>> Kevin Butterfield:
Good afternoon, everyone.
I'm Kevin Butterfield, Director
of the John W. Kluge Center.
My great pleasure to be
sitting here with Tanisha Fazal,
a professor of political science
at the University of Minnesota
and the author of a new book,
"Military Medicine and
the Hidden Costs of War."
Thanks for being here
at the Library of Congress.
>> Tanisha Fazal:
Thank you for having me.
>> Kevin Butterfield: I'm curious about
your track into writing this book.
There's deep study of the
history of medicine across
multiple wars from the
19th century into the 21st,
and it doesn't seem to track exactly
with the previous publications
that I see on your own
publication record.
How did you get
started down this path?
>> Tanisha Fazal:
Well, there is, I guess,
maybe one similarity with
some of my previous work,
which is that I have
a little bit of a
history of coming to my research
projects as a result of being annoyed.
And in this case, what happened
was that I was writing
my second book, which is on
international humanitarian law,
or The Laws of War, and I had a
paper out of that book on why it is
that we no longer see peace
treaties in wars that states
have with each other.
And, you know, like academics do,
I was trying to get that paper
published, and one of the
reviewers, one of the peer
reviewers for that paper, really
wanted me to engage with
what was at the time,
a new literature arguing
that war was in decline.
And that led me to--
>> Kevin Butterfield: This is
Steven Pinker, if I'm not mistaken.
>> Tanisha Fazal: Yeah.
That led me, somewhat begrudgingly,
to pull Pinker's book off the shelf.
And it was, you know, I had it.
I was going to read it one day,
but it's really long.
And so I started reading it.
And the first half of
this book, which is called
"The Better Angels of Our Nature:
Why Violence Has Declined", is about
kind of interpersonal violence,
how we treat our pets,
spanking children,
things like that.
But then the back half of the
book is about an argument that
Pinker is making about
the decline of war.
So now we're in my wheelhouse,
and I realized really quickly
that the empirical basis for
Pinker's claim that war was in
decline was a decline
in battle fatalities.
But, of course, over the same
long arc of history that Pinker
is talking about, there have
been dramatic improvements in
medicine. So effectively,
what's happened is that battle
casualties have been shifted
from the fatal to the non-fatal
column. And that kind of led to
this whole new research agenda
on military medicine.
>> Kevin Butterfield: In fact,
there's this baseline ratio
that's key to your work that I've
learned from reading
through the first few chapters.
Is this reference to the
wounded to kill ratio?
There's even a graph that
helps us visualize it.
But in reality, this graph could
go even farther back in time,
probably, and still show
something quite consistent.
Can you talk to us about the
consistency up to a certain point
in this Wounded-to-Killed ratio?
>> Tanisha Fazal: Yeah. So the
Wounded-to-Killed ratio is exactly
what it sounds like.
It's the percentage,
the number of people
killed compared
to the number of people wounded.
And for a very long time,
centuries, really going back further,
what this chart is
just showing you is the
Wounded-to-Killed ratio just
for the United States since the
founding of the Republic.
But going back further in time
and around the world, not just
for the United States, the
Wounded-to-Killed ratio was
considered to be
very stable at 3 to 1.
So the rule of thumb was
that for every person killed,
you would have
three people wounded.
And this was something that
people really set their clocks by.
And, you know, so much so
that if they were trying to fill
in data on casualty reports or
statistics, they would kind of
reverse engineer if they had
any missing data using this,
this rule of thumb.
But as you see from this chart,
for the US, it's really drift.
You know, there's a little bit of
a jagged line, but it's
definitely drifting forward over
time and then really jumps up
in the more recent wars in Iraq
and Afghanistan, where
depending on who you talk to,
the Wounded-to-Killed ratio is
somewhere between 10 to 1 and 17 to 1.
And I should note also that
there are, you know,
the Wounded-to-Killed ratio
does not include disease.
It does not include
psychological illness.
This is, you know, the physical
wounds that we can observe.
>> Kevin Butterfield: And in the
opening paragraphs of the book,
you use a private James Spaulding.
I wrote down his name so I
can remember this, a real life
figure from the Civil War era
who served and was wounded in
1865. And you lay out
a bit of a different,
some alternative biographies
that could have happened for
Private Spalding had he
served in different wars.
One useful starting point for us
is what actually happened to him,
because I want to start
with the Civil War and then move
forward in time.
Talk to us about Spalding if you
remember the details of his story.
Hopefully you can get it close.
But as his story was
one of literally millions,
literally hundreds of
thousands, I should say.
But tell me about what happened
to him and a little bit about
where the Civil War figures
as a starting point for your study.
>> Tanisha Fazal: Yeah. So Spalding
is wounded in the Civil War,
and he kind of does better.
He seems like he's on
the road to recovery.
When you read the medical
history, it's all of these very
19th century, not surprisingly,
medical terms that sound
troubling from the vantage
point of the 21st century,
because it's not how you would
treat somebody today.
It seems like he's on the road
to recovery, but he ends up
succumbing to an
infection and dying.
And the reason that I begin
not only the book, but
also it's sort of the first
empirical foray,
a major empirical foray in the
book is a discussion of the
Civil War, is because I think
it's a really important baseline
for thinking about military
medicine in the context of the
United States. It's in the pre
germ theory of disease era,
right, which has real
implications for the ways in
which disease is handled.
