Throughout recent history there has been a pattern whereby military medical care improves in wartime and these advances are lost by the time the next conflict occurs. This dip in medical performance potentially represents lives that may be lost and recovery that may be impaired for our young servicemen and women at the start of every new conflict. When reviewing the wars of the last two centuries, three themes emerge. Firstly, post-war military cuts fall disproportionately on medical services, leaving a mismatch between the size of forces that can be deployed and the ability to care for them when injured. Secondly, insufficient medical representation in military operational planning results in the neglect of medical logistics; and finally, technical and procedural lessons are not adequately captured and incorporated into training and doctrine.
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For most of the 21st century the UK military has been engaged in prolonged campaigns of high-intensity conflict. In 2018, our involvement in the Middle East and North Africa continues, but thankfully casualties are now infrequent. This represents an opportunity to reflect on the hard-won lessons of recent years where a massive joint effort meant that those injured in combat had a greater chance of survival than in any previous conflict.1
However, great advances in battlefield medicine have also been seen in previous conflicts and then subsequently forgotten.
This repetitive drop in the performance of our combat casualty care system potentially results in a human price being paid at the start of every new conflict, which results in unnecessary loss of life.
In my years in the senior leadership of the Defence Medical Services, I fought to prevent this peacetime drop in performance, so much so that my US colleagues coined the eponym the ‘Walker dip’ to describe what I was fighting against.
This paper examines the fluctuations in both the number and performance of those tasked with providing military medicine from the nineteenth century to the present day. Several themes recur after each period of conflict. Furthermore, proposals are made as to how we can manage the challenges of the present so we can prevent our own ‘Walker dip’ in the time that we carry the responsibility of caring for the young people that are subject to the dangers of service in the Royal Navy (RN) and our sister services.
The Nineteenth Century
The Napoleonic War 1803-1815
The 12 years of the Napoleonic wars provided ample opportunity for surgeons to improve both their individual war surgery skills and the overall combat casualty system. By the end of the Peninsular War in 1814, Wellington’s army had refined their combat casualty care system over the years as they fought their way from Portugal and through Spain. By the time Toulouse had been captured in the last major battle of the conflict, mortality had dropped to 11% (which was considered an impressive achievement at the time),2 but by the Battle of Waterloo a year later in 1815, the mortality rate had fallen even further to 9%.3 This improvement in the care of the wounded was attributed to the recognition of the medical consideration in military planning, increases in medical staff, improvements in their training and experience, development of medical treatment facilities near the front and improved medical logistics. However, it is important to realise that at that time, prior to the 1858 Medical Act,4 less than 10% of those serving in the RN as ship’s surgeons, or equivalent in the Army, held a university medical degree.
The Crimean War 1854-1856
After Napoleon was finally defeated in 1815, there were considerable reductions in military staff, which persisted for nearly 40 years until the Crimean conflict. Sadly, the hard-won lessons from the Napoleonic wars were neglected in the years that followed. This severe ‘Walker dip’ meant that the Crimea became a byword for army incompetence and inefficiency, mainly because of the poor way that casualties were treated.
At the beginning of the Crimean War, the Medical Department of the Army was essentially a civilian organisation, that operated largely independently of the Army, and was in turn ignorant of its planning and capability. Regimental doctors were independent of the Army Medical Department, and had no way to transfer casualties to the rear or in turn request medical supplies.5 A stark illustration of the appalling care is the mortality rate of 9% amongst casualties being evacuated by sea from Balaclava to the Bosporus, a voyage of only 36 hours.
In her post-war 1858 publication “Notes on matters affecting the health, efficiency and hospital administration of the British Army”, Florence Nightingale lamented the drop in the performance of the Army Medical Department, reporting that the sickness rate had risen from 21% in the Peninsula to 39% in the Crimea, 40 years later.6
Although many others similarly campaigned for improvements to the sanitary hygiene and combat casualty care of British forces, Florence Nightingale has been credited with some of the key reforms during and after the Crimean War, including the reorganisation of the Medical Department, the creation of an Army Medical School, the establishment of a Department of Medical Statistics, and a barrack and hospital improvement scheme.
