ISPP 2015

Career Opportunities in Pharmacy
Was World War I good for medicine? (NATO Review)

Was World War I good for medicine? From 1914’s grim reality
to today’s virtual reality It’s hard to do justice with words what happened here in Ypres
between 1914 and 1918. So numbers may help explain better. There were four major battles here,
which were fought ferociously. The third one alone had 15,000 dead
at the end of the first day. By the end of the campaign there were 270,000 dead
on the allied side alone. In terms of the artillery, the British
in September in one day in 1917 fired one million shells
from over 2,000 guns. And at the end of all this, Ypres
had how many houses standing? Just four. This was the first total war
that mankind had ever experienced. So, it was a war of a different nature, which nobody
had experienced before. New ballistic weapons,
chlorine gas, mustard gas, higher velocity rifle cartridges,
new improved machine guns… All of these weapons
and more awaited troops, heading off to fight in World War I.
And the effects were devastating. At least nine million dead
and more than double that wounded. The accepted wisdom is
that the high number of casualties in the First World War
was caused by the trench warfare between the two opposing sides,
which went on for years. However, I’m in a cemetery
where ten thousand of the soldiers who fought
in the First World War are buried. How many of these
were killed during combat? Just five per cent. Wounds were susceptible to infection,
as they often contained shrapnel and were sustained while wearing
dirty uniforms in muddy trenches. Antibiotics had not yet been invented posing a massive challenge
to war doctors. Wynand Korterink
is the Medical Advisor for NATO Headquarters’
International Military Staff. So, Wynand, tell me: how important
was infection and disease in causing deaths
in the First World War. When they started
the First World War, they didn’t think
about healthcare or medicine. Instruction of hygiene was poor. And taking care of patients
was old fashioned in a way. Anaesthetics
were also a huge problem. They would use chloroform masks
and other kinds of anaesthetics, but sometimes, very often, soldiers
would wake up during operations, others were killed accidentally. Blood transfusions
were a really messy thing. Blood had to be pumped out of
one person and into another person. The lack of hygiene,
especially in the trenches, with all the lice
and the trench feet etcetera… That was a purely hygiene issue.
Bad food also. And the other part
was infected wounds. And then there is another part
that is infectious diseases. Actually, the influenza
of 1918 killed more people than the First World War in itself. Knowledge of key
medical practices was poor compared to today’s medicine, but the outbreak of the war
provided a massive opportunity to test
new techniques and treatments. You could say that the battlefields were one huge laboratory
in the medical field, where the best in their field
would come to try out new things. Marie Curie, with her daughter Irène,
went along the frontline and installed X-ray machines
all along the frontline. The technique was known,
but was never used on such a scale. War was looked upon
by many doctors, not as an enemy because it killed and had maimed,
and had wounded and had made sick. War was a colleague,
war was a teacher. War was the doctor of doctors. It was not just the medical practices
that were often not up to scratch, some of the personnel
helping the soldiers, were not qualified to do so. There was no time for training. When you got your degree,
you had to go. Even if you didn’t have a degree at all,
sometimes you had to go, because you were
needed somewhere else. So you got unqualified doctors treating physically and
psychologically unqualified soldiers. Most people working in healthcare
were actually volunteers. Red Cross organisations,
but also local volunteers, nurses from monasteries…
all came to support the soldiers. One of the best-known injuries
was shell shock, but while this phenomenon
was suffered by forces from all sides, they dealt with it
in very different ways. Shell shock as such
was a huge military problem. How can you recognise shell shock? How can you be sure
that someone is not faking it? You had
some psychiatrists, some doctors, who were more progressive,
but even as far as 1925, the military medic,
who wrote the official history of medical services
of the Canadian army, wrote that shell shock
was a kind of hysteria and that there was
no remedy against femininity as he would describe it. The British and the French looked upon the psychologically wounded
and sick more in gender terms. The psychologically wounded were
feminised, they were weaklings. And how better can a psychologically
wounded soldier prove that he is better again
than to do his bit at the front? So, Germans looked
upon the psychologically wounded in economical terms. They were
a bit like factory workers on strike. This meant that in general
German doctors were satisfied when they got their psychologically
patients back to the weapons factory. They didn’t fight anymore,
but they did their bit for the war. There was terrible suffering
on the front, but also back home. Not just because most
of the vital food and medicines were sent not to them,
but to the front. During the war civilian
healthcare suffered enormously. For instance in France, before
the war there was one doctor on, I think, 2,500 civilians.
During the war it was one on 14,000. And if there was a doctor,
he had no medicines because they also
were ordered to the front. If we put ourselves back a hundred