It's the first really major war
that the US is fighting, and
they have to stand up a
military medical system
in the way that they had it before.
And there are number of really
interesting advances, but also
problems that they can't really
solve in the Civil War.
And I think it's also a really
interesting and important case,
and provides a baseline for
thinking about the way that
the United States has dealt with
benefits for military veterans as well.
>> Kevin Butterfield: I want to
hopefully kind of bifurcate our
conversation a bit. I want to look
at medicine first and come to
benefits in a bit, but these
are the two pillars of your work
here. The long term, the long
tail of the costs of war
come down to those who have
served in the war and what
happens to them after,
including the benefits provided
to them. So I want to
come to benefits soon.
But the Civil War itself, you
mentioned that the germ theory
of disease is just
beginning to emerge.
It's certainly no real
understanding of it.
And disease is a clear killer.
But there's also, in terms
of the battlefield deaths
themselves and battlefield
wounds, it's different from
later wars as well.
And I noticed a distinction
between gunshot and explosions.
Can you talk to us a bit about
the different methods of war?
>> Tanisha Fazal: So we let's take
a look at this chart here.
So, you know, in the Civil War
and also in World War II,
the way that most people who were
injured and who die as a result
of injury die those sort of the
cause of injury is
gunshot. But then we have the
shift starting around World War II
from guns to bombs.
And, you know, if you think about
this in the context of the Civil War,
gunshot was really problematic,
partly because of the type,
the very specific type of rifles
and even bullets that were used,
or something called the Minié
ball that was used that really
tore through flesh and also fabric.
And remember that in the
Civil War, people didn't use
personal protective equipment.
They were effectively dressed
the way that you and I are
in terms of the kind of protection
that their clothing could afford
to them. And so you had these
bullet wounds tracking dirty
fabric through the wounds
in an era where there is
really no understanding of
the germ theory of disease.
And so that makes it much more
likely that people are going to
succumb to infection in the
way that Private Spalding did.
>> Kevin Butterfield: When we move
forward in the book and of course,
in history, World War
I and World War II,
you bring these together into the
world wars as a way of looking at.
But there is, of course, great
change, both in medicine
and in the methods of warfare
in World War I or World War II.
One of the things that I'm curious
to know more about is
by the time we get to World
War I, obviously we have a more
sophisticated, better
understanding of disease and
dealing with injury.
But I think it's fair
to say that there's a more
robust medical infrastructure
supporting those who are
serving. Can you tell us
about the First World War?
>> Tanisha Fazal: Yeah. So this is,
I think the First World War is a really
interesting case
for so many reasons.
And one of which is that at the
turn of the 20th century,
you start to have medicine
really become professionalized,
certainly in the United States.
And one of the consequences of
that which is positive, which is
that you have a lot
of specialization.
And so the US military
medical community
is much better equipped in a lot
of ways to enter a World War II.
Not in every way. And I'll
explain why in just a moment.
World War I, excuse me then,
than for example, the Civil War.
And they've also been observing
what the Europeans are doing.
Because, remember, the US
enters World War I quite late,
but at the same time, this
military medical community or
really the medical community
generally is remarkably
overconfident, so much so that
they say they create
what they call a "safe
war" movements,
which just sounds like a
complete oxymoron, right?
>> Kevin Butterfield:
What did they mean?
>> Tanisha Fazal: What they meant was
that this is, you know, we are so good
at our jobs that war is going to
be no more dangerous than living
your regular civilian life.
And if you become ill or if you
become injured, we're going to
be able to get you back to
where you were, if not better,
which is really, I think,
very remarkable.
And of course, they were not
able to live up to that promise.
And World War I, I think
is also really interesting
because even though the
medicine is much better,
more US troops die as a result
of the 1918 flu pandemic than
from battle or
from injury in battle.
>> Kevin Butterfield: When
soldiers are in the front lines,
and there were very well-defined
front lines in the First World War
as we know in trenches quite
often. There was an awareness in
this period to begin to move
them away from the field of
battle into medical facilities.
And there's even a graph that
you show in the book that was
worked out at the time. Am I right?
That this was a pipeline,
really, of dealing
with injured soldiers.
First of all, tell us where you
found this and a little bit
about the kinds of materials
that you're able to work with.
And tell us about what
evacuation of the injured
looks like in this period.
>> Tanisha Fazal: Sure. So okay, so
evacuation is actually really critical
to medical care in conflict
or really to trauma care in
general, but certainly to
medical care in conflict because
somebody is injured
on the front line.
And you really have to be able
to provide medical care at every
stage of evacuation.
And so you need to have this
chain of evacuation, as what
it's called, set up pretty clearly.
And just going back for a
moment to the Civil War, this is
something where, you know,
oftentimes we talk about
military medicine in the Civil War
as being somewhat medieval.
That's the word that's
often used to describe it.
But one area where there was
significant advancement was
actually with respect to evacuation,
where Jonathan Letterman,
who is appointed as the medical
director of the Army of the Potomac
ends up actually
standing up a proper
ambulance service that's
actually fully staffed with
ambulance drivers instead of
members of the band,
for example. What's interesting is
that these lessons are kind of lost.
