The surprising biomedical legacy of the Iraq War

Monday marked the 20^th anniversary of the Iraq war, which resulted in an estimated 110,600 deaths of Iraqis and 4,431 U.S. servicemembers killed and 31,994 wounded in action across eight years. Those stark numbers cannot truly tabulate the tragedy that countless families and servicemembers have endured.

But on this anniversary, it is also worth looking at something unexpected: The terrible war has led to startling advances in medical care. As a young captain in the U.S. Army, I was deployed to Iraq as part of my career in military intelligence. That journey would lead me to make a major course change, and today I am working to push the boundaries of health care technology to benefit soldiers and civilians alike.

Armed conflict and medicine have long been intertwined, leaving us duty-bound to apply lessons learned from the former to guide and shape the latter, and to try to extract as much benefit as possible from the great suffering and destruction that armed conflict brings. The field of orthopedics traces its origins to the battlefields of the Middle Ages, when soldiers used rudimentary canvas splints to treat traumatic injuries. In the same way, the Iraq War saw medics find new ways of stopping blood loss and saving limbs, with these advances leading to improved standards of care in peacetime medicine, including in completely separate clinical indications such as vascular repair, composite tissue transplantation, and hemostasis. The U.S. deployed its full military power against an adversary with limited financial and technological resources, including body armor to protect servicemembers from assault rifle fires.

However, insurgents used asymmetric warfare, including turning to improvised explosive devices to target personnel and their armored vehicles with devastating effects. Nearly 70 percent of wounds to U.S. personnel were the result of these makeshift devices. Many servicemembers who sustained injuries from IEDs suffered massive trauma to their extremities, requiring physicians to resort to equally improvised techniques to increase survival rates from this new profile of injury. Working in challenging conditions, U.S. military physicians had to radically change how they treated combat casualties.

When faced with an extremity injury caused by an IED, among the top priorities for combat casualty care medics in the field is to stop bleeding. As a result, there was a resurgence in the development of improved tourniquets, a technology that had fallen out of favor. The use of walking blood banks, or soldiers who can give blood for emergency transfusions while out in the field, also improved survival rates. Alongside these age-old techniques, new hemostatic agents were applied to open wounds to stem bleeding. Tourniquets and hemostatic powders developed for the war in Iraq are low-cost and do not require extensive experience for application. They can in turn improve responses to injuries like traffic accidents, especially in developing countries with high incidences of trauma injuries but low access to medical care. These technologies can stabilize a patient and stop them from bleeding to death before they can get to a hospital, drastically improving survival rates.

With medics better able to rapidly control hemorrhage and prevent contamination, survival rates remained relatively high, with 90 percent of wounded soldiers making it back to the U.S. alive. However, even as we marvel at the progress that wartime medicine has made, the battlefield also highlights medicine’s limits. Surgical procedures may be able to initially save a limb after an explosion, but if the bones in the limb fail to heal, the servicemember may be forced to undergo delayed amputation weeks or months down the line. One study found that 15.2 percent of combat injury amputations occurred three or more months after the initial injury.

In total, some 6 percent of servicemembers wounded in Iraq experienced amputation. As doctors strive to provide the best aftercare possible for amputees, we have seen the process become increasingly streamlined with innovations such as powered prosthetics and vacuum suction sockets for above the knee amputation. However, a more favorable outcome would involve preventing amputation and saving soldiers’ limbs. At the forefront of the battle to save limbs is the relatively new field of regenerative medicine, where researchers are searching for ways to regenerate bone and surrounding tissue. Iraq War injuries prompted the Department of Defense to establish a regenerative medicine program to improve outcomes for soldiers wounded in the line of duty. It should not be necessary for servicemembers to make a choice between keeping their limbs but remaining wheelchair-bound and undergoing delayed amputation to regain mobility via prosthetics.

However, many regenerative therapeutics currently used to regenerate bone and tissue have safety concerns associated with them. For example, bone morphogenetic protein 2 (BMP2) is a naturally occurring human protein and has a powerful potential to regrow bone resulting from wartime trauma injuries; however, it currently lacks the precision delivery to safely target the site of an injury. This has led to inadequate success rates and alarming side effects such as bone formation in unwanted places. Fortunately, military researchers seeking to reduce the incidence of delayed amputation have been able to engineer bone regenerating proteins to be more targeted and stay at the site of trauma, leading to complete regeneration of very large defects.

One such advanced regenerative medicine product for bone regeneration is currently supported by the Congressionally Directed Medical Research Programs and has led to rapid clinical translation. This research, born out of the Iraq War, will also change the game in wider medicine. Any condition which requires bone regeneration, be it in orthopedics, spine trauma, or dentistry and facial reconstruction, will be vastly improved. The ability to engineer proteins for precise delivery and local persistence also has implications for many therapeutics ranging from wound healing to targeted cancer therapeutics.

History shows us that the United States has engaged in a major armed conflict on average every 20 years. We should take advantage of these periods of relative peace to make sure we are as prepared as we can be to face the medical challenges of the next major conflict. Even better than developing these new techniques in the battlefield would have been having them beforehand — or not needing them at all.

A graduate of West Point, Luis Alvarez served in the U.S. Army for 20 years and received his Ph.D. in biological engineering from MIT where he was a Hertz Foundation Fellow. He was the founding deputy director of the Department of Defense’s Regenerative Medicine Program Office as well as lead for the DoD’s nerve agent pharmaceutical countermeasures program. He founded Theradaptive following his time in the Army.