When the Korean War broke out on 25 June 1950,¹ less than 10 years after the United States had entered World War II and less than 5 years after that war had ended, the situation was improved over the situation in December 1941 in only one respect: No well-organized blood bank system was in operation, but a plan for the supply of whole blood and plasma did exist. The plan had not been implemented, however, because it had been prepared only a short time before the outbreak of hostilities. It is extremely unfortunate that planning had not begun earlier, for the need for whole blood arises whenever combat commences; the Korean War proved again that whole blood cannot be provided promptly and efficiently unless supplies, equipment, trained personnel, and a detailed plan for its collection, processing, transportation, and distribution have already been set up.

When the Korean War broke out, the course of events in respect to the blood program was as follows:

1. Blood collecting teams were immediately utilized in Japan, to meet the first need for blood in the field.

2. These supplies proved inadequate as action became more intense, and requests for whole blood were sent to the Zone of Interior.

3. The American Red Cross was asked, as in World War II, to become the collecting agency for blood for the oversea airlift. Fortunately, this agency already had in operation a blood collecting program to supply blood to civilian hospitals in the United States, and could build upon it.

4. Later, when the initial program proved inadequate, an Armed Forces Blood Program and a National Blood Program were established and remained in operation until the end of active fighting in Korea.

5. A plasma program was also developed which later had to be discontinued because of the risk of serum hepatitis associated with plasma infusions (p. 776). The production of human serum albumin was substituted for the production of plasma and was supplemented by the production of plasma expanders (the so-called blood substitutes of World War II).

¹ That date should be borne in mind. Unless the dates of the various activities to be described are borne in mind and are related to the dates of the Korean War (25 June 1950, when the invasion of South Korea occurred, and 27 July 1953, when the armistice was signed), it will not be realized that, in many instances, the actions were almost too late.

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In spite of the expedient nature of the blood program, casualties in Korea never lacked the blood they needed, but the comment is justified concerning this war, as it was concerning World War II, that the efficient way to provide blood for combat casualties is not to wait for the need for it to arise and then to provide it, at least initially, by a series of improvisations.

It is interesting, and somewhat depressing, to note in various reports of conferences concerning the blood and blood-derivatives program in the Korean War how quickly the World War II experience seemed to have been forgotten and how the tendency was again evident to concentrate on agents other than whole blood in the management of combat and other casualties. At a meeting of the Subcommittee on Shock, Committee on Surgery, NRC (National Research Council), on 14 November 1951 (1), Dr. Walter L. Bloom rather impatiently called the attention of the members to the fact that the entire philosophy of plasma expanders was questionable. Military and surgical groups, he said, should define the limitations of these substitutes, and they should be considered as suitable for emergency use only. The first need of combat casualties was for whole blood.

A knowledge of certain background facts is essential to the story of the blood, plasma, and plasma-expanders program in the Korean War, beginning with one major difference between this program and the similar program in World War II: In the Korean War, the program covered civilian defense as well as military needs. In World War II, the two responsibilities were entirely separate. The development of the program that provided blood and plasma in the Korean War is best described chronologically.²

In September 1945, with the end of hostilities in World War II, the whole blood program was discontinued immediately, and the plasma program was terminated as promptly as contracts could be ended. The research that had been a part of both programs also came to an end except for the plasma-fractionation studies, which were continued in Dr. Edwin J. Cohn's laboratory at Harvard.

During the interim between the wars, needs for whole blood in Army hospitals were met within the hospitals. There were no plans, militarily or otherwise, to stockpile reserves of plasma for a national emergency. Indeed, had such a disaster occurred, there would have been no program to put into effect. The whole blood program would have died between the wars except for the stimulus provided by the activities of the American Red Cross.

² Unless otherwise indicated, the data in this section of this chapter are derived from the excellent and well-documented account of the blood, blood derivatives, and plasma-expanders program in the first 2 years of the Korean War prepared by Col. Patrick H. Hoey, MC, USAF, Chairman of the blood and blood derivatives group (2), and the convenient account of the historical development of the Office of Assistant Secretary of Defense (Health and Medical) prepared by Miss Elsie LaMantia (3).

