Military Medicine and the Changing Costs of War

Tanisha Fazal, University of Notre Dame

Research Grant, 2016

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The decision to go to war is often framed as a cost-benefit analysis. But what if we are getting the costs systematically wrong? A positive trend—improvements in military medicine that save lives on the battlefield—has led to significant underestimation of the costs of modern war.

The costs of war, both human and financial, are traditionally conceptualized in a time-bound manner. Specifically, the human costs of war are typically described in terms of battle fatalities, while the financial costs of war focus on military materiel. This view of the costs of war is not appropriate to today’s wars.

Over the past two centuries, dramatic improvements in military medicine, alongside the historic expansion of the veterans’ benefits system, have increased the long-term downstream costs of war for the United States in ways underappreciated by both policymakers and the public.

In an era of anticipated increased great power competition, updating our understanding of the costs of war is an especially urgent task.

Consider first the implications of improvements in military medicine for the human costs of war. The ratio of soldiers wounded to those killed in battle held steady at 3:1 for centuries.

Over the course of the 19th and 20th centuries, however, that ratio began drifting up with improvements in medicine. In the US’s most recent wars in Iraq and Afghanistan, the historical wounded-to-killed ratio more than tripled; today it lies between 10:1 and 17:1. As a percentage of those deployed, many more military personnel are returning home having survived wounds they would not have survived in past conflicts. Improvements in military medicine, from better preventive care to advances in hemostatics to investment in air evacuation, are the principal cause of this shift.

But the lives saved are often indelibly altered. Returned military personnel and the families who care for them bear visible and invisible costs of war for decades. The US government also bears significant long-term financial costs of war as a result of these military medical improvements. Veterans Affairs (VA) spending today outstrips that of agencies such as the Departments of Agriculture, Education, and Homeland Security. And while concern over the cost of Civil War pensions was so great that anticipation of creating a new generation of pensioners arguably delayed the US’s entrance into World War I, to suggest reducing veterans’ benefits today would likely invite rare bipartisan backlash.

To be clear, I do not argue that we should roll back military medicine or veterans’ benefits. Instead, key decision-makers must take these downstream costs into account when considering military action. US defense policy is currently pivoting from counterinsurgency wars in the Middle East to meeting challenges posed by more conventional rivals Russia and China. In an era of anticipated increased great power competition, updating our understanding of the costs of war is an especially urgent task. That war appears cheaper than it is today makes the world a more dangerous place. The medical consequences of the US military’s current pivot to great power competition are profound and speak directly to the importance of considering how medicine may affect future costs of war. Because the most recent wars have been land campaigns, relatively little attention has been paid to naval and air medicine. And ongoing conversations about the national debt and federal budget have already sparked debate over future veterans’ benefits.

National security experts expect that future US wars will look quite different from those of the recent past. But as long as force is used in war, there will be developments in medicine and costs associated with the wounded. Gaining an understanding of these costs before deciding whether to use force is essential to informed policymaking

Bibliography

1. Fazal, Tanisha M. 2021. “Life and Limb: New Estimates of Casualty Aversion in the US.”International Studies Quarterly 65, no. 1 (March 2021): 160–172. Fazal, Tanisha M. and Kreps, Sarah. “The United States’ Perpetual War in Afghanistan.” Foreign Affairs, Snapshot, August 20, 2018. Fazal, Tanisha M. “A New Korean War Would Kill More US Military Personnel Than You Think.” The Washington Post, The Monkey Cage, January 8, 2018.