Everything that Letterman
does, that it's kind of lost
somehow in between the
Civil War and World War I,
and there's a little bit of
reinventing the wheel and
reminding the US military
medical personnel, reminding
themselves, oh, this is how
we did it in the past, and we
should really
resurrect this system.
And that resurrection is what
you see here in this image,
which is from the Stanhope
Bayne-Jones paper.
Bayne-Jones was a military
doctor in World War I.
And it's at the National
Library of Medicine history
reading room, which is,
you know, you're an historian.
I'm not an historian, but
I love history and archives.
So I spent a lot of time there,
and it was really striking to me
when I came upon this document,
how similar it was and the
echoes of Letterman's work in
the Civil War, but also how they
really had to get back
to where they were.
They had kind of forgotten it
was a lesson that had been lost.
>> Kevin Butterfield: And
this is something I know that
have the ability to get to
injured soldiers quickly and to
bring them the medical care
that they need is something that
the 20th century made great
advances in from this period
forward. I wanted to move
chronologically, but as I
understand it, this is still
very much seen as the
key to helping soldiers is
to get to them quickly and to be
able to offer medical care as, as
soon as possible after the injury.
>> Tanisha Fazal: Yeah. I mean, this
is something that doctors figure out
very quickly in war that if you can
get people to a higher level
medical facility or higher
level medical care more quickly
then their odds of survival
really shoot up.
And in the more recent wars
in Iraq and Afghanistan,
the principle of the
golden hour was applied.
And so this is the idea that if
you get somebody to higher level
medical care within the first
"golden hour" of injury,
then they're really going
to be much more likely to
survive. And this was not only
applied kind of in principle,
but it was a rule that was
instituted by Gates when he
was secretary of Defense in 2009.
He instituted the golden hour rule.
So you couldn't actually-- You
had to be able to evacuate
people within that
first hour of injury.
Now, one of the reasons that
you could do this in Iraq and
Afghanistan is because
the US had air superiority.
So there was a lot of air
evacuation that's happening and
a lot of not only Army, but
Air Force vehicles that are really
kitted out for that purpose.
And that is part of the
explanation for, you know, when
I showed you the Wounded-to-Killed
ratio chart, that
rapid increase in the odds of
survival, the increase in the
Wounded-to-Killed ratio.
People sometimes today, you
know, everybody's trying to get
their golden hour
or that time down.
People talk about the
platinum 15 minutes today.
>> Kevin Butterfield: Wow.
>> Tanisha Fazal: Yeah.
>> Kevin Butterfield: And that's
a clear air superiority versus
contested superiority in the skies
is pretty key to write that,
for instance, wars going on in
the world right now.
I'm thinking of Ukraine.
That's something quite different.
>> Tanisha Fazal: Absolutely
>> Kevin Butterfield: Am I
right in drawing that conclusion?
>> Tanisha Fazal: No, you're
absolutely correct about that.
And for sure, US, I mean, military,
the military in general,
but also military
medical personnel are
paying very close attention to
what's been happening in Ukraine
and really noticing that, you know,
this is a conventional land war.
And there's been sort of a pivot
in the US foreign policy community
in terms of looking
ahead to thinking about
the possibility of what's
called peer or near peer
competition, as opposed to the
kinds of wars and the kinds of
opponents that the US faced
in Iraq and Afghanistan.
So thinking about a potential
war with Russia or with China,
certainly, you know,
neither Ukraine nor Russia has
air superiority in that
conflict, and that has really
compromised evacuation time.
So when you look at the
Wounded-to-Killed ratio
for the Russians and the Ukrainians, it
looks closer to the World War numbers
than it does for sure, than the Iraq
and Afghanistan numbers for the US.
>> Kevin Butterfield: One of the things
that I learned from the book is
it seems to point in both directions,
that is, learning lessons from
previous wars, but also, as you
mentioned before, between the
Civil War and the First World
War, sort of losing some of the
knowledge that you had acquired,
hard won knowledge from the
previous conflict.
There's a couple of graphs that
you show that I think came out
of the Countway Library of
Medicine at Harvard that talk
about learning, sort of working with
the data from the First World War
and thinking about
the Second World War.
Am I remembering this correct?
And this is a an opportunity
to begin to draw
some of that information.
The clicker not moving forward.
>> Yeah.
>> Yeah. Interesting.
There we go. So tell us about this.
And I believe I'm right here,
these are attempts
to sort of draw information
from previous conflicts that to
better inform what we
could do differently now.
Talk to me.
>> Tanisha Fazal: Yeah. So these are
from the Edward Churchill papers at
the Countway library,
which is at Harvard.
Churchill was a major figure
in the US military
medical community in World War II.
He was a real dean of American
military medicine at the time,
a little bit of a controversial
figure in some ways, but did--
Was behind a lot of
significant advances.
And what this chart shows is different
from the Wounded-to-Killed ratio.
This is something closer
to what's called the
thinking about the
case fatality rate.
So of the number of people
who you get, who are treated,
who are trying to treat, how
many of them do you save. Right.
And so what this
chart shows is that the--
or it's kind of the flip of that
because it's the mortality.