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Postwar activities in respect to blood began on 26 July 1947, with the passage of the National Security Act (Public Law No. 253, 80th Congress), which established the Department of Defense (2). This act provided for the establishment of NSRB (National Security Resources Board) to advise President Harry S. Truman on policies relating to industrial and civilian mobilization. It also provided for the policy just mentioned, the integration of civilian and military health resources. Finally, it authorized steps leading toward a more unified control of national medical services.

On 1 January 1948, the then Secretary of Defense, Mr. James V. Forrestal, appointed a Committee on Medical and Hospital Services of the Armed Forces, to study all questions of common interest to the three medical services, with a view to obtaining maximum efficiency and economy in all their operations. Secretary Forrestal's committee consisted of Maj. Gen. Paul R. Hawley (Ret.), chairman (hence, the Hawley Committee); the Surgeons General of the Army, the Navy, and the Air Force; and Rear Adm. Joel T. Boone, MC, USN, who served as executive secretary.

In the meantime, the President had appointed a Commission on Reorganization of the Executive Branch of Government under Ex-President Herbert Hoover (the Hoover Commission), which, by the middle of 1948, had two task forces working on the coordination of health and medical matters in the National Military Establishment:

1. The Task Force on National Security (the Eberstadt Committee).
2. The Task Force on Federal Medical Services (the Voorhees Committee).

The Hawley Committee had recommended that a civilian committee be established, to serve in a consultant and advisory capacity to the Secretary of Defense on medical and health affairs, and both of these task forces made similar recommendations.

On 9 November 1948, still another committee was appointed, the Armed Forces Medical Advisory Committee. Its chairman, Mr. Charles P. Cooper (hence, the Cooper Committee), also served as Deputy to the Secretary of Defense in the fields of medicine and health. The committee consisted of the Surgeons General of the three services, General Hawley, and a number of distinguished civilian physicians.

The recommendations of this committee immediately identified a structural weakness in the Office of the Secretary of Defense: There was no agency or personnel in it to implement committee recommendations after the Secretary had approved them. The Surgeons General, who were members of the committee, were in the untenable position of making recommendations to the Secretary and then receiving these same recommendations from him for comment. This phase of the problem was solved by removing the Surgeons General from membership on the Cooper Committee.

In February 1949, the Joint Chiefs of Staff asked that the Cooper Committee consider the entire question of "unification or coordination" of the Armed Forces medical services, including the possible development of a single medical service. At the end of 2 months of intensive study, the committee recommended against a single Tri-Force medical service. Instead, it recommended that the recommendations of the Eberstadt, Voorhees, and Hawley Committees should be implemented and that an organization be established in the Office of the Secretary of Defense, with authority to act on committee and other recommendations.

In accordance with this recommendation, the Medical Service Division was set up in the Office of the Secretary of Defense in May 1949, with a director who had authority to

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establish general policies for the medical services of all three Armed Forces. The Hawley Committee was then dissolved and its subcommittees were transferred to the Medical Service Division. The Cooper Committee continued to function.

On 29 September 1949, the Medical Service Division was renamed the Office of Medical Services. Its current director, Dr. Richard L. Meiling, was named Director of Medical Services and Assistant to the Secretary of Defense for Medical Affairs. Dr. Meiling established a Medical Advisory Council consisting of the three Surgeons General, who met weekly in his office. After the Korean War broke out, the Surgeon General of the U.S. Public Health Service and the Medical Director of the Veterans' Administration were added to the membership of the Council.

The Cooper Committee continued to function throughout 1950, as did the Office of Medical Services. On 2 January 1951, the Cooper Committee and the Office of Medical Services were replaced by an Armed Forces Medical Policy Council, whose director was named Assistant to the Secretary of Defense for Health Affairs. The Council consisted of the three Surgeons General; a dental surgeon; and two other civilians, Dr. Isidor S. Ravdin and Dr. W. Randolph Lovelace III, both of whom had had wide medicomilitary experience. With the establishment of this council, there was now fully carried out, for the first time, the intent of Congress as expressed in the National Security Act of 1947 (p. 715). Also for tile first time:

1. There existed in the DOD (Department of Defense) an organization with authority to coordinate medical policy within the department as well as between the department and other governmental agencies and civilian medical and allied health organizations.

