The Effects of War
The question of what causes war, like the question of what caused this or that particular war, has consumed mountains of paper and oceans of ink, and the answers are still disputed. There is a much clearer understanding of the effects of war. The most obvious and dramatic effect is the destruction of people and their homes, their factories and offices, their schools and museums. Pictures of blasted buildings, rubble-strewn streets, corpses of humans and animals, such poignant icons of lives ended or ruined as a broken doll lying among shell craters – all this provides a familiar point of reference concerning the hideousness of war. There is a near-consensus that war is evil; and yet, driven by the inexorabilities of how our world is constituted, billions of dollars are spent annually all round the world on guns, missiles, submarines, soldiers and all the other preparations for conflict, as if conflict were as inevitable as death itself.
Employment of the phrase ‘near-consensus’ implies that not everyone thinks war is bad – indeed, there are some who think it is a positive good. One can dismiss the posturing of the poet Filippo Tommaso Marinetti, the ninth paragraph of whose ‘Manifesto of Futurism’ (1908) says ‘We will glorify war – the world’s only hygiene – militarism, patriotism, the destructive gesture of freedom-bringers, beautiful ideas worth dying for.’ This feverish document, written after Marinetti and his equally young friends had stayed up all night becoming hysterically pleased with themselves, then racing off in Marinetti’s car and overturning it in a ditch, is really a paean to that new thing, the car, and its speed, which Marinetti loved; completed by a hefty dash of misogyny (‘scorn of women’ is oddly tacked to the end of the ‘we will glorify war’ paragraph) and complete rejection of the past (‘museums are cemeteries’ – ‘We will destroy the museums, libraries, academies of every kind’). As an intoxicated jeu d’esprit it would overstate its importance as symptomising weariness with peace in the years before the catastrophe of 1914. But it is oddly prophetic. In the Second World War, museums, libraries and academies lay beneath the onslaught of ‘carpet bombing,’ in which there might have been a deliberate effort at ‘culturecide’ involved.1
Marinetti was neither alone nor the first in describing war as a form of hygiene. Few could think that it is the kind of hygiene that cleanses a society of its dregs, for it is the brave and the fit who go to perish in wars, not the skulkers and dodgers and black marketeers, who survive and reproduce. Instead it is extolled as the kind that summons humanity’s highest virtues and best creative powers. Thus Ruskin:
When I tell you that war is the foundation of all the arts, I mean also that it is the foundation of all the high virtues and faculties of men. It is very strange to me to discover this, and very dreadful – but I saw it to be quite an undeniable fact . . . I found, in brief, that all great nations learnt their truth of word and strength of thought in war, that they were nourished in war and wasted by peace; taught by war, and deceived by peace; trained by war, and betrayed by peace; in a word, that they were born in war, and expired in peace.2
One does not have to claim that war is good to say that there can sometimes be good reasons for going to war. This point is made by John Stuart Mill:
War is an ugly thing, but not the ugliest of things: the decayed and degraded state of moral and patriotic feeling which thinks that nothing is worth a war, is much worse. When a people are used as mere human instruments for firing cannon or thrusting bayonets, in the service and for the selfish purposes of a master, such war degrades a people. A war to protect other human beings against tyrannical injustice; a war to give victory to their own ideas of right and good, and which is their own war, carried on for an honest purpose by their free choice, – is often the means of their regeneration. A man who has nothing which he is willing to fight for, nothing which he cares more about than he does about his personal safety, is a miserable creature who has no chance of being free, unless made and kept so by the exertions of better men than himself. As long as justice and injustice have not terminated their ever-renewing fight for ascendancy in the affairs of mankind, human beings must be willing, when need is, to do battle for the one against the other.3
A cautionary note sounds when one reads that ‘a war to give victory to their own ideas of right and good’ is counted as one for which there are good reasons, because of course one person’s idea of what is right and good might not be another’s. Suppose the then US President George W. Bush was sincere in having this as his reason for launching the Second Gulf War of 2003; even when sincerely believed, it rings hollow. But the general tenor of Mill’s view is understandable. Basil Liddell-Hart made the same point seventy-odd years later when he said, ‘War is always a matter of doing evil in the hope that good may come of it.’4
Apart from those who extol war because they think it romantic and dramatic – Erasmus long ago drily remarked that ‘war is delightful to those who have no experience of it’ – there are more who point out that war is not always unmitigatedly bad in its effects. There have been occasions when military expenditure by a government has boosted the national economy and increased employment. It can bring positive social change, sometimes very significant, as witness the position of women in society after the First World War – many tens of thousands of them had worked in munitions factories, on farms and as nurses, experiencing life in ways quite different from their sheltered versions of it beforehand. Witness likewise the major social adjustments following the Second World War almost everywhere.5 In this latter war the armed forces of the United States unconsciously laid the foundations for Native Americans and African Americans to begin their painfully difficult assault on racial divisions in society.
