Covid-19, Establishment Thinking, and Lessons from the Great War

During the 20th Century, evidenced-based medicine (EBM) emerged as the dominant paradigm in healthcare. Efficacy (explanatory) and effectiveness (pragmatic), as evidenced from the randomised-controlled trial (RCT) led to a ‘pipeline’ approach to improvement in knowledge. Later in the century the RCT was surpassed by the ‘metastudy’ of the studies – systematic reviews to combine the results of multiple scientific studies – as the gold standard for establishing effect. However, this paradigm has many inefficiencies. In this article, we bring attention to the parallels to be found between the First World War and our current battle with CoViD-19. During the Great War, as the First World War was also known, the traditional ‘linear’ and rigid tactics that had been used by the establishment Generals for centuries were not fit for purpose in the increasingly complex battlefield of the 20th Century. This resulted in a tragic quagmire. Establishment thinking was challenged, resulting in a radical shift to a much more comprehensive, adaptable and flexible approach that was conducive to changing dynamic situations on the battlefield, that has been described as the Modern Style of Warfare. Tactics at the end of the war were almost unrecognizable to those at the start. We discuss how a complex and rapidly evolving pandemic has illuminated how the traditional approach to knowledge and improvement is not fit for purpose in this complex, evolving ‘battlefield’. Inefficiencies and inadequacies of the system are accounted for in lives lost, and, just as in the Great War, there is a need to adapt to the different war we are battling now.