2. The three Surgeons General had authority to represent their respective departments in the formulation of medical and health policies at the level of the Department of Defense.

There were no further changes of consequence in the medical structure of the Department of Defense until 1 April 1953, when DOD Directive 5136.4 established the position of Assistant to the Secretary of Defense (Health and Medical) in the Office of the Secretary of Defense. This was a considerable forward step. All medical and health policies, plans, standards, criteria, and other aspects of medical service could now be reviewed in the Office of the Assistant to the Secretary of Defense (Health and Medical), who also maintained liaison, on both a national and an international basis, with all other governmental and civilian health and medical agencies and associations. The advice of the Surgeons General was made available to the Assistant to the Secretary of Defense as necessary.

On 30 June 1953, Congress approved Reorganization Plan No. 6 for the Department of Defense. This plan authorized, among nine Assistant Secretaries of Defense, an Assistant Secretary of Defense (Health and Medical); thus, in effect, regularizing and giving authority to the plan adopted in the Office of the Secretary of Defense in April 1953. On 2 September 1953, the Secretary of Defense, by DOD Directive 5136.4, established a Health and Medical Advisory Council composed of civilians.

Meantime, the NSRB chairman, former Secretary of the Air Force W. Stuart Symington, had set up a Health Resources Office, which reported directly to him and which was responsible for the development of plans and recommendations relative to mobilization and allocation of health resources and for the medical aspects of civilian defense. Dr. Howard A. Rusk was appointed chairman of the special committee to advise Mr. Symington on broad policies relating to health resources. When these last actions were taken, the armistice of 27 July 1953 had already ended the fighting in the Korean War.

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The organizational steps just outlined were all extremely important and are entirely relevant to the blood program in the Korean War. They meant that, for the first time, the Department of Defense would coordinate and integrate all phases of its health program, including the blood program, to with broad policies established at the presidential level. It also meant that recommendations of task groups concerning coordination with other agencies would no longer be conflicting, since both military and civilian national health agencies would now act jointly, to meet the overall requirements of national mobilization.

One of the joint problems that came to the attention of the Director of Medical Services, Office of the Secretary of Defense, in 1949, soon after the establishment of his position, concerned military and civilian requirements for whole blood and blood derivatives. An inventory of existing stocks of plasma and other derivatives, early in October of that year, indicated that they were very low (p. 772); that there was no coordinated plan to expand them; and that, if an emergency should arise, there were no facilities for their augmentation. Only four laboratories were producing plasma commercially. Their combined annual production was about 300,000 units, and they had no incentive to expand it, for plasma was a nonprofit item.

This situation was viewed with the seriousness it deserved, and, on 26 October 1949 the Director of Medical Services, acting for the Secretary of Defense, appointed a task group to study the whole problem of providing blood, blood derivatives, and plasma substitutes (expanders) for the Armed Forces in peacetime and in war. The investigation was to cover such related matters as supplies and equipment for transfusion; training of personnel in the technical aspects of procurement, control, storage, transportation, and use of blood and blood derivatives to meet expanded requirements of an emergency program; and the development of a system of logistics capable of meeting requirements on a global scale (4).

The members of this Task Group included Capt. Hilton W. Rose, MC, USN; Capt. Lloyd R. Newhouser, MC, USN; Col. William S. Stone, MC, USA; and Lt. Col. (later Col.) Alonzo A. Towner, Jr., MC, USAF. The comprehensive report which they submitted to the Secretary of Defense on 15 March 1950 (4) had been approved by the Military Medical Advisory Council (the predecessor of the Armed Forces Medical Policy Council) on 14 February 1950. On 5 May 1950, the report was approved by the Secretary of Defense, in a memorandum addressed to the three Service secretaries, and thus became official DOD policy (5).

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As of this date, the retrenchment that had characterized all activities relating to blood in the postwar period began to be reversed, but it was almost too late: It was less than 2 months later that the outbreak of hostilities in Korea required the immediate translation of still theoretical concepts of a national emergency into a stern reality, though, fortunately, several additional weeks were to elapse before a request for whole blood carne to the Zone of Interior from the combat area.