Technology advances by giant leaps in the emergency of war; in 1939 biplanes were still in active service in Britain’s Royal Air Force, but by 1945 jet fighters, missiles and atom bombs were already in use. More acceptable technological advances than these, such as radar, computing and aircraft design, proved of lasting value. The science behind these developments advanced because it was given the amount of resources in funding and personnel that in peacetime would have been difficult to obtain.
Other benefits of war sometimes cited are that they result in alliances, they bring otherwise intractable conflicts to an end, and they stop the spread of malevolent ideologies such as Nazism. Some even add it as a plus – though this is a rather disagreeable claim – that they keep populations down. Conquerors in war have sometimes brought benefits to the conquered; consider Napoleon and the liberation of Jews in the parts of Europe that succumbed to him. Other warmakers have alleged less convincing benefits, usually to themselves: strengthening the nation, inculcating patriotism, gaining Lebensraum, averting the danger posed by an enemy growing in power. Another doubtful advantage of war is said to be that it helps one be better practised and prepared for the next war.
Perhaps the most considered defence of the positive aspects of war is offered by Ian Morris in War: What Is It Good For?6 His view is summarised in one of his section headings: ‘War makes the State, and the State makes peace’. The argument is that ‘by fighting wars, people have created larger, more organised societies that have reduced the risk that their members will die violently’. This works by more powerful societies conquering and absorbing less powerful ones, then imposing peace upon them. In less organised states of human affairs conflict, strife and homicide were far more prevalent, Morris says; so it is by grasping the nettle of violence that violence has been controlled, and with the peace thus won has come the preconditions for prosperity. ‘War, I will suggest, has not been a friend to the undertaker’, Morris begins; ‘War is mass murder, and yet, in perhaps the greatest paradox in history, war has nevertheless been the undertaker’s worst enemy.’7
There are several challengeable assumptions underlying Morris’s thesis. One is that war created the ‘bigger societies with stronger governments’ that he says impose peace. Another is that such societies are indeed imposers of peace rather than – in their tensions and conflicts of interest vis-à-vis other such societies – the chief cause of major war. A third is that life was less peaceful and safe for people before the big societies came into being. Let us consider these points in reverse order.
Morris adduces the view that violent death was more common in the Stone Age – taking this term to denote the period of 2 to 3 million years before the rise of settled cultures and metalworking about 8,000 years ago – with as many as 10–20 per cent of Stone Age people dying as a result of murder or fighting.8 This view, inferred by Lawrence Keeley from examination of conflict-related death rates in contemporary hunter-gatherer societies, is contested by Douglas Fry and his colleagues as discussed in the previous chapter.9 Suppose, however, that it is true that Stone Agers were violent. It could plausibly be argued that this could be a barrier to social aggregation into larger units with stronger forms of government, so the question of how these arose and succeeded in diminishing the violence – given that violence presupposes division – becomes acute. It could more plausibly be argued that as social groups grew larger and more organised, so their ability to assert their interests over other such groups likewise grew; and that this gave rise to war.
