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The Living Legacy of WWI: The Politics & Medicine of Treating Post-Traumatic Stress, with Tanisha Fazal

April 17, 2018

Detail from John Singer Sargent's Gassed (1919). CREDIT: Google Cultural Institute/Imperial War Musem London (Public Domain)

REED BONADONNA: I'm Reed Bonadonna. I'm a senior fellow for the Carnegie Council for Ethics in International Affairs, and I'm talking from the Carnegie Council building, here on Lexington and 64th in Manhattan. I'm the lead administrator for the Living Legacy of the First World War project that the Council is taking on today, and I'm going to be talking this morning with one of the nine Fellows who were selected to pursue research topics concerning the experience of the First World War.

Today's interview is with Tanisha Fazal. She is a professor at the University of Minnesota. I'll mention that in addition to the work that she is doing now for the World War I project she is the author of the recent book published by Cornell University Press, Wars of Law: Unintended Consequences in the Regulation of Armed Conflict. Her project title for the World War I project is "The Politics and Medicine of Treating Post-traumatic Stress (PTS) Since World War I."

I would like to give Tanisha a chance to flesh out that introduction a little bit and say where she is calling from and anything else she would like to say by way of self-introduction.

TANISHA FAZAL: First, it is good to be with you. I am really excited about the opportunity to work with this project on the Living Legacy of the First World War. I am sitting here in my office at the University of Minnesota. It is a very foggy day, but I have nonetheless a very nice view of the Mississippi River, which has thawed out a little bit since the recent deep freeze.

REED BONADONNA: Yes, we're having a cold one here in New York, too. Not cold by Minnesota standards.

TANISHA FAZAL: Yes. Well, we are recent transplants to Minnesota, so we are adjusting.

REED BONADONNA: Right. Got it.

Why don't we start with an expected lowball question: How did you get started on this project concerning post-traumatic stress and the First World War?

TANISHA FAZAL: I am in the process of writing a book on how dramatic improvements in military medicine and also the expansion historically of veterans' benefits have increased the long-term, downstream costs of war for the United States. There are certain changes that are pretty straightforward.

In the Civil War, the rate of deaths due to disease was incredibly high for both Union and Confederate troops. This goes down in World War I and in subsequent wars because now you have the germ theory of disease. After the Korean and Vietnam wars, there was some landmark research conducted by military physicians that showed that 38 percent of military fatalities were preventable had there been better practices regarding stemming of blood loss. Some of these improvements in military medicine are easy to understand. It takes some digging to figure out what the changes were, but for me one of the struggles in this project has always been how to deal with post-traumatic stress because that is much less straightforward.

Post-traumatic stress was not even a category in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until the 1980s, but it had nonetheless been recognized by military doctors for centuries if not longer. Post-traumatic stress is effectively mentioned by Homer in the Iliad, talking about Achilles. So it has always been there. Just because it shows up in the DSM in the 1980s does not mean that that is when it first appears as a disease or a condition, but it is not something that I think we really have a strong grasp of in terms of its historical trajectory in war.

World War I is a particularly interesting turning point because, for example, one of the medical developments that you have between the Civil War and World War I in the civilian world, even before the U.S. entry into World War I, is the development of medical specialties. One of these is what was called at the time "neuropsychiatry." So you start to have base hospitals as part of the American Expeditionary Forces that actually are specializing in again what was called at the time "war neuroses." This is really a turning point in terms of acknowledging and starting to identify and treat what we call today post-traumatic stress.

REED BONADONNA: I will just mention a personal connection of my own to the topic. I was in Iraq during the invasion in 2003 as a field historian, and I wound up traveling around a lot in my field historian role with a Navy psychiatrist whose name was Koffman, and at that time he was one of the very few Navy psychiatrists, or so he told me, who had any background in the treatment of PTS. No coincidence, we wound up going to a lot of the same places because I was interested in interviewing people from the units that had been in the most action for historical reasons, and he was visiting those same units because some of the Marines were already having some problems with what they had seen and done in theater.