How many people
are dying as once they're
actually treated or seen.
And you see that the, you know,
in all these different
categories of different parts
of your body that could be
injured, the mortality rate for
World War II is lower than for
the previous wars.
And so this is, you know,
this is partly--
This is the kind of evidence
that doctors at the time were
really pointing to, to
demonstrate the efficacy of
their practices and procedures.
>> Kevin Butterfield: And in the
next graph I recall, this is actually
sort of looking at some of the
utility of the information
gained. Am I right, out of the
First World War, looking at
how it affected and improved
outcomes in the Second World War?
>> Tanisha Fazal: Yeah.
So there's a little bit of--
There are definitely some
lessons that are learned, but
there are also a lot of lessons
that are lost between wars.
So for example you know,
some of the medical equipment
that was used in World War II
was just kind of old World War I
medical equipment that had
been put in boxes.
And people are unwrapping
them and they're wrapped in
newspaper from 1919, for example.
And so that doesn't suggest much
in the way of lessons learned.
But there, you know,
there were--
And part of the reason, when
you think about the comparison
between those two wars is
because the US is actually not
in World War I for very long.
And so there's there's this really
comprehensive 17 volume set,
an official medical history
of World War I.
And reading it through it was
fascinating that there were all
these plans that people in the
military medical community had
made, and they just didn't
have time to execute them.
And to me, that shows that one
of the reasons, or one of the
conditions under which you get
the most advances in military
medicine is the duration of the
war, because you just have
more time to learn.
And so World War I, US
participation is very short.
World War II, it's much longer.
And so there are many more lessons
that are learned as a result.
>> Kevin Butterfield: In the book,
you quite naturally move into
the counterinsurgency wars,
following the section
on the World wars.
But, of course, there are
important conflicts in between
Korea and Vietnam. I just
wanted to ask you
what might you say about that period
in between 1945 and the 21st century?
What are some of the
outcomes and lessons
learned out of Korea and Vietnam
that are useful for your study?
>> Tanisha Fazal:
Well, I think, you know,
one, Korea and Vietnam
are interesting--
To me, they actually present
a little bit of a mystery.
Some of that timeline
is a little bit of a mystery,
but some of it is a little
bit of a preview.
So the preview part is thinking
about, for example, in Vietnam,
we're talking about a
counterinsurgency war.
I mean, it has a conventional
component similar to the World wars,
but it is in a lot of ways
a counterinsurgency war.
And so that's kind of a preview
to what happens in Iraq and
Afghanistan and has
implications for, you know,
how do we evacuate? What are
the kinds of wounds that are
sustained? You know,
things like that.
What are the types of
illnesses that you have to deal
with in these different theaters?
But there's also a little bit
of a mystery for me, which is
that part of, you know, when
you look at this chart, still,
you know, why there's so much
of an improvement in World War II
compared to previous wars
has to do with the fact that
in World War II, Churchill,
who I mentioned, you know,
this is from his papers and who
I mentioned earlier, really pushes
for the US military to change
its transfusion practices.
So the military, US military
has been using plasma
for transfusion.
And Churchill says, no,
we need to be using
whole blood as opposed to
plasma, because not only does it
replace fluid, it provides oxygen,
which is really what you need.
And so he is successful
in this crusade.
And doctors in the field really
notice a difference right away.
Sometime between Korea and the
conflict in Somalia in the early 90s,
the US stops using whole blood
in a prehospital setting in the
field. And I think this is a--
No one's really been able
to figure out precisely why.
There are some possible
explanations having to do with
the challenges of blood typing
in the field, having to do with
the difficulties of screening
blood in the fields
for disease. There were some
hepatitis outbreaks as a result
of some of these
transfusion practices.
But for me, that's part of
what's really interesting about
some of these conflicts in sort
of the mid 20th, the mid to
late 20th century as compared to--
As part of the timeline of
military medicine then to now.
>> Kevin Butterfield: There's a lot of
detail we can get into
in the 21st century conflicts, but
I want to focus on one innovation
or a couple, maybe two topics.
The nature of the, essentially
the growing numbers of bombs, IEDs,
as we came to learn
in the Iraq conflict
and how that changed
the nature of injury in
the field, but also in particular
the ways in which
the use of tourniquets in
the field came to be a massively
life saving and transformative.
And I don't want to say innovation
because clearly it's not,
but an initiative to get to
make the tourniquet available
and used. Can you talk to me
about either or both of those?
>> Tanisha Fazal: Yeah. So
let me-- Hopefully this will--
Here we go. Okay.
So, you know, as you, as I
showed you a little bit ago,
there has been this shift in
terms of the cause of injury
from guns to bombs and bombs
arguably can do a lot more
damage to your body in terms of
both visible and, you know,
internal injuries.
So this is from the
Emergency War Surgery Handbook
and it shows all the different
causes of injury from blast
overpressure to toxic gases.
This is somebody who's in an
armored vehicle that, you know,
in the hypothesis here is that
they're going over an improvised
explosive device.
And so that really changes
the injury pattern.
Right? But one of the
innovations of the
more recent counterinsurgency
wars is something that is kind of
mundane, but it turns
out hugely important.