The report by the Task Group to the Director of Medical Services on "A Suggested Program of Whole Blood and Blood Derivatives for the Armed Forces" in March 1950 analyzed the problem; summarized the commercial potential for dried plasma; and outlined the requirements for stockpiling plasma and for the collection, distribution, and use of whole blood. In substance, the report was as follows:

Whole human blood, required in modern therapy, cannot be stockpiled because it is extremely labile; it requires constant refrigeration and precise technical control and handling; and, under present procedures, it cannot be stockpiled for more than 30 days.

The Armed Forces can operate blood banks to meet peacetime requirements but cannot supply wartime necessities. It is not desirable to use combat troops as donors. Neither in peacetime nor in war can the Armed Forces provide blood derivatives.

The reserves of blood derivatives left from World War II will largely be outdated by the end of 1950, though some can be reprocessed, at about a third of the cost of new products. The total amount that has been reprocessed, however, will provide only a third to a half of the required war reserve (set at a million units) for the Armed Forces. Reprocessing and handling can be carried out only by specially trained personnel, with considerable technical background.

The present civilian program for blood and blood derivatives is not adequately organized or planned to meet the requirements of the Armed Forces, the civil defense program, and other civilian needs in time of war.

The wartime needs can therefore be met only by a national program, which must be organized in peacetime.

At this time (March 1950), the blood procurement situation in tile United States is as follows:

1. Twenty-one blood banks are in operation in Armed Forces installations. All have standardized equipment and supplies, are centrally controlled, and would be capable of

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operating under wartime conditions. Four of these banks are each collecting 300 pints a month. The others are collecting from 50 to 250 pints each.

2. Some two or three thousand nonprofit blood banks are in operation, most of which belong to the American Association of Blood Banks.³ About half of these banks actually draw and process blood. The remainder, whose chief function is to serve their own hospitals and adjacent rural communities, act merely as storage and issue points for blood drawn elsewhere. When the operations of these banks are entirely intrastate, they are under no control and their equipment, supplies, and procedures are not standardized. If, however, these hospital banks would adopt NIH (National Institutes of Health) standards and could produce significant surpluses above their own needs, they could contribute to the national blood program.

3. Four commercial blood banks are in operation in New York. Others are in operation in Dallas, San Francisco, and Chicago, and there are a few smaller banks in other locations. They lack trained personnel and uniform standards, and it is doubtful that they could expand significantly in time of war.

4. Only three commercial biologic laboratories are now collecting blood for plasma: Cutter Laboratories, 100,000 pints per year; Hyland Laboratories, 40,000 pints per year; and Sharp & Dohme, 150,000 pints per year. All these laboratories produced plasma during World War II, and Sharp & Dohme also produced plasma fractions, which only Cutter Laboratories is now producing.

Equipment can be manufactured by a number of larger firms as well as some smaller firms, on reasonably short notice, with certain exceptions. There would be difficulty, for instance, supplying 15- to 20-gage needles for intravenous and donor sets if they should be required at once, though within 6 months, well over a million could easily be produced.

Recommendations

The Task Group, on the basis of the World War II experience factor, set the replacement requirements for each combat casualty who survived to be hospitalized at one 500-cc. unit of whole blood and the same amount of plasma or other blood-derivative. Only group 0 blood would be used, preserved in ACD (acid-citrate-dextrose) solution; typed for the Rh factor; and refrigerated at 4° to 10° C. from collection until administration.

The Task Group did not think that the Department of Defense of itself could procure such amounts of blood and blood derivatives and therefore recommended immediate coordination with other interested governmental and non-governmental agencies in the development of a program that would meet the standards and fulfill the requirements of the Department of Defense, as well as civilian requirements, in peacetime and in wartime.