He also introduced me, which I have read and I have now in my collection, to one of the books that you referenced in your proposal, Ben Shephard's A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century.

TANISHA FAZAL: It is a fantastic book.

REED BONADONNA: Big classic in that field.

You mention going back to Achilles. You are probably aware that there are groups out there—I think one of the biggest and most successful has been a group called Theater of War—who are using classical drama, for example, the play Ajax is one that they have used a lot. They have been performing plays like that to help soldiers get over some of their own PTS symptoms and their feelings of having been betrayed by the command and fighting in a war of dubious outcome and that kind of thing.

What do you think of ideas like that? There is another effort to put the humanities to use in treating people with PTS-like symptoms or the other symptom called "moral injury" (MI). Do you get into this very much in your work? I guess it is new, so in that sense this is not a World War I treatment we are talking about, but you are also making the connection between World War I in your project and current times.

TANISHA FAZAL: Yes. Let me say a couple of things about that. The first thing I want to say is that I am not a clinician, so I am not in a position to judge the efficacy of various treatment methods. I want to be clear about that. I have a Ph.D. in political science, not an MD, although I am learning of course a great deal of medicine for this project.

Second, just to circle back to the point you were relating about your own experience in Iraq and your work with the Navy psychiatrist, one of the questions that I am grappling with in this project is whether PTS looks different depending on the kind of war that is being fought. In World War I, you have trench warfare, you have clear front lines. It is not hard to think how that could be extraordinarily stressful and could induce PTS, but in the most recent counterinsurgency wars that the United States has fought, it is a very different situation on the ground.

Given your experience, you can speak to this even better than I can, but I will just say that to not be able to necessarily distinguish between civilians and combatants, the kind of civilian casualties that we have heard about and that U.S. troops have witnessed in Iraq and Afghanistan I think would probably induce a very different set of symptoms, so this is one of the things I am going to be looking at.

But then to speak specifically to your question about drawing the humanities into treatment of post-traumatic stress, again I am not a clinician, but my reaction to that is, first of all I will say I suspect it is probably part of this effort that at least from what I understand was really started by someone named Jonathan Shay, who wrote a couple of books. One is called Achilles in Vietnam: Combat Trauma and the Undoing of Character, and the other is Odysseus in America: Combat Trauma and the Trials of Homecoming, where he was actually using the classics as a way to help veterans begin to work through their post-traumatic stress. My sense is that if it helps, then it is probably something worth doing.

I think one of the real challenges with post-traumatic stress is assessment, both in terms of initial diagnosis and in terms of the assessment of the efficacy of subsequent treatments.

REED BONADONNA: Right. I am going to back off a little here and talk more about the project itself, but I want to get back to some of the contemporary relevance as we go.

You mentioned a number of places where you will be doing your research. We are still early days, but I wonder how far you have gotten into your research. How many of these places, Veterans Bureau, National Archives, you have been able to access, and whether there have been any interesting discoveries there in your research as you have gone forward from your original proposal, any surprises or occasions you would like to talk about or what you are looking forward to.

TANISHA FAZAL: I have not yet taken the trips to archives. I am actually leaving in about 10 days for my first visit to Washington, DC, as a kind of early visit to look preliminarily at some of the archives and collections held at the National Archives both in Washington, DC, which is where a lot of the Veterans Bureau [archives], which was predecessor to the Veterans Administration (VA), are held. There are some held in the archives in College Park. I am also hoping to visit the National Library of Medicine, which is in Bethesda in the kind of [inaudible] complex over there near Walter Reed and such.

I have not conducted that research yet. What I have been focusing on in preparation for that trip is really working through the secondary literature on military medicine in general but post-traumatic stress in particular.

One set of primary documents that are available online and available here that I was happy to discover over winter break—I am looking at them right now—is this enormous and enormously heavy 15-volume set of books put out by the Medical Department of the United States Army in the World War that cover a variety of different topics. The one I am holding in my hand right now is Volume X, and it is on neuropsychiatry.