These thoughts in fact address both the third and second of Morris’s claims, because – in relation to the second – the argument that war needs organisation, planning, mustering of resources, direction of the energies of the group to the prosecution of hostilities, suggests that it is organisation that is a precursor of war and not its inhibitor.
The first point about violence in prehistoric human life either implies that war or the preconditions for war lie in human nature, or that the social arrangements of prehistoric societies were such as to goad otherwise co-operative human beings into smashing one another’s heads with stone axes. In the previous chapter we saw some reason for thinking that it is the social arrangements rather than human nature which merit the blame. If this is right – and it remains in dispute – it challenges Morris’s case.
It is indisputable that the number of people who have died violently and prematurely, as a percentage of overall population, has decreased throughout recorded history, with an even steeper drop since the seventeenth and eighteenth centuries – the centuries of the Enlightenment. This is a case made powerfully by Pinker and others.10 Figures are variously cited to illustrate the claim; an order of magnitude according to some estimates is that in the year 1250, 1 in 100 people were victims of murder, but by the year 1600 that had dropped to 1 in 300, and by 1950 to 1 in 3,000.11 Note that these are homicide figures, not figures for war deaths; and they could more plausibly be attributable to better policing or more education or increasing prosperity than a change in human nature. But war deaths as a percentage of population have also declined dramatically, not just since medieval times but, as noted, throughout known history. Is this a beneficial effect of war, as Morris argues?
It is not as simple a matter to answer this as Morris claims. The number of wars has also been in decline since medieval times, but their lethality has dramatically increased; so even though smaller percentages of the rapidly growing world population are killed in them, the absolute numbers have grown vastly larger. A count over the last 400 years tells us that there were twenty-two wars between major powers in the sixteenth century, eleven in the seventeenth century, eight in the eighteenth, five in the nineteenth and six in the twentieth. The standard, and convincing, reason given for the decline in the number of wars is their increasing cost and destructive capability; firepower and the cost of increasingly necessary standing militaries from the sixteenth century onwards are a disincentive to war-making.12
It is therefore no surprise that the figures for the twentieth century’s wars, and especially for the First and Second World Wars, should be horrifying, and eradicate any sense of satisfaction one might feel that population percentages of violent deaths have fallen. The numbers for these wars include, as they must, civilian deaths, and deaths from all causes incident on the prevailing state of war; recent and contemporary warfare puts everyone on the front line. The death toll in the First World War is estimated at 20 million, in the Second World War between 40 million and 85 million with a geometric mean at 58 million. Add in the other wars and civil wars of a violent century – another 20 million at least – and the total conservatively hovers around 100 million. The number of deaths in war since the beginning of recorded history is put at about 500 million. This makes the combined death tolls of the wars of the twentieth century nearly 20 per cent of recorded history’s entire war mortality.13 This is a shocking figure. It makes the Morris thesis, and indeed the optimistic view of human progress implicit in Pinker and elsewhere, less plausible.
We talk of deaths here, but must not forget that the greater firepower of modern war means that the destruction of things that matter to lives – homes, workplaces, cultural artefacts, infrastructure, fields and crops – is also involved. The rampaging of medieval crusaders might be destructive of towns and farms in their path, but the range of their annoyance was far more limited than that of a single squadron of missile-armed fighter-bombers today. This effect of war, therefore – the demolition of lives and things that matter to lives – not only has not changed but has worsened by far.