It has to do with data
collection. So as a result of
having a much more robust
system for collecting data in
the field, the military medical
community is able to produce
evidence based medicine.
And one of the things that they
find, and they're relying here
on earlier literature that
shows that in Korea and Vietnam,
38% of battle deaths were
preventable, and they would have
been prevented if hemorrhage
had been controlled more
effectively. And so this is really
confirmed by all of this
data in their early years of
the Iraq and Afghanistan war,
and it leads to these new practices
around dealing with blood loss.
And one of those is the invention.
So there's a return to the
use of whole blood, which has
stopped being used.
And, you know, Edward Churchill was
crusading for it in World War II,
someone named John Holcomb,
who ends up using it
in the field and is kind of terrified
to do it in the Battle of Mogadishu,
is a person who really
crusades, or someone who
really crusades for it in the
Iraq and Afghanistan wars.
But then there's also this new
kind of tourniquet that's
invented, which is called the
combat application tourniquet.
I have one here as well.
And the idea behind the
combat application tourniquet is
that it's sometimes called
a one handed tourniquet or
a ratchet tourniquet. And so
the idea is that you could just
apply it yourself.
You don't need somebody
else to apply it for you.
And that can really be helpful
if you're in a firefight,
for example, because you don't need
somebody else to put down their
weapon and defend you.
You can even maybe defend yourself.
And this has been something
that's been considered so useful
and so important that in Iraq
and Afghanistan, on US bases,
you would see US troops walking
around with these tourniquets
loosely applied, so that if
they needed to, they could just
tighten them and hopefully
save their limb and really
save their life
should they be injured
>> Kevin Butterfield: I do need to
shift to talk about veterans benefits.
And then, of course, I'd like
to go to questions from the room
and from the online audience.
But one of the takeaways
is clearly that as we're
across 150 years, as our
society has gotten better at
saving lives in the field as we've
fought brutal and bloody wars,
there are many people
coming home surviving.
Many people not. Obviously,
fatalities are still a major
part of every war, but many
people are coming home and
they're both injured and
uninjured soldiers returning
home. And there is a system
in place by which they are
recipients of
well earned benefits.
And that goes back to
the American Revolution.
Certainly the Revolutionary
War pensions are
an important, speaking of data,
a very useful data source for
historians of the early 19th
century, because we have a lot
of information about all
these pension applicants.
But the Civil War pension system
is a major expansion of that
because of the scope
and scale of the Civil War.
Tell us a little bit about veterans
benefits from the Civil War
into the 20th century.
>> Tanisha Fazal: Okay.
So tall order.
>> Kevin Butterfield: I know, right?
>> Tanisha Fazal: As
succinctly as possible.
>> Kevin Butterfield: You don't have
to make it all the way to the present.
Just get us started.
>> Tanisha Fazal: Well, I mean,
starting with the Civil War, this is a,
you know, I think the Civil War
Veterans benefit system is a
pension based system
because that's, as you said,
it's exactly the system that the
US has had basically since the
founding of the Republic.
But the politics around the
pensions look quite different
after the Civil War because of
both the size of the war and
consequently the size of
the veteran population.
So after the war, in order to
get a pension, you have to show
that you have some sort of
disability that's associated
with your military service.
But politicians at the time,
assisted by lobbying groups like
the Grand Army of the Republic,
which is a predecessor to the
American Legion today, start to
realize that, oh, there's this
constituency that we can really
appeal to if we liberalize the
benefit system. And so that's
exactly what they do, is they
start liberalizing eligibility
for veterans pensions and
veterans benefits such that by
1893, 40% of the US federal budget
is accounted for by these pensions.
And so this is actually a real
problem in the US just
domestically, politically.
There's a concern that there's
this veterans class, but also
just the financial implications
like this is a long tail
of the costs of war.
The last remaining recipient of
a civil war pension, it was the
the daughter of a Civil
War veteran died in 2020.
Right. So this is something
that lasted a very
long time. And it was a real
concern for the US upon entrance
or thinking about entrance
to World War I, is one reason
that the US was actually
reluctant to enter World War I
and enters fairly late, and
leads to a shift in thinking
about the nature of benefits.
So it goes from pensions to
rehabilitation, because you have
all these overconfident
doctors and then--
But that doesn't work either.
So then you get the
bonus march, right?
This protest by veterans in 1932.
And then there's another concern.
>> Kevin Butterfield: Protesting
that the benefits being
provided to them are
insufficient to support them.
>> Tanisha Fazal:
Exactly. Yes.
You know, and in the middle of
the Great Depression as well.
And so when we get to World
War II, there's this concern that,
you know, we don't want
another bonus march because
we're talking about
many more people.
This would be a disaster.
So they reconfigure veterans
benefits into something that's
more familiar today, which is
the GI Bill, which focuses on
educational benefits.
So it's this idea of like
setting up veterans
economically. And that really
has been the foundation of
veterans benefits since.
>> Kevin Butterfield: And there's
a couple of graphs in the book
that help give some
sense of the long arc
of what you've just described here.
Of course, one of
them is right here.
The percentage of federal budget
spent on veterans benefits
is deeply affected by the size
of the federal budget, right.
Can you just tell us a little bit
about what we're seeing here?