It is really interesting to hear the role of psychiatrists and psychologists in World War I or to learn about it from the doctors themselves. Really their role started even before troops were deployed in assessing the psychological or psychiatric qualifications, or disqualifications as the case may be, of various draftees, assessing them for their fitness for being deployed. You can kind of see reading through these books that they were definitely also struggling with how to treat post-traumatic stress. They did not have a lot of experience in dealing with it, especially in wartime, and so you can see them struggling through it in these primary accounts of the doctors.

Another piece of this project that I have been working on is looking at veterans' benefits. Today veterans diagnosed with post-traumatic stress disorder (PTSD) do get benefits, they do qualify for benefits. But there is a really interesting story about the historical arc of veterans' benefits in the United States that I am working my way through. After the Civil War there was a system of pensions for veterans but really not much in the way of health care. There were veterans' homes, but the benefit system was really focused on pensions.

This eventually became very controversial politically, because it was eating up a lot of the federal budget. In fact, a number of policymakers and other leaders in the United States who were very ambivalent about the possibility of the United States entering World War I because they were worried that this would only increase the pension rolls in a way that would be fiscally unsustainable for the United States. So the nature of veterans' benefits changed after World War I away from pensions and toward rehabilitation.

Right now I am reading a terrific book by an historian named Beth Linker called War's Waste: Rehabilitation in World War I America, and it is about rehabilitation after World War I. But this rehabilitation was entirely focused on physical ailments and not at all focused on psychiatric illnesses. There is an untold part of the story that I am looking forward to being part of telling.

REED BONADONNA: That's great. As an English major, when I think of World War I, I cannot not think of the World War I poets. I think maybe in talking about trauma and distress of body and mind, Wilfred Owen is maybe the leading poet of that era. He may be the best poet to come out of the First World War anyway. Siegfried Sassoon writes a fair amount about soldiers who have been wounded. In some of his poems, he is obviously working out questions of what it would be like if he were seriously wounded. They all write about madness at one time or another.

As Paul Fussell said, "Oh, what a literary war." World War I is famous for creating a huge amount of high-quality literature which reflected, I think, a lot of attempts to understand the condition of wounded and distressed men coming out of their war service. Has any of this been significant to you as background in your work?

TANISHA FAZAL: Of course, I am familiar with it on a superficial level. As a footnote, my recollection from reading A War of Nerves, which you just mentioned earlier, is that Sassoon and Owen knew each other in a psychiatric ward in Britain, so it sounds like they were having conversations about this and probably had a lot to talk about.

There is another book, or trilogy actually, that speaks about these issues, by Pat Barker called The Regeneration Trilogy, which is about post-traumatic stress. I have not yet dove into the literary aspect of it. That is the treat. I am holding that out as part of my reward for doing the digging, which I also enjoy very much—doing the historical work and the political analysis—but at some point I will start looking more at the literary piece of it.

There is also, I think, interesting visual art around military medicine in World War I, although I don't know if there is so much visual art about post-traumatic stress, but there is that famous painting by Sargent of the soldiers who are blinded by the gas holding onto each other to get themselves to medical treatment.

REED BONADONNA: That was here in New York at the New York Historical Society a little while ago for an exhibit.

TANISHA FAZAL: Oh, really?

REED BONADONNA: I went to see it. Yes.

TANISHA FAZAL: I would have loved to see that.

REED BONADONNA: I was going to mention, I have read The Regeneration Trilogy. Also, in addition to his poetry, Sassoon wrote a lot of prose about his war experience. In these accounts in particular Dr. Rivers was the lead physician who treated Sassoon and I am pretty sure also Owen. This was at a place called Craiglockhart in Scotland, which was a hospital for officers who were suffering from neurasthenia, or whatever the terminology was, and Owen and Sassoon both wound up there. Rivers comes across as quite a heroic figure, really successful in clinical terms, but also wrestling with the ethical, the moral issues that had been raised by their service for some of these soldiers.