The Task Group also recommended that the Department of Defense assume responsibility for the direction and implementation of the whole blood program and its coordination with other agencies, including the American Red Cross; Armed Forces blood banks; commercial biologic agencies; and nonprofit and commercial blood banks. It was noted that, if these various separate groups were to serve as an integrated national blood group, they must be tightly controlled because of the multiple risks attending the use of blood, including its perishability; incompatibility; possible errors in grouping, typing, and cross-

³ Although this is the figure used by the Task Group, it seems high unless every hospital laboratory storing a few pints of blood is considered a blood bank.

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matching; contamination from unsound techniques; unsatisfactory conditions of storage; and possible transmission of such diseases as malaria, syphilis, and hepatitis.

Finally, the Task Group recommended that the Director of Medical Services should be responsible for, and direct, the continued study and implementation of the Department of Defense blood program and till coordination of tile activities of tile department with those of other agencies.

In addition to these basic recommendations, the Task Group made tile following specific recommendations:

1. That transfusion supplies, equipment and procedures as standardized for the Armed Forces be standardized by all participating agencies, with the Director of Medical Services, DOD, taking the necessary steps to accomplish this objective.

2. That biologic standards for blood and blood derivatives be uniform throughout the country, with necessary legislation to assure the adoption of the desired criteria.

3. That all military combat plans include logistic requirements for blood.

4. That all blood donations be voluntary.

5. That a war reserve be established for plasma, plasma substitutes (expanders), and transfusion supplies and equipment, with economical maintenance of estimated requirements, and that a system be devised for replacing deteriorated supplies, so as to maintain a satisfactory and economical reserve.

6. That research on blood preservation and on improvement of transfusion equipment be emphasized by the Department of Defense. It was suggested that the sum of $100,000 be allocated annually for the next 2 or 3 years to provide for additional research in these fields.

It was essential, the report of the Task Group concluded, that the agency for civilian and military whole blood requirements that was developed in peacetime should be of such a character that it could be expanded in time of war to meet logistic requirements and organization, training, and operating procedures. Such an agency should have ramifications down to the community level, so that, in an emergency, all potential sources of blood could be tapped. Also, the personnel of such an agency should be so organized and trained that, in time of war, its existing operational activities would simply have to be expanded.

Continuing misconception of requirements for whole blood.- Another depressing phase of the development of the blood program after World War II was the position taken by the Director of Military Supply and the Acting Chief, Requirements Coordination, Munitions Board, in April 1950, in connection with the recommendations of the Task Force (6).

Both granted the necessity for a national blood program, the importance of its prompt development, and the wisdom of correlating military and civilian requirements, policies, standards, and procedures. These officers, however, could not agree with the recommendation that the Director of Medical Services, Department of Defense, be responsible for, and direct continued study and implementation of, the DOD blood program and its coordination with other agencies. Nor could they agree that the director should take steps to accomplish standardization of related military and civilian supplies, equipment, and procedures, for the following reasons:

1. Blood and blood derivatives are considered a supply commodity or munition.

2. The Munitions Board is legally responsible for developing coordinated policies relating to military supplies.

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3. The blood program is no different from other programs and must be handled in the same manner as other programs.

It would be hard to imagine a more total misconception of the requirements and implications of a whole blood program. The position of these officers, obviously taken in complete ignorance of how whole blood must be procured, handled, and administered, represented everything the Subcommittee on Blood Substitutes, NRC, the Blood Transfusion Branch, Office of The Surgeon General and other agencies and personnel had fought against during World War II. Had these ideas been permitted to prevail, the entire whole blood program for Korea would have foundered and many lives would probably have been lost from the use of incorrectly handled blood. The controversy had no chance to develop, however, for the Secretary of Defense, in August 1950, gave the operational responsibility of the blood program to the Directorate, Armed Services Medical Procurement Agency, and directed the Director of Medical Services, DOD, to prescribe the policies and standards for the implementation of the program (7).

In May 1950, Dr. Meiling assumed the chairmanship of a Blood and Blood Derivatives Committee in the Department of Defense, which had the function of determining the need of the Armed Services for plasma and whole blood. He at once appointed an ad hoc committee on blood and blood derivatives to serve in an advisory capacity to him.