>> Tanisha Fazal: Yeah. So I mean,
you see some spikes here
in the start of the graph which
represent what's happening in terms of
not only the Civil War.
Right. Because you're seeing
some veterans benefits
associated with the Civil War,
but also World War I and then
World War II.
But then, you know, the
composition of the federal budget
changes because the US,
you know, economy changes over time.
And so there are these
sort of spikes with these
different wars, but
it seems to level off.
But then you really start to see it
taking up again in the early 2000s.
And that's representing
what's happening in Iraq and
Afghanistan, but also the fact
that in 1973, the US switches
from a conscription or draft
system to the all volunteer force.
So now all of a sudden,
you actually really need
benefits in order to draw
people into the military.
And if I can just move forward
in your graph, you know,
that's very much reflected here.
If we look at not the percent
of the budget, but just
normalized 2000 to dollars, how much
we're spending on veterans
benefits, you see a real
increase over time because
you have to remember that,
you know, you're always paying
not just for the current cohort,
but also previous cohorts of
veterans at the same time.
>> Kevin Butterfield: And your
reference to the all volunteer army
that we now have, which numbers,
I think in your book, at about
1.5 million active duty at the
moment. These are all people
who are brought in to the
armed forces, encouraged
and essentially induced
to enlist based on their sense
of duty, of course, but also
benefits, potential benefits.
So there's a recruitment
package of sorts that's
essentially put together.
Is that a key part of
what's happening here?
>> Tanisha Fazal:
Yeah, absolutely.
And, you know, this is
something that the military
is very concerned about
recruitment in the era of the
all volunteer force,
increasingly so for lots of
reasons having to do with the
fact that there's a sense that
there are fewer and fewer
Americans who are eligible
physically, like who were
actually would qualify for
the military, but also
willing to do that.
And so the packages increase
and you have the different
services competing with each
other to try and recruit people
into the Marines versus the
Army versus the Navy, etc.
So you really need to have this
very strong benefits package
in order to get people to
join the military today.
>> Kevin Butterfield: Now
we're having this conversation
just across the street
from the US Capitol.
I had a sense coming in, I think,
somewhat naive, that
veterans benefits were not a
political argument to be had,
that there was bipartisan
support. And I think that's true
across much of history. But
I learned from your book that
maybe some of that is beginning
to shift, that there's a bit of
political, I don't want to say
conflict, but certainly emerging
political disagreement
about veterans benefits.
Can you tell us a little bit
about what you're seeing
in the last several years
in Washington, D.C.?
>> Tanisha Fazal: Yeah, I mean, I
would say that it's been in the last
ten years or so, you know, the kind
of political polarization that we
see in the US today has is of
an older vintage than the past
ten years, But even in that
era of political polarization,
veterans benefits were one of
the rare issues where it seemed
like everybody was kind
of on the same page.
But ten years ago, the Chairman of
the House Veteran Affairs Committee
said that veterans
benefits were no longer
a sacred cow in American politics.
And that was, I thought, a
really striking thing to say for
somebody, especially
in that position.
And I think that comment
was reflecting his own, not just
his read of the politics, but
to some extent, maybe his own
politics. And one of the
interesting things that I
came across in doing
the research for the book,
especially looking at some of
the more recent politics, is and
I would love it if somebody
else were to really take this
and run with it and see whether
this hypothesis is borne out by
the Empirics is that there's,
I think, potentially an
interesting partisan
realignment that's happening
around veterans benefits, where
historically we think about the
Republican Party as the party
of the military and the party of
veterans, but increasingly
Democrats.
And maybe this is part of kind
of the left's agenda of trying
to come up with a more coherent
set of foreign policy plans and
visions. But increasingly,
Democrats, I think, have been
really investing a lot in
veterans benefits, for sure.
So think about the debate the
last few, just a few years ago
about the Pact act, where
you have Jon Stewart out there
really arguing strenuously for
that, for the Pact act and a lot
of Democrats on board and
really pushing for this, but
against significant
Republican resistance.
And so it will be interesting.
It's definitely something I'm
keeping an eye on to see to what
extent that's a harbinger of a
potential political realignment
or a partisan realignment
around these issues.
>> Kevin Butterfield: The
transformation of medicine
across roughly a
century and a half
that you explore in the book,
the growing numbers of
people surviving injury and
war and this look at, again
across that same century and
a half of veterans benefits and
the US national investment in them.
These are important
historical stories.
I'm a historian. I see them
as valuable inherently.
But you also do have some
thoughts about what this might
mean about how the
United States policymakers
in particular, might use this
information to think about the
future. Tell us a little bit
about what you think might be
some policy applications of this,
the information
described in the book.
>> Tanisha Fazal: Yeah, I mean,
Really the main argument of the book
is that these two pillars that
you described, these dramatic
advancements in US military
medicine combined with the
expansion, especially since
World War II, of the veterans
benefits system, have increased
the long term downstream costs
of war in ways that we
tend not to appreciate.
So when we think about the
costs of war, when most people
think about the human cost
of war, they think about it
in terms of fatalities.
But increasingly that's not the
nature of casualty, is that US
forces are sustaining their
non-fatal casualties.
When most people think about
the financial costs of war,
they think about how much is it cost
to get a fighter jet up in the air.