That is my long lead-in to asking the question: Your story is partly about things getting better and us getting more competent in treating wounded people and dealing with the costs of war, but I wonder if you are coming across anything from this long-ago war that gives you an idea at this time, maybe because of the literary sensibility that was abroad or figures like Dr. Rivers who were sort of creating this new process of psychiatry in the field on the fly, that they did it better at that time, that there are things about the way they treated PTS and moral injury which perhaps have been lost and are worth recapturing.

TANISHA FAZAL: I have not gotten that sense, at least not yet, but maybe I will from the research. The sense I have gotten, and I have been focusing mostly on the U.S. part of this, is that the American doctors were really trying to figure it out. For them, the ethical issues were dealing with the possibility that people who were seizing, etc., were malingering. As doctors, they are trying to figure out—doctors in the military, as you know, have a very different role to play than doctors in the civilian world. They are part of a military command structure, and really what they want to do is return people to duty. If somebody does not look sick, then there is this issue that they have to deal with of: Is this person really ill or is this person essentially faking it, are they malingering?

This is an ethical issue that from what I understand, at least to date in my research, was in some ways one of the soldiers had to tell it as well because once they realized that there was this diagnosis of shell shock available, there were some people who did pretend because they did not want to be in the war anymore. It is completely understandable to not want to be in the war anymore, but then there are obviously of course many people who were legitimately made ill by the war.

Then another ethical issue that I think these doctors always have to deal with, including today, is when can you send someone back to war? When can you return them to duty if they have been diagnosed with post-traumatic stress?

I have not really come across so far in my research indications that treatment of post-traumatic stress was better in the past than it is today. Maybe I will, but not yet.

REED BONADONNA: Very good.

One of the sentences in your proposal, you say that we're "missing the story of how we got from then"—which is World War I—"to now." I wonder if in a few words you could give us the summary of the narrative of how you understand it, of how that progression took place.

TANISHA FAZAL: I can tell you what my questions are. One of my goals in the Fellowship is always to try to figure out answers.

I think that one of the arcs that I want to fill in is the distance between a time when you could barely diagnose post-traumatic stress, and it was not called post-traumatic stress, and so people were—as you mentioned, Dr. Rivers—figuring it out on the fly. It certainly was not something that was accepted after the war, when people came home, as a legitimate illness, whereas today it is quite different. There are pretty clear diagnostic regimens for post-traumatic stress.

It is something that is much more accepted in American society for sure. I recently ran a survey of West Point cadets, and one of the things I asked them was whether they thought that post-traumatic stress ought to be included as an injury by the VA and by the U.S. military, and the clear majority of them said yes. So not only is this something that is now accepted in society, it is also accepted amongst the military. It is okay to have and be diagnosed with post-traumatic stress in a way that it was not, I don't think, in the past. I think that change is pretty remarkable and something that I am going to be trying to figure out.

REED BONADONNA: Okay. Since this is a project about the legacy of the First World War, and I know these answers, almost all are going to have to be tentative because we are just beginning, but what is the legacy? Here we are studying these events of a hundred years ago in an effort that they not be lost at the time, that we recollect things that happened, things we ought to have learned. What is the most important for us, for people in general, for America to remember about the aspect of the World War I experience that you are doing your research in?

TANISHA FAZAL: You are asking a really big question there. Started with a softball, but you're not ending with one, I'm pretty sure.

I think that if we wanted to start with the present and then reverse the lens and look back, one of the struggles that the United States has always had is how to compensate and care for its veterans. The way this looked with respect to post-traumatic stress in the immediate aftermath of World War I is a striking contrast to the fact that shell shock had really some recognition that there was something called shell shock which is the predecessor of what we call today post-traumatic stress. Yet it did not translate into the way that veterans' benefits were really thought of after World War I.

On the one hand you have this legacy, this medical legacy of, yes, we realize that this is a medical problem that military personnel on the battlefield can contract, it is a disease that people can get. But there is this disconnect then between how we are going to support military personnel after the war.