War’s effects do not stop when the shooting stops. At the end of the Second World War 40 million Europeans were refugees. Even as the Syrian civil war that began in 2012 was continuing, 12 million Syrians had become refugees. Every war has driven people from their homes and homelands, and although most return when peace supervenes, many cannot. At time of writing the UN refugee agency (UNHCR) was still dealing with more than half a million refugees from the Balkans conflict of the 1990s. In Colombia, in the half century of conflict with FARC which started in the 1960s, 4 million people were displaced from their homes – 10 per cent of the population. War’s consequences in these respects are fruitful in prolonging problems and laying the foundations for recurrent conflicts; the Israel–Palestine situation is a paradigm case.14
And then there is trauma. The impact of war on combatants and non-combatants alike is one of the effects of war which has come to be more studied and understood in the course of the last hundred years than ever beforehand, doubtless because the nature of weaponry has produced more pronounced and observable effects. The closer one gets to the present day, the more frequent and pronounced is the war trauma experienced by soldiers in the armies of advanced countries, because more of them survive as a result of improvements in body armour and medical care on the battlefield. Mental illness and impaired cognition are the two principal ‘invisible wounds’ noted in studies of post-traumatic stress disorder (PTSD), major depressive disorder and traumatic brain injury (TBI). The first is typically a reaction to trauma; the second to loss, as in the death of comrades; and the third to the effects of blast exposure or concussive impacts to the helmet or head.
Boxing, American football, soccer, rugby, even cricket and baseball, can all cause TBI, though a bullet or shrapnel hitting one’s helmet, and proximity to an explosion, doubtless have greater effects. Depression arising from grief at the death a friend, a loved one or a family member, is a familiar and widespread phenomenon, though its being so does not make it easier to bear. So the war-induced version of both these categories is readily understandable in comparison to the non-war-induced instances of them.
With PTSD one can speculate that matters are the other way round. The condition was formally recognised and labelled in 1980 and is defined in the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders as ‘a reaction to a psychologically traumatic event outside the range of normal experience’. There are of course plenty of cases of non-war-induced PTSD; people involved in, or who are witnesses of, a murder, train wreck, earthquake or any highly shocking and disturbing event that is out of the ordinary, might suffer PTSD as a result. But a combat zone is where traumatising events occur repeatedly and on large scales, and where anticipation of their occurrence is a constant. Fear, extremely loud sudden noises, uncertainty, confusion, hyperventilation and high levels of adrenaline, with death a real prospect and not untypically the witnessing of others’ deaths, mutilations or agonies, can readily be imagined as an experience apt to leave a profound mark. Military psychiatry accordingly has much to offer the general understanding of PTSD. It is likely that studies of ‘shell shock’ in the First World War gave the first major impetus to better understanding of this and related mental health phenomena.15
One of the reasons for war-induced PTSD among soldiers in combat units is a factor central to their role: the question of killing. David Grossman, a psychologist and career soldier, stresses this point in On Killing – the first full study of the psychological experience of killing based on examination of soldiers’ experiences. He observes that there is a ‘powerful, innate human resistance toward killing one’s own species’ which armies have had to work hard to develop ‘psychological mechanisms . . . to overcome’; and that acts of overcoming this resistance is one primary source of the trauma soldiers feel.16
This is so even with the training and conditioning that front-line troops are given. Grossman writes, ‘Just as I do not wish to condemn those who have killed in lawful combat, nor do I wish to judge the many soldiers who chose not to kill. There are many such soldiers; indeed I will provide evidence that in many historical circumstances these non-firers represented the majority of those on the firing line.’17 He cites examples:
R. C. Anderson, a World War II Canadian artillery forward observer, wrote to say the following:
I can confirm many infantrymen never fired their weapons. I used to kid them that we fired a hell of a lot more 25-pounder [artillery] shells than they did rifle bullets. In one position . . . we came under fire from an olive grove to our flank. Everyone dived for cover. I was not occupied, at that moment, on my radio, so, seeing a Bren [light machine gun], I grabbed it and fired off a couple of magazines. The Bren gun’s owner crawled over to me, swearing, ‘It’s OK for you, you don’t have to clean the son of a bitch.’ He was really mad.