years with what they knew then, did they do the best job they could? From a military point of view
they did a marvellous job. Without medicine,
without medical care the battles would have
been fought with far less men. Because of that they probably
wouldn’t have lasted that long and the war probably would have
been over before November 1918. With a different outcome because
the US wouldn’t have joined in. Medicine during the war did not
only save lives, it cost lives as well. The enormous number of injuries and
the specific nature of the wounds, meant that both sides
had to reconsider how to treat their wounded soldiers. This led to changes,
especially in how to get soldiers from the battlefield
to the hospital bed. On the military side,
the whole system of evacuation and how to organise an evacuation,
got specialised during World War I. At the beginning
of the war they realised they needed to change healthcare, and all the logistics,
but especially healthcare. So for example,
they needed mobile hospitals and doctors and stretcher-bearers
at the front to bring the patients back because they lay wounded
on the battlefield for days. So they needed an evacuation chain. Wounds to the stomach had
to be operated as soon as possible and as near
to the frontline as possible. So advanced
surgical stations would open at only one and a half miles,
two miles from the frontline. The speed of treating soldiers
became a key issue in World War I. Four out of five battlefield deaths
occur in the first hour after being wounded. This
became known as the golden hour and has today even been refined
to the first platinum ten minutes. Real evacuation change started here
and now we have the golden hour and the ten-one-two, etcetera. All kind of improvements
of the inventions that were done here. While some claim that medical
advances helped civilian healthcare, there is also evidence that civilian
advances helped during wartime. Some say:
Look at the Second World War, without it we wouldn’t have penicillin.
No, penicillin came from 1928. But it was strange stuff,
we don’t use that. And then in 1942 there was
a huge fire in Boston, in a nightclub. Had nothing to do with the war. All medicines were gone
and then some doctor said: I have some of that weird stuff here.
Maybe it helps. And it did help,
it did help enormously. So what… And then he said:
Well, let’s get this to our soldiers. In fact, I think, penicillin is
one of the most neglected… …causes for allied victory. The Germans didn’t have penicillin. The medical advances of World War I
were built upon in later conflicts. Korea saw the development
of the mobile army surgical hospital or MASH. By the time of the Vietnam War, air
ambulances became more common and quicker to treat injured soldiers. In the Korean War, 17,000 casualties
were evacuated by helicopter, but by 1969 in the Vietnam War 200,000 casualties a year
were transported by air. This plus the number
and availability of hospitals meant the treatment
fell to less than one hour on average, down from the average
of four to six hours in Korea. And after the experience in Vietnam, many civilian hospitals in the US
introduced air ambulances. And they continue to play
a key role in Afghanistan today. The medical part
of ISAF was focussing, not only on the field hospitals
that we have deployed, but also on bringing
the patients to those hospitals. Over a hundred helicopters were used to bring these patients
to central hospitals. The problem today is not
the lack of advances in technology. Unimaginable advances have been
made since a hundred years ago. The problem now is
that there are too few doctors and medical personnel
to practise that medicine. In the EU only
we are expecting to have a lack of about one
million health workers by 2020. So the world is changing. There’s a growing shortage
of doctors worldwide. A growing shortage of nurses. In a hundred years
we will reach ten billion people, over ten billion people in the world. There aren’t going
to be ten million more doctors graduating in the next fifty years. But the only way to alleviate
that is to use technology. Less medical personnel
means more flexibility is needed. Telemedicine could provide this. We don’t have doctors
to put on every ambulance, so I’m going to give you a virtual
doctor. We cannot be everywhere. With telemedicine we can be
mostly everywhere we want. It can save lives. If before… Such patients,
their transfer was done within hours. Now with this system,
we can do it within the hour because we get the information
and then if we have a helicopter the decision can be taken very fast. Doctor Arafat has seen
how this system has saved lives. For example,
when he saw irregular heart signs on patient information
being sent back from an ambulance, he could see
that urgent action was needed. The doctor jumped in the helicopter
and in six minutes treated the patient. If the helicopter wouldn’t
have been sent with the doctor and would have worked
the normal way, the patient would have
had to go for about forty minutes driving in the ambulance. The chance that this rhythm would
have deteriorated into a cardiac arrest and we could have lost the patient,
was very high. So, not being present should
no longer be an obstacle for doctors wanting to treat patients.
Operations have already taken place with the surgeon on one continent
and the patient on another. On September 7th 2001,
Jacques Marescaux from Strasbourg at the European Telesurgery Institute,
was in New York and operated
on a patient in Strasbourg. He took her gallbladder out,
a cholecystectomy, using the Zeus robot. So, the patient is in France with
a team of physicians and surgeons, the robot is hanging above her