I think that is a legacy that America has really struggled with—and I am sure not just the United States—in subsequent conflicts. I have not yet looked at the Second World War, but I have looked a little bit at the more recent conflicts, and you really do see a sea change in how post-traumatic stress is dealt with in the military, in the medical world, and in society writ large in the United States.

REED BONADONNA: Great answer. I know it was a big one.

I will mention another literary connection. There was a novel made into a film with Gregory Peck called Captain Newman, M.D., about a World War II Army Air Corps psychiatrist. It is really a neat story about—and the title says it: yes, he's an Army officer, he's Captain Newman, but he's also Captain Newman, M.D., so he has these somewhat conflicting professional obligations to care for people and to turn them back into fighting raw material and send them back to their aircraft if they can take it.

Here is kind of a lowball question maybe. One of the historians we have had contact with here at the center talks about the American Revolution, and he says if you want a sort of sense image of the American Revolution, think of the smell of whiskey and onions because this was probably a pervasive smell in army camp, in the line, among the American army that fought and won the American Revolution.

Does any sort of sense impression of the work that you are doing or the time and the milieu that you are studying occur to you that this is what it felt like, this is what it smelled like, visually that this was the experience that you had as a researcher or that the people who you are studying were going through?

TANISHA FAZAL: In terms of senses, it is not so much a smell, but rather the contrast between light and dark in multiple dimensions, obviously day and night, but also training in the countryside in France after troops crossed the Atlantic in these villages and the beautiful countryside, and you are housed with people living there sometimes.

REED BONADONNA: Pastoral.

TANISHA FAZAL: Yes, that's exactly the right word—versus being in a trench and the darkness of that.

But even in the midst of trench warfare you hear these stories of people making their way back to the countryside briefly, or even truces with the Germans, some of which are quite famous, where there is this sense of we're down, it's dark, and then we get exposed to the light. So I think that would at least so far be the main sensory impression that I have from the American experience in World War I.

REED BONADONNA: I think Owen the poet is great on that in some of his scenes of the trenches, the contrasting images of bright sunlight and brutal and seriously worked-over environment that the soldiers are operating in, bitter cold sometimes, wet.

TANISHA FAZAL: They are mazes intentionally, sometimes intentionally with dead ends for when the other side recaptures it. It is an incredible system, an incredible geography and architecture that was set up.

REED BONADONNA: I am pretty much out of questions about your project. Two things: What question didn't I ask? Is there some way that you would like to wrap up the discussion of your project, "The Politics and Medicine of Treating post-traumatic Stress Since World War I," and/or the book that you have written, Wars of Law, which is going to come out in May? You might be conducting an interview about that in particular, but I just wanted to give you a chance if you would like to say anything about your new book, maybe if there is any connection with the project that you are working on now.

TANISHA FAZAL: I think maybe I will take a second and try to do both and respond to your question about whether there is a connection between the book that I have coming out on international humanitarian law and how that has changed historically and what the implications have been for civil and interstate war, and this project.

I would say that there are two connections. There is the very obvious connection that the first codified international humanitarian law that was about land warfare—the first codified international humanitarian law, period, was about maritime warfare —was the 1864 Geneva Convention on the protection of the wounded. So this idea of delivering medical assistance to the wounded is something that I definitely talk about in the first book. That is the inspiration for the founding of the International Committee of the Red Cross (ICRC), which have of course delivered medical aid, both the ICRC and the national Red Crosses as well have been instrumental in delivering medical aid since the 19th century and certainly today.

The second is a bit more anecdotal and personal in the sense that there is maybe a little bit of an inside-baseball funny story that actually led directly from that project to this project on military medicine and the changing costs of war, of which the Fellowship on post-traumatic stress and the living legacy of the First World War is a part.

I had an article I had written on why it is that we no longer see peace treaties after interstate war that was being reviewed for publication in a journal. One of the reviewers was pushing back at me a little bit and saying, you really need to engage with this new—at the time—work that was coming out by people like Steven Pinker, who is a psychologist at Harvard and a public intellectual, who was making the argument that war was on decline.

