Flat White

What the Great War taught us about ‘establishment thinking’

25 March 2022

12:00 PM

25 March 2022

12:00 PM

Establishment thinking can be lethal, especially when the establishment are the ‘elite’ and their prevailing paradigm is not adaptable enough to meet a novel complex challenge.

Australians experienced the lethality of ‘establishment thinking’ during the first world war (The Great War). The futile slaughter on the battlefields of Gallipoli and the Western Front affected our cultural heritage. A century later, the establishment’s response to Covid would have benefited from lessons derived from The Great War.

In the broader context, this discussion is existential to elitists who believe they can control other people’s lives based on the simplistic trend of ‘evidenced-based policy’ when instead they should heed what history has taught us about understanding complex, dynamic systems.

The simplistic linear tactics of 19th century warfare were inappropriate for the industrialised warfare that the first world war created. Many Australians might not be aware that tactics at the end of this war were almost unrecognisable to those at the start, becoming much more comprehensive, adaptable, flexible, and conducive to changing dynamic situations on the battlefield.

This heralded what has been described as the Modern Style of Warfare ‘perhaps the most significant conceptual development in all the long history of war’. (Bailey, The First World War and the birth of modern warfare.)

It was observed that:

‘The revolution (of paradigm) of 1917-18 occurred because prevailing ideas firmly rooted in the establishments of the day were out of step and unyielding to the multiple pressures of change.’ (Bailey.)

‘The Modern System dissolved the huge, rigid formations that had dominated battlefields for over 4,000 years,’ and most importantly, ‘freed up individuals to act as they thought best.’ (Ian Morris) 

Many generals could see past the futile establishment thinking, including General Sir John Monash, who was a leading proponent of change.

The tactics early on in the first world war provide an analogy to the current establishment’s practice of Evidence-Based Medicine (EBM) grounded in the ‘tactic’ of randomised controlled trials (RCT).

RCTs can be vital in deciphering reproducible, biological relationships. However, we must acknowledge that using a method which demands that everything about the system remains static (to maintain reproducibility) in order to gain knowledge about a complex system (such as a pandemic) that is rapidly and profoundly changing in real-time – will predictably cause inefficiencies.

Consider, for example, the reproducibility crisis in even basic biological experiments, where the system can be completely controlled. 

With multiple different treatments/patients/disease stages related to Covid, individual reproducible scientific experiments could easily run into the millions or billions to gain the required knowledge. Last century, economists came to realise the ‘knowledge problem’ related to understanding dynamic systems. 

This first world war analogy highlights the problem where strategies that are not both sufficiently individualised and adaptable within ‘the fog of war’ can lead to catastrophically lethal inefficiencies. 

So, what have the results been?

There have been many aspects to Covid: origins, predictive modelling, don’t-mask-then-mask, airborne spread, etc. But let’s look at treatments. We are now 27 months into the pandemic and millions of people dead. Based on the EBM paradigm, and the beneficiary of inordinate goodwill and resources, how many treatments have the World Health Organisation come up with? 


Up until March 2022 – only three!

 Corticosteroids, IL-6 inhibitors (or Baricitinib as an alternative) and monoclonal antibodies. Anyone with a diploma in the Bleedin’ Obvious would have adopted these treatments, long before the WHO. Sorry to all the millions of people who died in the meantime while confirming the bleedin’ obvious. Actually, the WHO is not sorry at all. 

The WHO has finally released a ‘conditional recommendation for use of Molnupiravir’, an agent that also had a large signal of effect. 

In early 2020 – based on clinical response, pathology and biochemistry – clinical innovators recognised that Covid was ‘a steroid-responsive disease; However, timing is critical.’ (Based on EVMS Critical Care Covid  Management Protocol 2020.)

Despite protests from the establishment, these clinicians recognised that, ‘Providing supportive care and waiting for the cytokine fire to burn itself out simply does not work… This approach has failed and has led to the death of tens of thousands of patients.’

This same protocol in early 2020 lamented, ‘The systematic failure of critical care systems to adopt corticosteroid therapy.’