In the second half of the century there were medical advances that would have a significant impact on military medicine. Building on Louis Pasteur’s germ theory, Joseph Lister demonstrated that antiseptics could kill bacteria in traumatic wounds and on a surgeon’s hands and instruments.7 Within the military there was gradual professionalisation of Medical Officers, and improvement in their salaries as they received first Royal Warrants and then full commissions, but their pay still took many years to equalise with that of general officers.
Boer War 1899-1902
Problems perceived in the Crimea and the apparent reforms combined with military medical advances should have given enormous patient benefits. The Royal Army Medical Corps (RAMC) was formed in 1898 immediately before the Boer War, with only 540 Medical Officers spread across the entire British Empire with medical equipment which ‘was very obsolete, some of it dating back to the Crimean War’.8 The Army Medical Department was again unprepared for major warfare, and there was a dramatic mismatch between the number of fighting troops which could be placed into the field and the medical units to support them.8 Then, as now, there was a reliance on reserve forces and civilian volunteers, with civilian surgeons, physicians and whole hospitals eventually proving essential to maintain levels of care to the fighting units. The Army were also dependent on the British Red Cross and St John’s Ambulance for assistance with transporting casualties the large distances back to ports from where they could be repatriated.8
The Army Nursing Service (ANS) had been formed in 1881, and its members served in the Boer War; their enormous contribution to the care of the casualties from that conflict underscored the importance of a formal system of recruiting and training a professional corps of nurses for future conflict. The more formally constituted, regular military nursing service was established in 1902, the Queen Alexandra’s Imperial Military Nursing Service.
Another important change was the establishment of the Army Medical College in London and the concurrent founding of the Journal of the Royal Army Medical Corps.9 Both developments were explicitly aimed at the recording and dissemination of hard-won lessons of conflict, an important attempt to mitigate against the post-Crimea ‘Walker dip’.
The Twentieth Century
First World War
At the outbreak of the First World War, the RN had not forgotten the lessons from previous conflicts and rapidly instigated first aid training among its ships’ companies - a practice still integrated into basic and annual training today.10 On the Army side, the relatively small, but professional and experienced British Expeditionary Force that was Britain’s initial land contribution was supported by internal medical units augmented by reserves and non-military, volunteer medical organisations.11 Despite this, however, Medical Officers were seldom allowed to enter the inner sanctum of Operational HQ, and medical issues were rarely given consideration in decision-making during general war-fighting.
Reserves were identified to support the six initial Expeditionary Force divisions, but it quickly became clear that this was not going to be a rapid battle, rather an event that grew considerably and required ever-increasing staff with the numbers of dead and wounded dwarfing those seen from any previous major conflict.
One of the key medical events in the First World War was the series of ‘Inter-Allied Surgical Conferences’ in Paris in 1917, which were held for the purposes of establishing and disseminating best practice. The results of these were published in an attempt to prevent this knowledge being lost in a post-war ‘Walker dip’.12
Second World War
The First World War left the military and indeed the country exhausted and financially depleted. National expenditure turned to economic repair and social redevelopment. Medical field units were axed and medical recruitment into both the RN and RAMC was reduced, but even the more modest manpower targets were often not met. The RAMC particularly struggled with recruitment and retention after the First World War.13 A ‘Committee on the Medical Branches of the Defence Services’ was established to address these issues, chaired by the head of the Home Civil Service, Warren Fisher. It reported in 1934, mainly focused on improving pay and conditions for Medical Officers. Tellingly, the recommendation that the Director General of the Army Medical Services should have a seat on the Army Council was rejected,14 indicative of a continued lack of medical representation in general military planning.
