs,
shells, and machine guns, yet only 30 percent of the wounded
died. By the Korean War, the weaponry was certainly no less
terrible, but the mortality rate for combat-injured soldiers fell
to 25 percent.
Over the next half century, we saw little further
progress. Through the Vietnam War (with its 153,303 combat
wounded and 47,424 combat dead) and even the 1990–91 Per-
sian Gulf War (with its 467 wounded and 147 dead), mortality
rates for the battle injured remained at 24 percent. Our tech-
nology to save the wounded seemed to have barely kept up
with the technology inflicting the wounds.
The military wanted desperately to find ways to do bet-
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Casualties of War
53
ter. The most promising approach was to focus on discovering
new treatments and technologies. In the previous century,
that was where progress had been found—in the discovery of
new anesthetic agents and vascular surgery techniques for
World War I soldiers, in the development of better burn treat-
ments, blood transfusion methods, and penicillin for World
War II soldiers, in the availability of a broad range of antibi-
otics for Korean War soldiers. The United States accordingly
invested hundreds of millions of dollars in numerous new
possibilities: the development of blood substitutes and freeze-
dried plasma (for infusion when fresh blood is not available),
gene therapies for traumatic wounds, medications to halt lung
injury, miniaturized systems to monitor and transmit the vital
signs of soldiers in the field.
Few if any of these have yet come to fruition, however,
and none were responsible for what we have seen in the cur-
rent wars in Iraq and Afghanistan: a marked, indeed historic,
reduction in the lethality of battle wounds. Although more
U.S. soldiers have been wounded in combat in the current war
than in the Revolutionary War, the War of 1812, and the
Spanish-American War combined, and more than in the first
four years of military involvement in Vietnam, we have had
substantially fewer deaths. Just 10 percent of wounded Ameri-
can soldiers have died.
How military medical teams have achieved this is impor-
tant to think about. They have done it despite having no fun-
damentally new technologies or treatments since the Persian
Gulf War. And they have done it despite difficulties with the
supply of medical personnel. For its entire worldwide mis-
sion, the army had only about 120 general surgeons available
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54
Better
on active duty and two hundred in the reserves in 2005. To sup-
port the 130,000 to 150,000 troops fighting in Iraq, it has been
able to put no more than thirty to fifty general surgeons and ten
to fifteen orthopedic surgeons on the ground. And these sur-
geons and their teams have been up against devastating injuries.
I got a sense of the extent of the injuries during a visit to
Walter Reed Army Medical Center in Washington, D.C., in
the fall of 2004, when I was invited to sit in on what the doc-
tors call their “War Rounds.” Every Thursday, the Walter Reed
surgeons hold a telephone conference with army surgeons in
Baghdad to review the American casualties received in Wash-
ington. The case list for discussion the day I visited included
one gunshot wound, one antitank-mine injury, one grenade
injury, three rocket-propelled-grenade injuries, four mortar in-
juries, eight improvised explosive device (IED) injuries, and
seven with no cause of injury noted. None of these soldiers
was more than twenty-five years of age. The least seriously
wounded was a nineteen-year-old who had sustained exten-
sive blast and penetrating injuries to his face and neck from a
mine. Other cases included a soldier with a partial hand ampu-
tation; one with a massive blast injury that amputated his right
leg at the hip, a through-knee amputation of his left leg, and
an open pelvic wound; one with bullet wounds to his left kid-
ney and colon; one with bullet wounds under his arm requir-
ing axillary artery and vein reconstruction; and one with a
shattered spleen, a degloving scalp laceration, and a through-
and-through tongue laceration. These are terrible and formi-
dable injuries. Nonetheless, all were saved.
*
*
*
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Casualties of War
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If the answer
to how was not to be found in new technolo-
gies, it did not seem to reside in any special skills of military
doctors, either. George Peoples is a forty-two-year-old surgical
oncologist who was my chief resident when I was a surgical
intern. In October 2001, after the September 11 attacks on the
World Trade Center and the Pentagon, he led the first surgical
team into Afghanistan. He returned after service there only to
be sent to Iraq, in March 2003, with ground forces invading
from Kuwait through the desert to Baghdad. He had gone to
the U.S. Military Academy at West Point for college, Johns
Hopkins Medical School in Baltimore, Brigham and Women’s
Hospital in Boston for surgical residency, and then M. D. An-
derson Cancer Center in Houston for a cancer surgery fellow-
ship. He owed the army eighteen years of service when he
finally finished his training, and neither I nor anyone I know
ever heard him bemoan that commitment. In 1998, he was as-
signed to Walter Reed, where he soon became chief of surgi-
cal oncology. Peoples was known in training for three things:
his unflappability, his intellect (he had published seventeen pa-
pers on work toward a breast cancer vaccine before he finished
his training), and the five children he and his wife had during
his residency. He was not known, however, for any particular
expertise in trauma surgery. Before being deployed, he hadn’t
seen a gunshot wound since residency, and even then, he never
saw anything like the injuries he saw in Iraq. His practice at
Walter Reed centered on breast surgery. Yet in Iraq, he and his
team managed to save historic numbers of wounded.
“How is this possible?” I asked him. I asked his colleagues,
too. I asked everyone I met who had worked on medical teams
in the war. And what they described revealed an intriguing
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Better
effort to do something we in civilian medicine do spottily at
best: to make a science of performance, to investigate and im-
prove how well they use the knowledge and technologies they
already have at hand. The doctors told me of simple, almost
banal changes that produced enormous improvements.
One such change involved Kevlar vests, for example.
There is nothing new about Kevlar. It has been around since
the late 1970s. Urban police forces began using Kevlar vests in
the early 1980s. American troops had them during the Persian
Gulf War. A sixteen-pound Kevlar flak vest will protect a per-
son’s “body core”—the heart, the lungs, the abdominal
organs—from blasts, blunt force trauma, and penetrating in-
juries. But researchers examining wound registries from the
Persian Gulf War found that wounded soldiers had been com-
ing in to medical facilities without their Kevlar on. 
They hadn’t
been wearing their vests.
So orders were handed down holding
commanders responsible for ensuring that their soldiers al-
ways wore the vests—however much they might complain
about how hot or heavy or uncomfortable the vests were.
Once the soldiers began wearing them more consistently, the
percentage killed on the battlefield dropped instantly.
A second, key discovery came in much the same way, by
looking more carefully at how the system was performing.
Colonel Ronald Bellamy, a surgeon with the army’s Borden In-
stitute, examined the statistics of the Vietnam War and found
that helicopter evacuation had reduced the transport time for
injured soldiers to hospital care from an average of over eleven
hours in World War II to under an hour. And once they got to
surgical care, only 3 percent died. Yet 24 percent of wounded
soldiers died in all, and that was because transport time to sur-
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Casualties of War
57
gical care under an hour still wasn’t fast enough. Civilian sur-
geons talk of having a “Golden Hour” during which most
trauma victims can be saved if treatment is started. But battle-
field injuries are so much more severe—the blood loss in