At a dinner party someone asked Albert Einstein what weapons might be used in a Third World War. He replied, “I don’t know what weapons might be used in World War III. But there isn’t any doubt what weapons will be used in World War IV. Stones and spears.”
In writing these columns, I aim to guide pilots through health issues that might impact their flying. I am, however, aware that many of our number have fired guns in anger or flown in combat, and we thank the latter for your service. And while this missive is apolitical, I must address the Ukrainian war to explain the far-reaching medical consequences as it affects all of us in many ways. But first, I thought you might like a quick journey through the history of battlefield medicine, which has produced many incredible advances.
Prior to the 1700s, soldiers who fell were left to their fate until Napoleon’s chief surgeon, Dominique Larry, suggested removing the wounded. He designated brancardiers (stretcher-bearers) for this task and then horse-drawn ambulance carts; the word “ambulance” derives from hôpital ambulant, French for “walking hospital.”
Given available primitive medical care, most died from bugs, not bullets. In the American Civil War, over 60% of the Union losses of 304,369 men were from malaria, dysentery, typhoid and other disease. And in the Spanish-American war of 1898, for every man dying in action, ten succumbed to typhoid. In fact, it was not until the early part of the twentieth century that the “disease era” became the “trauma era” – we got better at controlling disease to some degree, and yes, medical knowledge increased, but weaponry evolved faster. And another philosophy evolved: while killing an enemy combatant was good, maiming him was even better as that would occupy brancardiers, healthcare workers, and resources and send a disfigured soldier back to civilian life to terrify the populace.
In the First World War (1914–1918) the Royal Army Medical Corps (RAMC) triaged patients into one of 3 groups:
Triage systems continue today, but during trench warfare dreadful conditions existed with little shelter, mud, human waste, infestations of rodents and lice and unburied corpses. I strongly recommend Peter Jackson’s 2018 documentary They Shall Not Grow Old with colorized footage and dubbed voices that capture the horror.
Another watchable movie is Radioactive, which details Marie Curie’s phenomenal life and achievements including bringing new-fangled X-rays to the front lines in the “radiological car” she invented, which doubtless helped guide many surgeries and saved countless lives.
This war also introduced widespread blood transfusions and antiseptic techniques that contributed to improved survival from injuries that would previously have proven fatal. As a result, nearly three quarters of a million British troops returned home with major injuries and deformities. This inspired a Kiwi doctor, Harold Gillies, to establish a specialist hospital to treat facial damage in what was the birth of modern plastic surgery. With over 40,000 amputations, improvements in artificial limbs such as articulated legs and claw hands allowed many to regain some semblance of a normal life.
In the years between the two world wars, sulfa drugs and penicillin were developed and played a huge role in addressing infections that would otherwise have killed many more. Of course, today, antibiotic overuse has placed us in danger of resistant bugs that pose an existential threat. World War II also led to improvements in fluid resuscitation of warriors in shock with dried plasma, albumin and other infusions. Such developments meant that whereas only 4% of injured soldiers in the first conflict lived to tell the tale, in the Second World War, that number leapt to 50%. These battlefield inventions have influenced progress in every single medical specialty, but of course, trauma is the major “winner.” The concept of the “golden hour” has informed how civilian trauma is handled in all big cities today – helicopters, well-trained paramedics replacing the brancardiers’ “scoop and run” practice, and designated medical trauma centers with specially trained doctors and allied healthcare professionals.
During WWI the concept of “shell shock” was born; some who were close to exploding ordnance would behave strangely and maybe run from the trenches. And some of them were shot as deserters. Many might have been suffering from traumatic brain injury (TBI) caused by the explosive shock waves which travel at immense velocity, much faster than any bullet, as energy transferred is the mass of an object multiplied by its speed squared. Being anywhere near an explosion is akin to being hit over the head with a sledgehammer. So, many cases of shell shock almost certainly had physical damage to the brain.
We hear much of post-traumatic stress disorder (PTSD) these days, but true PTSD requires experiencing something awful firsthand, not reading about it online. And PTSD causes depression, anxiety, and addiction to name a few. The United States National Institute of Mental Health grew out of wartime awareness of these sequelae. Think of our Vietnam-era vets who could not fit into society and joined the ranks of the homeless, or those returning from Iraq and Afghanistan committing suicide in large numbers. The toll on the millions of people from Ukraine with PTSD will be felt across the globe.
We have all seen the images of civilian and military dead and physically injured. But what of all the chronic diseases that Ukrainians suffer from, cancer, diabetes and others? And acute diseases like heart attack, stroke, pneumonia? And fragmentation of society leading to loss of hygiene – no running water, food, sanitation? All of these impact those in the war zones, of course. But when they leave as refugees, they take their problems to well-meaning neighboring countries. How will they cope?