Eventually, the establishment came around. But did the EBM paradigm produce a highly nuanced, flexible, adaptable corticosteroid regimen that aligns treatment with feedback and response parameters? (Equivalent to the Modern Style of Warfare.)

No.

It produced a potentially lethally feeble suggestion for a one-size-fits-all low dose of corticosteroid that a Somme-like RCT merely demonstrated was somewhat better than nothing. It is highly improbable, if not implausible, that a one-size-fits-all low dose could be the optimum dose of steroid for every patient with this overwhelming disease.

Is this the best we can do? This one-size-fits-all regimen of steroids is the sort of inefficient feeble response that the old Soviet-style command economy would produce, not the sort of adaptable response that would evolve through market forces, contributed to by clinicians around the world.

IL-6 blockers (specific immunosuppressants) were introduced into rational, patient-centred treatment approaches that were achieving significant results back in the early months of 2020. Yet IL-6 Blockers were not recommended by the WHO until July 6, 2021. The recommendations for monoclonal antibodies, which the WHO notes have a ‘very plausible’ mechanism, were not published until September 24, 2021. 

Establishment thinkers were advocating for such a high standard of evidence (before allowing patients access to treatments for Covid) that would be the equivalent of people being denied access to parachutes outside of a randomised controlled trial. This was, of course, the basis of a brilliant parody of evidence-based medicine by Smith and Pell way back in 2003 in the British Medical Journal.

Interestingly, a prominent author pushing the establishment line argued that, ‘Yet, despite substantial evidence of potential harm, steroids and IL-6 inhibitors are now being given to patients with Covid in several countries.’

Yes, hallelujah!

Thankfully, these treatments (the two most important treatments for life-threatening Covid), were being given by enlightened clinicians based on the totality of accumulated knowledge to help save the lives of their most vulnerable patients; before the establishment gatekeepers granted ‘permission’. However, untold numbers of people died worldwide without receiving these treatments until later in the pandemic. This inefficiency must be acknowledged as part of the establishment’s paradigm. 

One radical change that General Monash introduced was to consider the wellbeing of individual soldiers, rather than using them as expendable substrate en-masse. The current medical establishment would do well to ponder this.

Establishment thinking was being questioned before Covid.

In 2019, the US National Institutes of Health released its new priorities for sepsis research. These priorities recognised that after decades of futile, mass homogenised RCTs there had been very little advancement. Instead, priorities included the generation of knowledge of how to determine which patients are responding and how to distinguish different clinical phenotypes. NIH now considers clinical trials to be of low priority for sepsis; a change in paradigm that aligns with the Modern Style of Warfare.

What is the equation? The up-sides and the downsides?

We don’t want to miss treatments that have an effect, and we don’t want to persist with treatments that don’t.

In a rapidly evolving lethal pandemic, some treatments may ‘slip through the cracks’ in either direction. However, only allowing the use of treatments that have satisfied the establishment gatekeeper’s one-size-fits-all paradigm creates far greater inefficiencies and disequilibria. If a treatment genuinely had no perceptible effect and had significant side effects and was highly expensive, there would be little evolutionary pressure for the treatment to be maintained.

We look back with disdain at early first world war Generals’ highly-inflexible, non-adaptable establishment thinking. Therefore, the most instructive concept highlighted by this analogy might be to recognise that at the time, the establishment’s prevailing paradigm was assumed to be self-evidently the most efficient. Intellectual constipation can entrench generation-lasting paradigms. Will we look back at the highly-inflexible, non-adaptable, one-size-fits-all treatment that many Covid patients receive in the same way?

In this context we need to encourage more free thinkers like General Monash, not censor them. We also need to dissolve the huge rigid formations that are dominating medical research.

The brilliant satire of establishment thinking by Rowan Atkison’s Blackadder is as relevant today as ever.

This is worth a watch: Advanced World War I Tactics with General Melchett – YouTube. Readers may also be interested in this paper on Elsevier’s SSRN.

Michael Keane is an adjunct associate professor at Swinburne University, adjunct lecturer at Monash University and consultant anaesthetist. He has academic interests in bioethics, human factors engineering, the use of evidence-based medicine and health policy.

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