Pinker's book was on my shelf. I don't know if you have read it, but it is 800 pages long, and it was one of those books I was going to get to one of those days. So all of a sudden I was forced to pull it off the shelf and read it.

REED BONADONNA: This is Better Angels of Our Nature that you are talking about?

TANISHA FAZAL: Yes, The Better Angels of Our Nature: Why Violence has Declined. It is a good book. I recommend it. It is a good, if long read. [Editor's note: Pinker debated author Robert D. Kaplan about whether the world was becoming more peaceful in a 2012 Carnegie Council event.]

One of the things I found really frustrating about it was that he had all of this really interesting historical data on the decline of violence, but he was defining violence exclusively in terms of fatalities, which I found very problematic given the historical span that he was covering. He has a chapter on homicide, but if you get knifed in the gut in London in 1418, you are going to have a very different outcome than if you get knifed in the gut in London in 2018. You are healthier to begin with. There are hospitals and ambulances and paved roads and antibiotics and anesthetics. Really if you wanted to make a claim for the decline in violence, you would have to look at attempted homicides—harder to get the data—rather than successful homicides, which is effectively what he was looking at.

And then he had a couple of chapters on war, which is more in my wheelhouse, and I was equally frustrated and started pushing back and making the argument that, well, war has become less fatal, but it has not become less frequent, or that does not necessarily mean it has become less frequent. If you measure violence exclusively in terms of fatalities and you are looking over a long historical timespan, then you are missing a really important part of the question, the part of the story which are these advancements in military medicine, where you just have many more people surviving but oftentimes coming home with very serious wounds, including post-traumatic stress, than in the past.

REED BONADONNA: Professor Fazal, would you like to wrap it up? Any parting thoughts about your current project, what the experience is like looking forward, what's next, anything?

TANISHA FAZAL: I am very excited about the project. I am looking forward to learning more about how this disease has been diagnosed, treated, and dealt with in not only the population of people deployed over the course of various U.S. wars, including and since World War I, but also how the veterans of these wars have dealt with post-traumatic stress as well. I think there are a series of interesting and important puzzles that speak to really key policy issues today.

REED BONADONNA: I am going to be unfair for a minute. I have what we Marines call a "saved round," which means I have a leftover bullet, and that is the question of moral injury, which has become—this is even more recent; I am not sure if I would call it a diagnosis, but a term that has been bruited about. I think Jonathan Shay claims to have coined the term, but there are others who were using it around the same time that he did.

It is a separate thing. For example, it may not be as subject to clinical treatment as PTS because it is more wrapped up with ethical questions which clinicians are sometimes not comfortable, that is not their expertise, with addressing, with the person on the other side of the desk from them.

TANISHA FAZAL: Right. They deal with a different set of ethics.

REED BONADONNA: Is your work reaching back to the past and also addressing contemporary relevance, are you planning on breaking out or having a discussion of moral injury? You were talking about being at a conference I think at the Air Force Academy recently, and there was a discussion of MI. Anyway, give me here at the end your thoughts about moral injury as an issue that might be wrapped up in your work.

TANISHA FAZAL: I don't see how you can do this without talking about moral injury. I think it has to be part of the story.

As you know, it is a relatively recent term. I suspect in the more historical research it is the kind of thing that is going to come up when I am reading memoirs and personal accounts both of soldiers and Marines and doctors. You see it discussed more explicitly, as you know, in the more recent literature.

I do think it speaks to this question of whether post-traumatic stress, and I think also moral injury, looks different in a conventional war versus a counterinsurgency war, which is not to say that it is more or worse in one or the other, but I think it would exhibit differently or present differently in those two different kinds of conflicts.

REED BONADONNA: Maybe we can end on that note. Good luck with everything, with your research going forward. I am still here as senior fellow and lead administrator for the project, so reach out to me any time you have a difficulty you want to talk about or questions about the schedule and how we are getting people together and things like that. I am sure we will be in touch over the next few months. Other than that, I will say good morning and have a great day.

TANISHA FAZAL: Thank you. You, too.

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