At its meeting on 28 July 1950- a month after the outbreak of the Korean War- the Military Medical Advisory Group, in a full discussion of the Blood and Blood Derivatives Program, decided that the American Red Cross should be the coordinating blood procurement agency for the Department of Defense and that the Armed Services Medical Procurement Agency should be assigned operational responsibility for the program in the Department of Defense.

A week later, when the Secretary of Defense formally assigned operational and technical responsibility for the program to the Directorate of the Armed Services Medical Procurement Agency, the directorate at once requested the chief of this agency to establish a blood and blood derivatives division within the agency. At the same time, the directorate requested that the director of Medical Services, Office of the Secretary of Defense, grant membership in the Task Group studying the Whole Blood and Blood Derivatives Program to the chief of the Procurement Agency and the chief of its Blood and Blood Derivatives Division.

All of these requests were granted. Col. Douglas B. Kendrick, MC, who had been in charge of the Army blood program in World War II from its inception until November 1944, was named chairman of the Blood and Blood Derivatives Group, which position he held for the next 2 years. On 1 May 1952, he was succeeded by Col. Patrick H. Hoey, MC, USAF, who held this position

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until the end of the war. Lt. Col. Arthur J. Carbonnell, MC, was the Army member of the group from 15 February 1951 to 18 February 1952.

On 12 September 1950, the Armed Services Blood and Blood Derivatives Division (which became the Armed Services Blood and Blood Derivatives Group a few days later) was officially established. It consisted of a professional staff and of administrative, field, laboratory, and liaison branches. Its mission was as follows:

1. To provide whole blood for FECOM (Far East Command).

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2. To provide whole blood for the production of dried plasma for the DOD War Reserve stockpile.

3. To reprocess outdated stocks of plasma produced in World War II.

4. To investigate developments in the field of plasma-expanders.

The actual division of responsibility for the blood and plasma program was that the Committee on Blood and Blood Derivatives recommended policy and the Blood and Blood Derivatives Group had the operational responsibility for its implementation.

The structural evolution of the blood and blood derivatives program in the Department of Defense between 1949 and 1953 is shown in charts 11, 12, and 13.

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The Subcommittee on Blood Substitutes, Committee on Shock, Division of Medical Sciences, NRC, had done such important work on the collection and distribution of whole blood and its derivatives, and had supervised so much valuable research, in World War II, that it was reactivated in 1948 as the Committee on Blood and Blood Derivatives. The work of the subcommittee had lapsed at the end of World War II, but in the interim before its reconstitution, the American Red Cross, which was entrusted with returning surplus

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blood derivatives to the people of the United States who had contributed them, used many of the same physicians who had served on the subcommittee on its own Committee on Blood and Blood Derivatives, thus maintaining their contacts with the blood program. The reason for the reactivation of the World War II subcommittee was the realization that a national emergency would demand huge amounts of blood and blood derivatives for civilian as well as military uses, and the subcommittee was promptly enlarged because of the complexity of the problems to be solved.

As soon as it was activated, the Committee on Blood and Blood Derivatives went actively to work. At its first meetings, the stage of existing knowledge in the special fields of blood and blood derivatives was assessed. Ad hoc responsibilities were delegated to particular members, who were directed to investigate equipment, preservatives, and sterilization of blood and blood derivatives. Contracts for research in the field of blood and blood derivatives were reviewed for the National Military Establishment and the Veterans' Administration.

At the meeting of the Committee on Blood and Blood Derivatives on 3 December 1949, much of the agenda concerned general principles and policies (8). Dr. Charles A. Janeway, chairman of the committee, pointed out that the blood program was an integral part of national defense and that the counterpart of this committee during World War II had sat as an advisory group to all agencies and organizations concerned in any way with blood. Its successor committee would perform the same functions.

Dr. Meiling, Director of Medical Services, Office of the Secretary of Defense, explained the functions of his office. Dr. Cohn spoke of the importance of the cooperation of all agencies concerned in the blood program. During World War II, he noted, no decision regarding blood products was ever made without the approval of the Laboratory of Biologics Control, National Institutes of Health. Many of these matters were within the province of the Food and Drug Administration. The World War II subcommittee had been careful never to recommend any action or procedure on the basis of research alone; the practicability of all recommendations was tested by pilot operations. It was possible that blood might be collected by some agency other than the Red Cross, which was now operating with no obligations to turn over any material to the Armed Forces in an emergency. The important consideration was that there must be a single blood program, cooperative and not competitive. In conclusion, said Dr. Cohn, "Failure to act until an emergency entails accepting the responsibility for being unprepared."