Colonel Albert J. Brown, in Reading, Pennsylvania, exemplifies the kind of response I have consistently received while speaking to veterans’ groups. As an infantry platoon leader and company commander in World War II, he observed that ‘Squad leaders and platoon sergeants had to move up and down the firing line kicking men to get them to fire. We felt like we were doing good to get two or three men out of a squad to fire.’18
By the time of the Vietnam War this picture had changed. Training had made combat units achieve a much higher firing rate than the 15–20 per cent in the First and Second World Wars. As a psychologist, Grossman was especially sensitive to the complex set of stresses Vietnam veterans had been subjected to in a losing war condemned rather than supported by people at home in the USA. He comments critically on ‘How the American soldier in Vietnam was first psychologically enabled to kill to a far greater degree than any other soldier in history, then denied the psychologically essential purification ritual that exists in every warrior society, and finally condemned and accused by his own society to a degree that is unprecedented in Western history.’19
There are other sources of PTSD of course. Survivor guilt is one. Loud explosions and gunfire in conditions of great danger would be enough by themselves to unnerve anyone. From the perspective of considering the effects of war, it is the sequelae of traumatic combat experiences that matter; the operative part of the label ‘PTSD’ is the ‘post’ part.
Manifestations of PTSD include recurrent and intrusive dreams and recollections of the experience, emotional blunting, social withdrawal, exceptional difficulty or reluctance in initiating or maintaining intimate relationships, and sleep disturbances. These symptoms can in turn lead to serious difficulties in readjusting to civilian life, resulting in alcoholism, divorce, and unemployment. The symptoms persist for months or years after the trauma, often emerging after a long delay.20
The manifestations are not only psychological. There is also a ‘far higher incidence of divorce, marital problems, tranquilizer use, alcoholism, joblessness, heart disease, high blood pressure, and ulcers’.21 During the First World War, when proper psychiatric study of ‘shell shock’ began, some of the more extreme immediate manifestations included uncontrollable shaking, paralysis, spasms, deafness, blackouts, aphasia and exhaustion. These symptoms of shock might well be expected to leave persistent effects, and indeed were seen in the days and weeks following first hospitalisation of the victims. It is the yet longer-term effects that manifest as PTSD. But the troubling fact is that PTSD can emerge in individuals who did not display any of the immediate symptoms of shock. Soldiers who survived their tours of duty, even in some cases returning to duty after physical wounds had healed, and who showed every sign of tolerating the stresses and challenges of war, might nevertheless turn out to be victims of PTSD later, as veterans. In studies of Vietnam veterans it was found that PTSD symptoms were almost exclusively experienced by soldiers who had been in ‘high-intensity combat situations’; other military personnel in Vietnam who had served in non-combat roles were psychologically indistinguishable from those who had served in posts at home in the USA.22
The incidence of PTSD among veterans is large both in percentage and absolute terms. Some 3 million US soldiers served in Vietnam, of whom anything between 18 and 54 per cent were estimated by the Disabled American Veterans Association to be suffering from some degree of PTSD – that is, between half a million and one and a half million people. Figures for US veterans of the conflicts in Afghanistan and Iraq between 2002 and 2008 were given as 14 per cent or 300,000 individuals by the Center for Military Health Policy Research report Invisible Wounds of War.23 That figure could be viewed as conservative; psychiatric disorders were cited as the reason for 30–40 per cent of soldiers discharged on medical grounds from the British Army during the Second World War.
