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J R Soc Med. 2017 March; 110(3): 87.
Published online 2017 March 1. doi:  10.1177/0141076817699077
PMCID: PMC5349386

An unsafe world that must learn from conflict

Does the world feel safe to you? It was mess enough before Donald Trump took up residence in the White House and began his war on anything he doesn’t like. A politician following through on his promises has something to commend him, except he would have something more to commend him if those promises were largely based on easily established facts. Trump’s factually loose style has alarmed the bookish world of science, a world that medical journals consider themselves a part of.

These high-minded scientific arguments will be rendered trivial, however, if Mr Trump invites us, the UK that is, to join him in waging World War III on the basis of a false report he’s seen on Fox News. As yet, despite his bluster, Mr Trump hasn’t yet declared war on anybody new, although yet is a long time in the world of monthly medical journals. We don’t know if Mr Trump’s policies will make the world less safe but an end to conflict isn’t prominent on his agenda.

Where there is conflict, you will find medical professionals. Indeed, the extreme conditions at the front line of any conflict provide the most challenging environment for clinical care. They also provide an opportunity, as undesirable as it might be, to learn new ways of managing severely injured people. The skill of medical staff in the armed forces is such that ‘unsurvivable’ injuries are now survived.

Arul and colleagues estimate that care improved so rapidly in the last decade that 265 people survived injuries that would have killed them at the start of that period; 572 people survived despite injuries that the NHS classed as life-threatening and 38 people survived injuries classed by the NHS as ‘unsurvivable’.1 But the lessons from the front line aren’t just about better treatments and techniques but also teach us how to tease out the best from teams working in extreme conditions.

The most important lesson from conflict is to avoid it, but health can thrive in the most unexpected circumstances. One example is the US occupation of Cuba in the early 1900s.2 A massive public health intervention was launched to control yellow fever in and around Havana, and it was a success thanks in large part to compulsory segregation imposed by the occupying forces.

Compulsory, however, doesn’t always mean good. This month’s research paper finds that annual competency reviews for UK trainees are an unsatisfactory tick-box exercise that assess clerical rather than clinical abilities, encourage minimal competence instead of excellence, discourage learning and create stress.3 There are some positives but in the interests of creating a safer world, we need our front line NHS doctors to learn as their colleagues do on the front line of conflict.4


1. Arul GS, Pugh HEJ, Kluth MJ, Bromiley M. Common goals, shared risk and a just culture: human factors lessons from the front line. J R Soc Med 2017; 110: 93–97. [PubMed]
2. Lechuga RI, Castro AC. Dramatic effects of control measures on deaths from yellow fever in Havana, Cuba, in the early 1900s. J R Soc Med 2017; 110: 118–120. [PubMed]
3. Viney R, Rich A, Needleman S, Griffin A, Woolf K. The validity of the annual review of competence progression: a qualitative interview study of the perceptions of junior doctors and their trainers. J R Soc Med 2017; 110: 110–117. [PMC free article] [PubMed]
4. Macrae C, Vincent C. A new national safety investigator for healthcare: the road ahead. R Soc Med 2017; 110: 90–92. [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press