By this time (December 1949), a great many problems had already been referred to the Committee on Blood and Blood Derivatives, NRC, and many more were to be referred to it before and during the Korean War. The recommendations made concerning them are discussed under appropriate headings. The contribution of the committee was incalculable. There were, however, many perfectionists on it, and, at intervals, the more practical-minded members felt constrained to remind them of current needs. If, for

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instance, excessive and unnecessary standards of accuracy were required, the volume of production would be impractically small. The point at issue was the quick determination of what agents were safe to put into people's veins from the standpoint of immediate or delayed antigenicity and toxicity.

At the December 1949 meeting, an ad hoc committee was appointed to consider all phases of the blood program, talk with civilian defense planning groups and other agencies, and then make recommendations to the Committee. The membership of this committee included Dr. Janeway, Dr. Cohn, Dr. Ravdin, Dr. Carl V. Moore, and Dr. Charles A. Doan.

At this same meeting, a number of changes were recommended in the 13 May 1943 agreement with the American Red Cross, both to bring the text into agreement with the current organizational situation and to indicate that collections of blood were for civilian needs as well as for needs of the Armed Forces. It was also recommended that a committee be formed to serve in an advisory capacity to the American Red Cross, Department of Defense, National Institutes of Health, Veterans' Administration, Atomic Energy Commission, and whatever agency would be responsible for civilian defense.

Some of the problems referred to the Committee on Blood and Blood Substitutes, NRC, might be mentioned here, to indicate their range and importance:

1. Could not a preservative solution be devised in which blood for transfusion and blood intended for plasma could both be collected?
2. What measures should be adopted to safeguard plasma to be stockpiled while it was being processed?
3. How could transmission of virus infections from plasma infusions be prevented?
4. Could the dating period of blood be extended?
5. How could the incidence of clots in collected blood be reduced?
6. Would siliconing the inside of collecting bottles improve the product?
7. What was the present estimate of the value of gelatin? Oxypolygelatin? Dextran? Periston? Inquiries concerning these and other plasma-expanders were to come up repeatedly.

The Committee on Blood and Blood Derivatives, DOD, recommended to the Secretary of Defense on 2 October 1948 and 10 January, and 13 February 1949 that the American Red Cross be officially designated as the agency to collect blood for the National Military Establishment. The Subcommittee on Burns, Committee on Surgery, NRC, also recommended, in November 1949, that some large-scale machinery for the collection of blood be set up.

On 20 July 1950, the Secretary of Defense, then Mr. Louis Johnson, recommended to the Chairman of the American Red Cross, then Gen. George C. Marshall, that the relation which had existed during World War II between that organization and the War and Navy Departments be reestablished between it and the Department of Defense to meet the needs of the Armed Forces for blood and blood derivatives (9). On 22 July, General Marshall replied that the Red Cross would at once increase its blood collections and that Adm.

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Ross T McIntire, MC, USN (Ret.), who was assigned to the Red Cross National Blood Program, would be assigned to work with Dr. Meiling on the necessary plans (10).

On 30 August 1950, Mr. Symington, as Chairman, NSRB, formally requested, through General Marshall, that the American Red Cross accept the responsibility for coordinating a nationwide civil defense blood program for recruitment of donors and for the collection, storage, processing, and preparation for shipment of blood and blood derivatives collected under the program (11). On 7 September 1950, General Marshall replied that the Red Cross would accept the specified responsibilities, on the assumption that local civil defense units would coordinate their planning with the national program (12).