Understanding the traumatic effects of combat began in the First World War when it dawned on the medical profession that the concept of ‘shell shock’ – a term coined by psychiatrist Charles Myers in a Lancet article in 1915 – was misleading. It had been thought that proximity to an explosion caused actual physical trauma to the brains of afflicted individuals. But it then became clear that this organic explanation was unsatisfactory, because the same symptoms were apparent in men who had not been close to a shell blast. Physicians accordingly realised that they were witnessing a functional disorder caused by the stress of actual or even anticipated vulnerability to danger in the trenches. They further began to see that supplementary factors such as fatigue, poor diet, long periods of exposure to the elements, and pre-existing factors such as psychological problems present before enlistment, were involved. Myers himself accordingly argued that the term ‘shell shock’ should be abandoned, though it remained lodged in common parlance throughout most of the twentieth century.24
It is painful to think how often soldiers suffering the trauma of war were described as ‘lacking moral fibre’, and treated as cowards or deserters. Three hundred and six British and Commonwealth soldiers were shot for cowardice or desertion in the First World War; most were probably suffering from trauma.25 Doctors were sympathetic enough to trauma victims to see, in the military’s keenness to return physically fit men to the front, and in its aversion to malingerers, a chance not just to help the victims overcome their trauma, but to protect them from court martial for cowardice. They did this by dealing with the trauma as quickly and as close to the front lines as possible. This technique came to be known as ‘forward psychiatry’, and Myers was one of its pioneers along with his French medical colleagues. The idea was to prevent victims getting used to their state of anxiety, which would ingrain it and make it more difficult to treat later. The further soldiers got from the front the more reluctant they were to return to it, so speed was of the essence. However Myers also recognised that hypnosis, a calm environment, and a chance to talk to the victim about his experiences and to make him aware of what had caused the trauma, were all helpful. These techniques were applied close to the trenches whenever possible.
Another pioneer of this approach was William Rivers, who treated Siegfried Sassoon and Wilfred Owen at Craiglockhart Hospital, a psychiatric unit for officers in Edinburgh. Some of Owen’s and Sassoon’s poems first appeared in the hospital’s magazine The Hydra (so called because before the war Craiglockhart had been a hydrotherapy institute), which Owen edited for six issues in 1917. But different approaches were tried at other hospitals. The London neurologist Lewis Yelland Andrews used electrical stimulation, applying electrodes to parts of the body afflicted by trauma-induced paralysis, thus treating the symptom but not the underlying cause. He was sometimes successful, thereby engendering unclarity about which kind of therapeutic approach was best – an unclarity that might have been resolved earlier if military psychiatry had not suffered the same fate as everything else as soon as the war was over, namely to be dismantled and forgotten. In the interwar years the British armed forces did not have a dedicated psychiatric service, which meant that veterans of the war received no long-term help. It was not until the third year of the Second World War that military psychiatry was again put on an organised footing.
This did not mean a complete absence of thought about the matter. The military decided to try screening psychologically vulnerable individuals at the point of recruitment in order to limit the potential for breakdowns and incapacity in the field. At the Sutton Emergency Hospital in Surrey psychiatrist William Sargant dealt with traumatised soldiers evacuated from Dunkirk in the summer of 1940, using hypnosis to achieve cathartic discharge of horrifying memories. But as the war went on, so the need for psychiatric services in the field again became pressing. The main theatre of British army operations in the years between 1941 and 1944 was the Western Desert and Italy, and it was here that an updated version of ‘forward psychiatry’ was implemented, known as ‘PIE’ for ‘Proximity, Immediacy, Expectation of Recovery’. Considerable claims were made for the success of the technique; after the D-Day landings, in the fighting through north-western Europe, it was claimed that two-thirds of psychologically traumatised men were returned to combat duty after PIE treatment close to the front. After the war the figure was revised down to near 10 per cent, a truer indication, borne out by experience in conflicts after the Second World War also.
A number of pointers appeared to emerge from the renewed endeavour of military psychiatry. Soldiers were seen to be more likely to suffer psychological trauma when retreating than when advancing, in circumstances of defeat rather than victory. They were more vulnerable to breakdown if there were prior indicators of low intelligence, lack of education or pre-existing mental conditions. It helped stiffen resolve if duty and loyalty to comrades was strongly and repeatedly emphasised. More significantly still, it had become evident that even first-rate and highly courageous fighting men, with outstanding service records, were susceptible to breakdown if over-exposed to intense combat. This taught the lesson that exposure to front-line conditions should be reduced, with correlatively increased opportunities for rest and recuperation.