But actually, most of what
we're paying for today for the
Iraq and Afghanistan wars are
about medical care for veterans
and other kinds of
veterans benefits.
So the main argument of
the book is that we are
systematically underestimating
the cost of war.
And if you systematically
underestimate the cost of
something, then you're more
likely to buy it, right?
So we should really be
rethinking how we cost out war
ahead of time. One of the
things that surprised me in
writing the book was that it
turns out the US is really bad
at costing out war, full stop.
And I think this is, you know,
just time and again, there's an
underestimation on the level of,
you know, really an order of
magnitude of the cost of war
when costing out war on the
front end. So I think we need a
better system to cost out war,
again, full stop.
But I think that when we do,
you know, hopefully improve that
kind of system, we really
need to think about the costs
associated with military
medicine and also veterans
benefits, because you do tend
to see military medicine
improving across the course of
a war, and you're always going
to have veterans benefits
in the United States as well.
So these are the things that
I would, you know, really like
policymakers to sort of
sit up and pay attention to.
>> Kevin Butterfield: Let's go to
questions from the room
and from our online audience.
We have microphones.
So if you're in the room and I
can start over here to my left.
>> Hi. Thank you so much.
I have two questions,
if you don't mind.
The first is whether or not
you have seen a lot of evidence
as to the counter story
of this one, which is that
as military medicine
has gotten better,
arms manufacturers,
military contractors,
military research have kind of
reverse engineered that in
order to create deadlier weapons.
And the second question is, I
do a lot of my research on the
revolving door between
military and policing and
military tactics coming home, if you
see something similar happening in
the medical field is as like
gun violence is happening and
civilian weapons are
getting more powerful.
If we see tactics of military
medicine, traveling home and
finding places in hospitals.
>> Tanisha Fazal:
Yeah, those are great questions.
So okay, so the first question
is about whether there's kind of
a back and forth between,
an intentional back and forth
between the improvements
in military medicine and the
deadliness of the weapons.
And I don't think it
quite happens that way.
I think, you know, there are
always arms manufacturers who
are trying to make the weapons
more and more deadly, but
I don't think that they're
saying, oh, they've got
penicillin now. Let's come up
with an anti something that's
going to where penicillin won't
work or where a whole blood
transfusion will work. So
I don't actually think it's
working quite in that way.
But your second question
about sort of how the revolving
door in the military medical
community between the military
and the civilian world is
actually really interesting.
I'm going to take a little bit
of a-- I'm going to spin it
a little bit and say that one of
the things that the military
medical community is really
concerned about right now is
something that they
call the walker dip.
And the idea behind the walker
dip is that they're essentially
worried that their skills are
going to become rusty because
there isn't a major war, which
is a good thing that the US is
involved in right now.
And so the thought is to in place
military medical personnel,
trauma surgeons, for example,
in civilian trauma centers.
Now, this is, you know,
it's an interesting strategy.
It makes me wonder what happens
when there is a war. Right.
What happens to
those trauma centers?
And that's something
that's always historically
a problem because, you know,
World War II, you have entire
hospitals that are essentially
decamping to Europe, and that
leaves everybody
stateside very shorthanded.
But you also definitely see
kind of a back and forth between
civilian doctors and military
doctors, because a lot of times
civilian doctors are, they are,
you know, in earlier eras,
drafted into military service.
And even today you have a lot
of people in the reserve and the
guard who are, you know,
in their civilian lives are
medical personnel. And they take
what they learn from
either site to the other.
>> Kevin Butterfield:
Another question from the room?
While we're waiting for one,
there's one area I did not
touch on, so this is my omission,
not yours. Because you
do discuss it in the book
and that's mental health.
Could you talk a little bit
about-- You could focus on
any one period, including the
present or across the entire arc.
How does that fit
into your study here?
>> Tanisha Fazal: Yeah. So there's
a chapter in the book on sort of
the invisible, what Adam Montgomery,
who is an historian based in Canada,
that what he calls the
invisible injuries of war,
war induced psychological trauma.
And I use that sort of very
clunky term of war induced
psychological trauma, which is
a lot of syllables, because what
we call today PTSD, you know,
the version of that, that was
experienced in past conflicts
had very different nomenclature.
So in the Civil War, they
called it, you know, first of all,
let me just say that you
cannot diagnose somebody,
obviously, in 1863 with PTSD today.
So I'm not claiming to do that.
But war induced psychological
trauma is as old as war itself.
I mean, Homer talks about it
in the Iliad, but so in the Civil War,
they call it sunstroke or
nostalgia or soldier's heart.
In World War I, of course,
it's called shell shock.
In World War II, they
strategically rename it.
They start to call it combat
exhaustion or battle fatigue.
And the reason that they rename
it is because there were so many
shell shock casualties
in World War I.
They want to avoid that, and
they also want to avoid the
stigma of that. And so the
theory that they develop is
essentially, you know,
we'll give you a rest, a respite
from the war. And they
would literally sedate people
for 48 hours or so, sort of take
them out of the fight and then bring
them back to their unit. And
the hope was that because it was
battle fatigue or combat stress
exhaustion, they wouldn't be
stigmatized in quite the same
way that someone with a
Shellshock diagnosis would.
