Is war in decline? Recent scholarship suggests that it is. The empirical basis for this argument is a decline in battle deaths over the past several centuries, a standard metric for counting wars and armed conflicts. Dramatic improvements in medical care in conflict zones—in preventive medicine, battlefield medicine, evacuation, and protective equipment—have raised the likelihood of surviving battle wounds today compared with past eras. Thus the fact that war has become less fatal does not necessarily mean that it has become less frequent. Original data on wounded-to-killed ratios, supplemented by medical research and interviews with physicians from the military and nongovernmental communities, is used to advance this claim. The results show that the decline in war is likely not as dramatic as some scholars have argued. These findings question the foundation of existing datasets on war and armed conflict. They also highlight the growing need for policy focused on the battle wounded.

Dead Wrong?: Battle Deaths, Military Medicine, and Exaggerated Reports of War's Demise

Background
From August 2006–August 2010, as part of the ISAF mission, the Armed Forces of the Netherlands deployed a role 2 enhanced Medical Treatment Facility (R2E-MTF) to Uruzgan province, Afghanistan. Although from the principle doctrine not considered a primary task, care was delivered to civilians, including many children. Humanitarian aid accounted for a substantial part of the workload, necessitating medical, infrastructural, and logistical adaptations. Particularly pediatric care demanded specific expertise and equipment. In our pre-deployment preparations this aspect had been undervalued. Because these experiences could be influential in future mission planning, we analyzed our data and compared them with international reports.

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Pediatric Surgical Care in a Dutch Military Hospital in Afghanistan

History of the bladder stone.

Introduction On January 11th 2013, France launched Operation Serval in Mali following Resolution 2085 of the Security Council of the United Nations. Between January and March 2013, more than 4000 French soldiers were deployed to support the Malian National Army and the African Armed Forces. Methods All of the patients who had surgery during Operation Serval were entered into a computerised database. Patients’ demographic data (age, sex, status) and types of performed surgical procedures (specialties, injury mechanisms) were recorded. Results 268 patients were operated on in Gao's Role 2 with a total of 296 surgeries. Among those operated on, 40% were Malian civilians, 24% were French soldiers, and 36% were soldiers of the International Coalition Forces. The majority of the surgeries were orthopaedic, and visceral surgeries were common as well, representing 43% of the total surgeries. Specialised surgical procedures including neurosurgery, thoracic, and vascular surgery were also performed. Forty percent of the surgeries were scheduled. War-related traumatic surgeries represented 22% of the surgical procedures, with non-war related surgeries and non-trauma emergency surgeries making up the rest. Conclusion this analysis confirms the specific characteristic of asymmetric warfare that it results in a relatively reduced number of war-related casualties. Forward surgical teams have to deal with a wide range of injuries requiring several surgical specialties. Surgeries dedicated to medical aid provided to the population also represented an important part of the surgical activity. Because of the diversity and the technicality of the surgical procedures in Role 2, surgeons had to be trained in war surgery covering all of the surgical specialties, while they maintained their specific skills. In France in 2007, the French Military Health Service Academy (Ecole du Val-de-Grâce, Paris, France) offered an advanced course in surgery for deployment in combat zones, with a special focus on damage control surgeries and the management of mass casualties incidents.

Surgical challenges in a new theater of modern warfare: The French role 2 in Gao, Mali.

Urinary calculi are being recognized more frequently in children and the urinary bladder is the most common site for stone formation in the lower urinary tract. Bladder calculi are grouped into three basic categories: primary idiopathic/endemic, secondary, and migrant. The incidence of vesical calculi has declined significantly in the last 70 years in developed nations owing to improvements in nutrition and socioeconomic conditions, but it is still high in developing nations. Primary idiopathic/endemic bladder calculi typically occur in children, in the absence of urinary tract infection (UTI), urinary stasis, or foreign body, and diet lacking in animal proteins is the major contributor factor. Comprehensive preventive and treatment strategies are critical for improving the quality of life of diseased children, in addition to helping to eradicate, or at least decrease, the incidence of endemic bladder calculi in developing nations.

Endemic bladder calculi in children.

Background: The mission of a Forward Surgical Team (FST) is to provide immediate lifesaving surgery to wounded U.S. and coalition forces. The degree of humanitarian surgical care provided to civilians is a topic of controversy. Methods: From May 2011 to November 2011, the surgeons of the 126th FST provided humanitarian surgical care to Afghan civilians. Results: The FST surgeons provided 553 surgical evaluations on 511 Afghan civilians. Of the patients, 95% were male and 38% were children. Forty percent of the clinic visits involved wound care and 20% involved a general surgery diagnosis. Seventeen percent involved an orthopedic diagnosis and 23% involved various surgical subspecialty diagnoses. Of the patients, 11% required a procedure necessitating the use of anesthesia. Interviews with Afghan patients and civic leaders identified a positive impact. Conclusion: This is the first report of humanitarian surgical care provided by surgeons of a FST in Afghanistan. Time and resource investment was mi...

Humanitarian care by a forward surgical team in afghanistan.

Objectives: Military surgeons have been providing humanitarian care in Afghanistan since 2002. There are scant published reports on the details of that care. We report here the experience of deployed U.S. Army general surgeons in the management of an endemic problem, bladder stones in Afghan children. Methods: A retrospective review was performed of pediatric patients presenting to an International Security Assistance Force humanitarian clinic over a 12-month period from October 2010 to November 2011. Symptoms at presentation, diagnostic modalities, and treatment provided were analyzed. The general surgeons of the 126th Forward Surgical Team (FST) provided surgical consultations for this military humanitarian clinic on a remote base in western Afghanistan. Results: Eight male pediatric patients of an average age of 4 years presented with dysuria and underwent further evaluation. In five patients, the use of a portable ultrasound machine led to the diagnosis of bladder stones. Three other patients ...

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Bladder stones in Afghan children.

Objective: Historically, compliance with malaria chemoprophylaxis by military service members (MSM) has been notoriously low, ranging from 30 to 56%. Since 2002, 28 to 85 cases per year of malaria have occurred in MSM deployed to Afghanistan. During their deployment to Afghanistan, the authors identified a low compliance rate with malaria chemoprophylaxis. A performance improvement project was developed to improve compliance. Methods: In July 2011, a performance improvement plan was developed to improve malaria chemoprophylaxis compliance in MSM arriving on a remote base in western Afghanistan. The plan included a 15-minute briefing and a medical consultation for MSM who had discontinued their chemoprophylaxis because of side effects. At the conclusion of their deployment, the MSM were surveyed on their compliance. Results: Ninety-four MSM attended the briefings. Eighty (85%) MSM completed the survey in October 2011. Ninety-eight percent were taking doxycycline (n = 78). Ninety percent (n = 72) re...

Michael Woll

Papers

Humanitarian care by a forward surgical team in afghanistan.

Bladder stones in Afghan children.

Improving compliance with malaria chemoprophylaxis in Afghanistan.