In the overwhelming number of all medical cases being treated by army doctors it was not always possible to apply the kinds of therapies pioneered by Myers and Rivers in the First World War, so there was much resort to sedation, even to the use of induced coma – a treatment employed by William Sargant who, highly sceptical of ‘talk’ therapies, saw it as a way of preventing bad memories and anxiety states from taking a permanent grip on the victim’s psyche. In Egypt one of the army psychiatrists, Dugmore Hunter, applied a highly robust approach, separating trauma victims into those who were unlikely to be much use on further deployment, and those who could be encouraged to stiffen their upper lips and return to duty. His method was one of selection rather than treatment, relying in effect on self-cure of those he deemed capable of it. He wrote:
In psychiatry, almost everything depends on the basic personality of the patient. Thus, one can afford to evacuate a good man early, knowing that he will return to the unit with high morale, having clearly benefited from rest and treatment. The poorest human material is like a cheap car, which must be run to the limit and then discarded. The psychiatrist cannot make good fighting men out of inadequate individuals.26
He dealt with ‘screaming and jabbering’ patients by slapping them or pouring cold water over them. Some he gave a humiliating dressing-down in front of comrades, others he publicly praised for their courage and determination to return to the fray. His no-nonsense approach was similar to the approach bordering on cruelty practised by French doctors during the First World War, who treated military ‘war hysterics’ with electric shocks or sent them to fester, abandoned, in public lunatic asylums.27
A very different approach was tried at Hollymoor Hospital in Birmingham for repatriated psychiatric cases: group therapy. In fact part of the motive for treating victims in groups was a logistical rather than a theoretical one, because there were not enough staff to deal with them one-to-one, but making a virtue of necessity proved interesting. Wards were organised on community lines, with patients taking part in discussions about how treatment and rehabilitation might work. Bonds between patients were forged, mutual help encouraged. Patients mentored newcomer patients. There were activities such as art classes, swimming and drama. Many of these ideas were preserved into peacetime psychotherapy in Britain’s National Health Service.
The effectiveness of these different approaches was always a matter of dispute and scepticism. But as more recent advances in dealing with PTSD evolved, especially as survival rates have risen because of effective body-armour, rapid helicopter evacuation of wounded men and expert front-line surgery, a significant shift has taken place: an understanding of the longer term effects, and the need for longer term help. In their carefully documented analysis of both the need for and the provision of such help in the United States, Tanielian and Jaycox describe new thinking about the kinds of facilities required and the barriers that stand in the way of traumatised veterans receiving help – not least among them individual veterans’ own reluctance to seek it.
On the principle that prevention is always better than cure, the US military introduced the ‘Battlemind’ system into its training regimes. The programme is:
designed to help soldiers cope with the stressors of the deployment cycle. Specially tailored pre- and post-deployment briefs inform soldiers on what they are likely to see and experience, describe common and normative [sic] mental health reactions, and give guidance for seeking mental health support. The briefings convey a key message: that soldiers are responsible for each other’s emotional well-being. This responsibility includes speaking to each other about troublesome experiences and being on the look out for budding mental health problems.28
NCOs are trained to encourage the sense of cohesion and mutual loyalty in a unit as a means of supporting its members in stressful conditions. This last, though, is an old idea – perhaps as old as military history itself.
War does not only affect soldiers. As we have seen, civilian victims of bombing, sieges, mistreatment at the hands of invading forces including rape and rapine, refugee crises, starvation, arbitrary arrest and execution, anxiety and grief for loved ones because of any of these afflictions, and anxiety and grief for sons and husbands – and increasingly now, daughters and wives – on dangerous postings in the armed forces, adds up to a mountain of misery for non-combatants. Stress disorders are accordingly found among them too. But both during and after conflicts, civilian sufferers have received much less attention than military sufferers, partly of course because the more urgent matter has always been the welfare of the latter, especially when the need was great to return physically fit personnel to duty. But the distinction between chronic and acute conditions, and the fact that medical professionals are the ones who define which conditions are worth dealing with, means that civilians in war take a back seat in discussions such as this.