Now, today, of course, we talk
about, we don't talk about
battle fatigue or
combat stress exhaustion.
We talk about post-traumatic
stress from sort of the primary
diagnosis and that I think
there's also a really
interesting history there,
because this is a term that,
well, it's very familiar today,
doesn't really enter--
It's not a technical
psychiatric diagnosis until 1980.
And the reason it becomes
one is because a group of
Vietnam veterans, as well as
clinicians, mental health
clinicians, realize that the
American Psychiatric Association
can be lobbied because they
recently observed that the
gay community successfully lobbied
the APA to remove homosexuality
as a disorder, so they lobby
them to include PTSD.
And they do.
And this is actually, you know,
it's been-- We've all, I think,
seen this really interesting
story of how there's a lot of
back and forth and
controversy around PTSD.
It's become less stigmatized.
But then also going back to the
question of veterans benefits,
there's this concern that
people are sort of trained to
apply for a PTSD diagnosis in a
way that will actually increase
their disability when they
separate from the military.
So it's, you know,
there's a lot there.
>> Kevin Butterfield:
Other questions from the room?
I see one on the back
row in the center.
>> Thank you.
I was wondering if you could
say something about your
journey through the archival
documents that you've showed us
and the different collections
that you've used, because I'm
assuming you're dealing with
quite sensitive information.
Did you run into major issues,
minor issues?
>> Tanisha Fazal: So--
I love archives.
So thank you for that question.
I think what's interesting
is that what we
think of as today, as sensitive
information was not necessarily
thought of that way in,
say, the 19th century.
So there's a six volume
official medical history of the
Civil War, which has pretty
detailed case reports
in a way that you would not be
able to access and should not
be able to access for military
personnel and more recent wars.
But I just don't think that
that was a concern at the time.
I will say that when the
pandemic started, I was working
on this book, and I actually
had taken out of the
library this official history.
The copies that I had were
from the late 19th century.
That's when they were published,
and they were kind of
crumbling in my hands.
And so I had a moment of panic,
and I had to switch to
digital in order to be able
to sleep at night.
But but a lot of the archival--
You know, the other thing
that was really interesting to
me when there were a lot of
things, but is that looking at
these different collections,
I'm mostly by doctors and they're all,
almost all men and certainly all white.
And so it really brings home
the sort of selection bias
in terms of what materials
are available to you.
But at the same time, they were
all friends with each other.
And so you can really kind of
start to get a complete picture
of their conversations
with each other.
And the way that sort of--
It was very clubby in a lot of ways,
and the ways that the medicine
work and sort of the
personality is at work as well.
If you're interested, there's
this one World War II surgeon
Henry Swan, who was a
beautiful writer, and his family
typed up his letters home
with, I think, with the
idea of making it a book.
And those are available digitally
through the National
Library of Medicine.
>> Kevin Butterfield: We'll take our
final question from--
Maybe we'll take
two more questions.
Take one from online
and one from the room.
Okay.
>> Thank you for the talk.
You pointed out a lot of
interesting factors that
affected how fatal injuries were
over the course of history.
Are there any kind of similar
events that affected how
fatal or how fatal, like PTSD
might have been, or like how
much it may have affected people's
functioning after they get home?
>> Tanisha Fazal: Yeah. So
that's a fantastic question.
It's a really hard question to
answer historically, because
again, you can't diagnose somebody
in 1917 with PTSD in 2024.
But for sure we are seeing
an increased suicide rate
amongst US military
personnel today.
It's hard to know how much of
that is due to PTSD per se, and
there is an interesting and
important set of controversies
around kind of the potential
overlap medically between PTSD,
for example, and traumatic brain injury
and other kinds of blast injuries.
Probably a lot of these things
are happening together.
It's a co-occurrence.
But diagnostically it's really
difficult to pull all of that apart.
>> Kevin Butterfield:
And our last question
will come from the online audience.
>> Yes. So someone asked what
resources or information sources
would you recommend for further
study on one's own in the issues
of military injuries
and military health?
>> Kevin Butterfield:
Aside from your own book.
[Laughing]
>> Tanisha Fazal: So I think if you're
interested in military medical history,
there are really, you know,
a really fantastic sources.
But if there's something that
you're interested in looking at
for what's going on today, I think
and I will say that for me,
one of the most productive
kind of approaches to research
for this book was actually
attending military medical conferences,
which I have to say,
as a political scientist,
or the exhibition floors of those
military medical conferences
you can imagine are much
more interesting than the
exhibition floors for political science
conflicts or conferences, rather.
So, you know, there's the Special
Operations Medical Association
conference, which is every May,
and there's another one, MHSRS,
Military Health Systems
Research Symposium
which is every September.
And that's kind of where you
can just go and really be a
fly on the wall and really see what
the, you know, what everybody is
talking about. And there's
kind of a vibe in the room.
You can really see dominant
themes emerging, you know,
in the panel sessions, in keynotes
and just also on the floor
kind of walking around.
>> Kevin Butterfield: Our
conversation today has been
with Doctor Tanisha Fazal at the
University of Minnesota
on her new book, "Military Medicine
and the Hidden Cost of War".
Thank you so much.
>> Tanisha Fazal: Thank you.
[Applause]