Though firepower has increased, lethality has decreased

From Better by Atul Gawande.

We have seen a similar evolution in war. Though firepower has increased, lethality has decreased. In the Revolutionary War, American soldiers faced bayonets and single-shot rifles, and 42 percent of the battle wounded died. In World War II, American soldiers were hit with grenades, bombs, shells, and machine guns, yet only 30 percent of the wounded died. By the Korean War, the weaponry was certainly no less terrible, but the mortality rate for combat-injured soldiers fell to 25 percent.

Over the next half century, we saw little further progress. Through the Vietnam War (with its 153,303 combat wounded and 47,424 combat dead) and even the 1990-91 Persian Gulf War (with its 467 wounded and 147 dead), mortality rates for the battle injured remained at 24 percent. Our technology to save the wounded seemed to have barely kept up with the technology of inflicting wounds.

The military wanted desperately to find ways to do better. The most promising approach was to focus on discovering new treatments and technologies. In the previous century, that was where progress had been found - in the discovery of new anesthetic agents and vascular surgery techniques for World War I soldiers, in the development of better burn treatments, blood transfusion methods, and penicillin for World War II soldiers, in the availability of a broad range of antibiotics for Korean War soldiers. The United States accordingly invested hundreds of millions of dollars in numerous new possibilities: the development of blood substitutes and freeze-dried plasma (for infusion when fresh blood is not available), gene therapies for traumatic wounds, medications to halt lung injury, miniaturization systems to monitor and transmit the vital signs of soldiers in the filed.

Few if any of these have yet to come to fruition, however, and none were responsible for what we have seen in the current wars in Iraq and Afghanistan: a marked, indeed historic, reduction in the lethality of battle wounds. Although more U.S. soldiers have been wounded in combat in the current war than in the Revolutionary War, the War of 1812, and the Spanish-American War combined, and more than in the first four years of military involvement in Vietnam, we have had substantially fewer deaths. Just 10 percent of wounded American soldiers have died.

The answer? Tight attention to detail.