Despite this, there was perhaps only a small dip in capability and performance between the world wars, mainly because so many senior figures at the start of the Second World War had served in the First. Perhaps the greatest example of this experience was Sir William Heneage Ogilvie KBE L/RAMC, who served as a volunteer in the Balkan War, a Major in the First World War and a Major General in the Second. He toured US medical units in 1943, lecturing on war surgery and particularly the ‘Seven Cardinal Sins of War Surgery’. He lamented that these lessons had been hard-learned and well-established in the First World War, and yet had to be re-learned by the new generation of surgeons who deployed for the first time during the Second World War; he later eloquently described this post-war dip in knowledge:15
‘What are the lessons of War? The school of war in which we learned those lessons is to return from postgraduate concern with surgical details which occupy our minds in peace-time, to the study of the basic principles of surgery, the reactions of the human body to injury and infection. These principles are unchanging. They have remained the same since the first super ape hit his fellow super ape with a club. They were the same in the Trojan War as they were in Korea. But in each period of peace they are forgotten and in each war they must be relearned before the detailed advances that have been made since the previous war can be incorporated into them.’
Korea and the Falklands
The period after the Second World War followed a similar pattern to that after the First; the military contracted in numbers, but disproportionately so in the Medical Services. Furthermore, as the military adapted their technology to the atomic, jet and computer age, medical equipment was not updated.13 The Korean War saw a return to high-intensity warfare and the RN again employed a Role 3 Hospital Ship, in this case HMHS MAINE, which transferred casualties between Korea and Japan while providing surgical and nursing care.16
Unfortunately, the lessons of the utility of Maritime Role 3 had been forgotten by the time the RN unexpectedly found itself planning large-scale operations in a distant theatre. There had been no hospital ships in the fleet for decades when the Task Group steamed to the South Atlantic in 1982. To solve this problem, a P&O Cruiser was taken up from trade and rapidly converted to a hospital ship.17,18
Medical support to the Falklands in many ways represented the end of a medical era; care would have been very familiar to surgical teams from the Second or even the First World War. Patients were hand ventilated via masks, instruments were cleaned rather than sterilised and surgeons operated in their shirt-sleeves.19
The Gulf War
Only eight years later, when British forces deployed to the Gulf, their medical capability was vastly different from that which had deployed to the Falklands. The Army deployed two full Field Hospitals, and the RN deployed its new Role 3 Primary Casualty Receiving Facility on Royal Fleet Auxiliary (RFA) ARGUS for the first time. Both types of facility were equipped with modern imaging, laboratories, critical care units and ventilators. It appeared that for the first time in modern history, lessons from the previous conflict had been truly learned and implemented, and no ‘Walker dip’ was seen, though it is important to acknowledge that the conflict resulted in relatively few coalition casualties, which meant that the combat casualty care system was not severely tested.
Iraq and Afghanistan
These two conflicts, often conflated, differ from most others in respect of their duration, intensity and the static nature of the deployed medical facilities. The large numbers of severely injured casualties and their rapid repatriation meant that public attention focussed not just on care in the field, but also on the care in the Role 4 facility back in the UK. These were the first wars fought in a modern era since all UK military hospitals had closed and initially there were well publicised issues with care at the NHS-military facility in the Royal Centre for Defence Medicine in Birmingham.20 However, lessons were learned and the new hybrid facility evolved as the performance of the combat casualty care system reached levels never previously seen.1
A unique feature of this recent conflict was the very deliberate effort to initiate systematic quality improvement and focussed research. Central to this was the establishment of the trauma governance system and the Joint Theatre Trauma Registry,21
which evolved from work performed by Brigadier Tim Hodgetts L/RAMC in Kosovo in the late 1990s.22 This system allowed new knowledge, techniques and research to be rapidly captured, evaluated and then fed back into the training cycle for those about to deploy.
Conclusions and lessons for the future
This examination of the last two hundred years of medical support to British military operations has demonstrated a cyclical pattern of wartime improvement and post-war dips in performance. Three themes recur in our history and seem to be associated with performance dips, namely a post-war reduction in military size falling disproportionately on the medical services, rendering them too small to support the number of deployable military forces; a failure of medical services to be represented in senior operational planning; and a failure to adequately capture techniques, tactics and procedures derived over the course of a conflict and incorporate these into doctrine and training.
We are all passionate about providing the best possible care for our young men and women who are placed in harm’s way in service of our country. In order to prevent these dips from occurring again, we need to think carefully about the both the successes and failures of our predecessors; emulate the former and avoid the latter.
Conflict of interest
The author is the former Surgeon General of HM Armed Forces.
I would like to thank Surg Cdr Jowan Penn-Barwell for his editorial assistance.