Tanisha Fazal, Military Medicine and the Hidden Costs of War, Oxford University Press, 2024, 256 Pages, INR 2,626 (Hardback), ISBN: 9780190057473
Professor Tanisha Fazal’s latest publication, ‘Military Medicine and the Hidden Costs of War’ analyses the various wars fought by the United States (a country that has been at war longer than most nations) with a focus on the advances in military medicine. Her main argument is that medical advances have led to a lower fatality to wounded ratio in the battlefield, resulting in a much higher rate of survival, which however, comes at the cost of increased disabilities amongst the survivors — both physical and psychological — translating into a huge long term burden of higher costs of longer treatment, rehabilitation, compensation, and veterans’ benefits, which can run on over decades. In Dr Fazal’s words:
Whenever human life is in the balance, costs and benefits ought to be weighed carefully. But this principle is especially crucial in wars of choice. We need to alter the way we think about war. We need to more effectively reckon with the costs of war before human lives on both sides, and the financial health of our country, are put at risk.
Prof Fazal, an expert and a prolific author on international law, security issues, sovereignty, and armed conflict, gives a compelling account of how war intersects with progress in medicine; and how each affects the other’s outcomes, discussing the changes in weapons and injuries, military medicine, and policies for veterans’ benefits, which have changed with each important war.
The book is arranged in four chapters, each devoted to one major war, from the American Civil War, through the two World Wars to the Vietnam War, and the more recent ones with Afghanistan and Iraq, with the last chapter describing the psychological trauma of the soldiers. Right from the first page, the author draws the reader in with her narration of the conditions during each war, weaving in personal stories and fascinating facts as well as the medical practices of that period. She highlights how medical advances have helped increase the effectiveness of the armed forces ― a fact that is not talked about often enough when military technological advances are discussed. Military medicine is a force multiplier, resulting in more soldiers surviving diseases and injuries that would have been fatal in preceding wars; but having more survivors also implies higher long-term costs, usually not taken into account when the economic costs of war are calculated.
The book explores myriad facets of military medicine ― the changing nature of diseases and wounds, how data collection and reporting affects casualty figures, the effect of changes in sterilisation, medication, treatment and evacuation, new methods of care which are now considered standard tactical medicine. It presents facts about the American armed forces, which are appalling and fascinating in equal measures: racism, patriarchy, the double discrimination faced by serving black women. These are interspersed with inspiring nuggets about the early path-breaking champions whose work led to military nursing emerging as a “respectable” profession; the oscillations between principles of earlier medical treatments ― such as the use of tourniquets to stop haemorrhage and the use of whole blood in preference to crystalloids ― abandoned after World War II, only to be embraced again during the Afghanistan and Iraq wars.
For readers of IJME, the discussion on ethical transgressions inherent in war are especially relevant ― how medical supplies, men and transport being under the control of different branches affects medical practice; the difference in evacuation priorities between field physicians and bureaucrats; the different approaches of physicians and other officers on letting soldiers rest versus getting them back to the frontlines rapidly, so that fighting strength is not depleted; the difference in medical management and segregation of patients and medical staff based on race, ethnicity and gender; the lack of sympathy for psychiatric patients because they “might be malingering” and setting a “bad example” for others. All this, and the ethics of providing treatment to the enemy or host country in counterinsurgency operations; the psychological trauma borne by soldiers faced with moral dilemmas in war, which according to Dr Fazal, has resulted in “more active-duty military personnel dying between 2006 and 2021 by suicide than were killed in action or from wounds. Veterans likewise suffer from an unusually high suicide rate” [pp150-240].
Over time, better medical management and evacuations have not only led to better survival rates but to more advanced, expensive treatment as well as rehabilitation for larger numbers, more extensive benefits, and pensions including lifetime medical care to serving staff as well as veterans and their families. Further, advancements in psychiatry have led to the gradual social acceptance of psychiatric diagnoses and their inclusion for disability compensations. But these advances and the efforts to reach every eligible veteran have led to an unforeseen increase in the ‘long tail of war’ the price of which will be paid, not only by the present but future generations as well.
Dr Fazal argues that although the costs of war are difficult to assess — being inherently unpredictable — often, they are not calculated as they should be resulting in short term aims and gains overshadowing the long-term costs. Pre-war costs are usually calculated in terms of the materials of war and deaths; but overlook the suffering of individual soldiers, their families and communities and long-term financial implications of the medical and other pensionary benefits for survivors. She stresses how erroneous data projections can affect policy decisions and public perceptions and why these cost analyses may not be put up in the public domain. This raises some very pertinent questions about calculation methods and the consequences for American policy decisions, which have had dubious results in the past. She highlights how the underestimation of long-term human suffering and financial costs by policy makers makes it easier to garner public support for the US military, so as to keep engaging in one war after another.
The author has a flair for storytelling, which combined with her research background, makes for compelling reading. The book is well researched, and her observations are supported by data, figures and diagrams from various military and medical articles. The personal narratives in the initial chapters add depth. A couple of stories illustrating the trauma and heartbreak caused by the stress of war would have added an emotional dimension to the last chapter too, especially as it covers the psycho-social effects and the stigma that psychiatric conditions carry.
The issues she touches upon resonated deeply with me, on both a personal and professional level. Serving as an armed forces physician for the last three decades, I see how these realities are still experienced in the field, day in and day out ― the difference in priorities and approach between medical and other branches; the long term suffering of those left alive after wars and counterinsurgency operations, alive due to the marvels of modern medicine but with wounds both visible and invisible; and the resultant burden of care being shouldered by their families and the nation. The cost of war everywhere is paid in ways more complex than the deaths on the battlefield.
In the current political scenario, where countries and societies all over the world are becoming increasingly polarised, and the public only too eager for the nation to engage in military showdowns, this book is a reality check on how we fail to understand the real price of war. The book is strongly recommended for scholars of military medicine, political science, economics, history, and all who are and can be affected by a nation’s military decisions: uniformed personnel, policy makers, politicians, and not the least, the public, especially young voters, who are citizens of the future. The value of history lies in the lessons it holds for the future.
Author: Savita Butola (savitabutola@yahoo.com, https://orcid.org/0000-0003-3732-7157), Deputy Inspector General (Medical)/ Medical Superintendent, Composite Hospital, Border Security Force, Srinagar, INDIA.
Conflict of Interest: None declared Funding: None
To cite: Butola S. The causality, casualties, and cost of war — what we should know but don’t. Indian J Med Ethics. Published online first on April 18, 2026. DOI: 10.20529/IJME.2026.024
Submission received: January 30, 2026
Submission accepted: March 12, 2026
Manuscript Editor: Sanjay A Pai
Copyright and license
©Indian Journal of Medical Ethics 2026: Open Access and Distributed under the Creative Commons license (CC BY-NC-ND 4.0), which permits only noncommercial and non-modified sharing in any medium, provided the original author(s) and source are credited.