The notion that the lethality rate "settled" at 25% after WWII is somewhat misleading. The rate actually follows a somewhat predictable, logarithmic path. If you were a military planner in 2001 asked to estimate the combat deaths of a long war in Iraq or Afghanistan, you would've used this logarithmic model. It would have predicted a lethality rate of 20.5%. The exact rate, of course, could not be predicted with much precision. So it would have been useful to know the range of lethality rates to expect. The model would predict that the actual rate would likely be between 14.2% and 26.8%. This would've been consistent with an ongoing improvement over the most recent experience in the Persian Gulf in 1991, when the lethality rate was roughly 24% (albeit on a very small base of wounded). It turns out that the rate for the current war, as of January 2010, is only 11.7% which is much lower than the 20.5% expected and even well below the range of what would be expected.
There are two ways to think about this. The first, explored by Gawande, is that the improvements prior to 2001 were the result of a process of discovery that led to incremental improvements year-over-year. This explains the near-constant decrease in the lethality rate every year since the Revolutionary War. Gawande attributes the significant improvement in the 2001-2010 rate in Iraq and Afghanistan to a change in the basic principles of R&D used by the military. After all, there have been no advances in medicine since the Persian Gulf War in 1991 significant enough to explain the transformational improvements suggested by steep decline in the lethality rate. But what if this seemingly smooth process of improvement is really the result of a series of big breakthroughs? These would lead to significant reductions in lethality followed by relatively flat periods of lethality.
This explanation is plausible. Antiseptics and anesthetics were more widely used after 1800, the use of combat medics was pioneered in the Civil War and amputations were more widely used in the Napoleonic period before WWI. During and after WWII, field hospitals and MEDEVACs became regular features of combat. These inventions could explain a step-function pattern rather than a smooth process of continuous improvement. In this context, the recent improvements in lethality are simply a result of a significant innovation. Without a significant improvement in medicine to explain the lethality declines, the step-function improvement must be in the systems and processes rather than the quality of the medicine or surgical techniques. Indeed, Gawande outlines several reasons for the recent improvement, which include:
- More widespread use of body-armor and eye-protection
- The development of Forward Surgical Teams (FSTs) of leaner and more mobile units of 20 surgeons, nurses, medics and other support personnel who are farther forward, closer to battle.
- A military surgical strategy focused on damage control, not definitive repair, "whatever is necessary to stop bleeding and control contamination without allowing the patient to lose body temperature... Surgeons seek to limit surgery to two hours or less, and then ship the patient off to a Combat Support Hospital (CSH), the next level of care."
There are two general conclusions from Gawande's observations. First, true innovation and improvement in disciplines like R&D and Product Development are more often the result of step-function breakthroughs than from continuous improvement. Second, a focus on performance can lead to further breakthroughs as the process of discovery reaches diminishing returns.
Source: http://content.nejm.org/cgi/content/full/351/24/2471 and Better: A Surgeon's Notes on Performance