How many old buildings in Ukraine destroyed by Russian shelling contained asbestos, now released into the air and harming those nearby and who knows how far afield? And modern weapons contain depleted uranium for armored vehicle protection or to penetrate such vehicles. Each explosion or loss of a tank liberates dangerous particles into the air that can cause lung damage and radiation damage. And that is just two examples of noxious substances contaminating the air we all breathe. We removed lead from gasoline slowly but surely and the data shows that the damage from lead is evident everywhere. Maybe we stopped just in time. But what else is next up for us? The worst nuclear accident took place at Chernobyl in Ukraine in 1986 and we saw with trepidation that site being occupied. In the eastern Donbas region four years ago, the destruction of industrial sites released so many chemicals that it was deemed to be an ecological disaster. And remember, this isn’t just some country “way over there” – they breathe the same air we do, drink the same water. It affects us all.
And what of infectious diseases? This war started just as Ukraine was pulling away from the pandemic, but with only 35% of their population vaccinated, and a massive exodus, might we see a resurgent coronavirus strain in this group of people? Nearly 20 years ago, Europe was deemed to be polio-free, but since October 2021, Ukraine has been dealing with a polio outbreak with two children suffering from the paralytic form and 20 more testing positive since then. For each active case there are 200 silent carriers, and according to Dr. Gabriele Fontana, a regional Health Advisor for UNICEF, 100,000 children remain unvaccinated and at risk. With the massive refugee situation, how many have crossed into Poland or other countries? And what could that lead to?
Tuberculosis, a major global killer, is also an issue, as Ukraine has the fourth highest tuberculosis incidence in the European region and the highest rates of multidrug-resistant TB in the world, reporting approximately 30,000 new cases of TB annually. How many have left their country bringing few possessions, but a fatal bug in what may be the greatest refugee crisis in living memory?
Turning to battle injuries, modern medicine is wiser than a swift saw, strong assistants and a swig of whiskey. But to do good work we need supplies, facilities and staff. One neurosurgeon I connected with in Kyiv was operating in a dark, cold, wet basement by flashlight. While brave pilots and others bring much-needed supplies, and volunteer medical units are supporting efforts, the sequelae of this war are awful to contemplate. Beyond the deaths, whose number we may never know, the injuries are legion. Prior to war, Ukraine was medically sophisticated but with a significant disease burden; over 2 million diabetics, a quarter of a million living with HIV and over 160,000 cancer patients. Medical supplies of even basic items like oxygen and morphine are critically low, and while many sick and injured have been transferred to other countries, many cannot get out due to either their infirmity or their location.
And for more consequences? Ukraine was known as the “breadbasket of Europe,” exporting greater than 40% of its grain to the Middle East and Africa, and more than 50 countries depend on Ukraine for their wheat. So, with farming effectively suspended and Black Sea ports besieged, others will starve, causing health and political tensions to rise elsewhere.
I mentioned PTSD above. This war will have caused massive numbers of people to be distressed and develop sequelae that may have downstream consequences; combat flashbacks, insomnia, nightmares and panic. And the traumatized children who were orphaned by the war? Same deal. Furthermore, some research suggests that future children born of parents who developed PTSD may inherit the problems. Not good.
Environmental considerations? Too many to mention. I have hinted at the nuclear threats from ill-managed power plants and disseminated plutonium, but then there is the chance a tactical weapon or worse might be deployed. Too scary to contemplate. Or chemical and biological weapons.
So why this article in AOPA? As pilots, I would like to think we are smart, have had some degree of success in life and have a moral as well as geographic compass. Please consider what you can do to help; doctors are providing telemedicine guidance to less experienced colleagues in Ukraine if unable to travel there personally. I know some GA pilots in Europe who are helping move supplies or evacuate the sick, injured or displaced. There are countless charities trying to do their bit.
I enjoy discussing my writing with friends at AOPA, and while I take 100% ownership if people disagree with my positions, I am always open to other perspectives. Gary Crump, who many of you know as a wise and faithful servant to our community, made some poignant comments that I want to include: “Their heartaches and pitiful circumstances are ours, even if we haven’t directly felt them yet. The air we breathe and the water we drink are not dispensed based on affluence and social standing.” The sooner we learn that we are all in this together, the better.
While hearing stories of human courage and decency lifts our spirits, we all hope that this conflict ends soon. For as H. G. Wells said, “If we don’t end war, war will end us,” and Plato maintained that “only the dead have seen the end of war.”