and he is in New York City driving the robot,
taking her gallbladder out. On the morning of September 11th
he was on his way down to the World Trade Centre
to give a press release. He didn’t get hurt, but obviously
something else happened. So, it’s the most
missed story of 2001. But telemedicine brings
its own new difficulties. You have time zones. You have geography.
You have bandwidth, right? You have nations
with different belief systems, cultural values and languages. The American physician
will be treating or giving advice to someone
who is working in another country, which may not be recognising
the qualification of that doctor. While treatment has
developed over the years, many injuries are remarkably similar, such as amputations
and traumatic disorder. But dealing with post-traumatic
stress disorder or PTSD has seen active engagement
with affected soldiers going back to where they were injured
to face the place and situation where the problem started. But what
about those who can’t come back? Well, now the place
can come to them. The Virtual Reality Medical Centre is
an example of how this can be done. Executive Director,
Brenda Wiederhold, showed me how it offers virtual reality scenarios to help PTSD sufferers
confront the source of their stress. This treatment helps
against IED attacks, which are linked causing PTSD with
the most common source of injury for soldiers serving in both
the Iraq and Afghanistan wars. And PTSD’s aftereffects,
such as depression, have led the US army
to initiate schemes such as the National
Suicide Prevention Week. We want to start therapy at a lower
level of stress and then build up. We’ve talked to them
before the therapy begins, we’ve found out
what their specific trauma is and so we start at a lower level,
a world that is not as traumatic, for instance the battalion camp
or the market place. And then we go up to the battlefield
as they can deal with that stress. Now what I should say also:
The sounds are quite important here. I just heard a sniper
shooting from somewhere. Correct. So you look up at a rooftop and you might see
one across the street. Your heart rate is up to 92
and your respiration is at… Very high. We’ve had people come out and say:
I can deal with anger better, I can talk to my children
without getting upset, my wife and I have
a better relationship, I’m able to go on another tour of duty.
I’m able to hold a civilian job. Another guy:
I’m able to get my college degree. But part of a mental recovery
can involve physical recovery. The Dutch Ministry of Defence’s
rehabilitation centre addresses both. The centre aims
to help people to be confident and carry out tasks
they could do before. We treat not only amputees,
but also people with brain injury, people with knee or ankle complaints. You can train stability,
but also balance. The system
has been used since 2008 and treats
about fifty patients a week. It’s so successful, it’s now being used
to treat military and civilian patients. Colonel Mert,
this particular part of the facility, you have the gym here,
you’ve got some tennis courts, you’ve got
a swimming pool behind us, how do you use these to help
treat the illnesses and injuries? Well, the military rehabilitation centre is the rehabilitation centre
for the military. It’s an obligation
that we have to our servicemen, to just keep on looking
for new ways to treat these patients. We want to keep them
as active servicemen. In the end, it’s about the therapist, which gives help
and treats the patient. The facility is just facilitating. Less medical personnel means
more reliance on new technology. But the developments in the medical field
in the near future are encouraging. We see developments in technology
that will allow us in the near future to have
unmanned patient evacuation. We can also see very, very
smart ways of artificial limb steering with the brain-machine interaction
that will really improve prostheses. But perhaps also very important
is that we realise better and we understand better
what shell shock or today PTSD is and how perhaps we can manage
people to get a normal life back. Smart watches are getting popular. But a smart watch is
a very advanced computer compared to the stuff
that we had six, seven years ago. There is a GPS in it and there is
a heart rate monitor in it and… There’s accelerometers etcetera. So, that gives a lot of possibilities
to monitor the function of a patient. The near future with nanotechnology and with 3D-printing,
stem cell technology, will change healthcare tremendously.
We’re on the brink of a new era that started already in World War I
realising what we needed. Today we realise what we can do. Technology is now so far
that we can make it into production and implement it in modern medicine. And finally, one of the key
messages from these Flanders Fields, from what happened
a hundred years ago, is that while medicine
can advance due to war, it doesn’t necessarily
need war to advance. The invention of penicillin in 1928, the unravelling of the DNA
structure in, what was it, 1953? All peacetime progress. Why don’t we ever say:
peace is good for medicine? War is our scourge;
yet war has made us wise. And, fighting for our freedom,
we are free. Horror of wounds
and anger at the foe. And loss of things desired:
all these must pass. We are the happy legion, for we know Time’s but a golden wind
that shakes the grass. Siegfried Sassoon – Absolution (1915)

4 thoughts on “Was World War I good for medicine? (NATO Review)

  1. Did any good come out of WWI?

    To mark the 100th anniversary, #NATOReview looks at what really killed troops in the First World War. #WWIcentenary

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