Indeed some of the information relevant to understanding civilian wartime trauma is distorted by the very conditions of war itself. For example, it was noted in France during the First World War that admissions to lunatic asylums dropped considerably. A natural explanation might seem to be that when there are real external concerns and threats to worry about, the incidence of neurosis falls: outer realities swamp inner imaginings. Closer examination reveals a more accurate story: many people left the towns for the countryside, where facilities for psychiatric care were sparser. Asylums closed or purposely reduced admission because many of the staff were called to support military medical services. A significant number of asylums changed function, being requisitioned by the military as hospitals for wounded and recovering personnel.29 A side-effect of the reduction in facilities for civilian mental health sufferers during the war meant that comparisons between them and soldier sufferers were ignored; on the face of it, a more synoptic view of the effects of stressful times and experiences on all who were mentally damaged by them might have been valuable to research.
In his account of the effects of war on the minds of those caught up in it, focusing principally on the First and Second World Wars and the Vietnam War, Ben Shephard makes two striking points, among others: that there is a cycle in the degree of attention given to the matter, in that the problem is first denied, then exaggerated, then understood, then forgotten, the forgetting taking place between wars; and that there are two contrasting approaches to the problem which he characterises as the ‘realistic’ and the ‘dramatic’, the former being the one dedicated to getting physically fit service personnel back into action as quickly as possible, while the latter is focused on the complex manifestations and symptoms of the disorders caused by trauma.30 He argues that the realist approach was discredited in the USA by the experience of Vietnam, and that the relative success of Second World War handling of the phenomenon variously called ‘shell shock’, ‘battle fatigue’ and PTSD, as efforts to understand it unfolded through the twentieth century’s wars, is under-appreciated. This last point is a valuable one to take away; perhaps the techniques developed at Hollymoor Hospital, reprising in a therapeutic setting the comradeship on the front line that to some degree works preventatively in supporting military personnel through stress, continued to be used after the war because, among all the alternatives tried, it best offered something of hope.
There is another intriguing point to be considered. Jones and Wessely raise the question in their history of military psychiatry whether each war produces its own distinctive kind of war trauma, related to the technology and military practices current in that war, and the attitudes and state of theory of medical practitioners also then current. Or are the traumas the same in all wars?
Supporters of the latter case will argue that differences are superficial related to cultural developments and reporting biases of patients and doctors. New diagnoses were coined for what many regarded as established syndromes. For example, Smith and Pear argued [in 1917] that ‘shell shock involves no new symptoms or disorders. Every one was known beforehand in civil life.’ By contrast, many believe that so-called Gulf War syndrome is a unique and novel illness related to modern toxic exposures and therefore quite unrelated to any previous phenomenon.31
The question that has to be asked about the effects of war is whether those regarded as positive – technological and social advances, the liberation of suppressed populations, the defeat of nasty regimes – compensate for negative effects such as destruction of homes, cities and cultural artefacts, and more especially still, the human suffering that occurs. Do the positive effects sometimes do even more than that – do they sometimes justify war? This question can be asked either specifically or generally. It can be asked of particular wars, either retrospectively, in the passing of historical judgement, or in anticipation, by national leaders calculating whether to go to war. And it can be asked of war as such, in the form: is war ever justified, given what and how it is? This topic is discussed in the next chapter, on just war theory.
One answer long since given, however, by someone who had witnessed the effects of the First World War with the keen eye of a great writer and the keen mind of a sensitive thinker, is this:
How senseless is everything that can ever be written, done, or thought, when such things are possible. It must be all lies and of no account when the culture of a thousand years could not prevent this stream of blood being poured out, these torture-chambers in their hundreds of thousands. A hospital alone shows what war is.
The writer was Erich Maria Remarque, in All Quiet on the Western Front.