The Boston Agreement.- Meantime, on 11 and 12 July 1950, the Committee on Blood and Blood Derivatives, American Red Cross, and the Red Cross Medical Advisory Committee on the National Blood Program met in Boston with representatives of the American Medical Association, the American Association of Blood Banks, and the American Hospital Association, to determine their relations with each other. The so-called Boston Agreement provided that these four agencies would cooperate with each other in peacetime and with the National Security Resources Board in time of war (13). In peacetime, there would be a free exchange of blood on a unit-for-unit basis, as would best serve community needs. As a matter of principle, surplus blood would be given to the Red Cross or other designated agencies for conversion into blood derivatives. In time of war, procurement agencies would be set up in communities not already served by Red Cross regional blood centers.

It was recognized at this conference that standardization of equipment for the blood program was desirable in peacetime and imperative in a national emergency. It was also recommended that all blood banks cooperating in the joint program should meet the minimum standards of the National Institutes of Health.

The blood program for the Korean War began in Japan. Here, in the interim between the wars, a few Army hospitals, all of which were authorized to provide definitive surgical care, collected blood from donor lists in accordance with Army Regulations No. 40-1715. These hospitals, located mainly in the Tokyo and Osaka areas, operated small banks, sufficient for their own needs.

Within 10 days after the outbreak of the Korean War (then considered only a police action), it became apparent that the Armed Forces in combat would

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require blood in large amounts, and plans were at once made for a centrally controlled blood procurement program in Japan (2, 14). Three initial steps were taken:

1. A special blood bank unit was formed from personnel of the 406th Medical General Laboratory to operate a blood bank there. As the bank was first set up, it consisted of a collecting and processing center in Tokyo, a transportation and courier center (later called the Blood Bank Storage Depot and Shipping Section) in Tokyo, and an advance blood bank depot at the 118th Station Hospital in Fukuoka.

2. 8090th Blood Bank Laboratory Detachment was organized as a temporary duty unit in August 1950 and was assigned to the 406th Medical General Laboratory. The detachment consisted of two mobile bleeding units and a laboratory unit. It functioned until 5 November 1951, when it was replaced by the 48th Blood Bank Laboratory Detachment.

3. Blood bank sections were activated in Korea, as organic parts of medical supply depots.

The necessary organizational steps were taken quickly, donors were recruited (fig. 167), and the first shipment of blood from Japan (69 bottles) was sent to the 8054th Evacuation Hospital in Pusan, Korea, on the night of 7 July 1950.

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For the first 5 weeks, the blood bank operated on an emergency basis, as troop strength built up rapidly and field medical installations were sent to Korea to care for casualties. It then became evident that the combat in which the U.S. troops were engaged would be considerably more than a local engagement, rapidly terminated, and that blood bank operations must be put on a firmer basis.

The first step was to determine a working ratio between anticipated casualties and future needs for whole blood. By the use of figures supplied by the Assistant Chief of Staff, G-1 (personnel), which were available daily and were regarded as accurate, a ratio was developed of 0.82 pint of blood to each casualty wounded in action and surviving to be hospitalized.

At this time, the donor panels in the Tokyo-Yokohama areas could supply, at the most, 100 pints of blood per day. Official approval had not yet been obtained for the use of Japanese donors, and, until the end of 1950, blood was secured only from noncombatant Army, Navy, and Air Force personnel; Allied Forces personnel; civilian employees of the U.S. Armed Forces; foreign nationals other than Japanese; and adult dependents of these groups.

When the needs of anticipated casualties were surveyed realistically, it was at once clear that available local donors could not possibly meet their requirements, and a request for blood was made on 15 August 1950 to the Zone of Interior (15) and promptly acceded to (p. 713). It was hoped, however, that local sources could continue to meet emergency needs and could also supply group-specific and Rh-specific bloods, which, as in World War II, would not be sent from the Zone of Interior.

After 6 months of combat, and after blood from the Zone of Interior had been reaching Korea for over 4 months, it was found that the ratio of blood to casualties had undergone a change. The factor then used, 3.32 pints of blood for each combat casualty who was hospitalized, was based on an experience factor for logistic blood requirements that included not only the blood actually used but the blood wasted in storage and distribution, a wastage that was then considered unavoidable in such a perishable product as blood in such combat circumstances as Korea.

The first bloods collected in Japan were transported from the bank at the 406th Medical General Laboratory to the advance depot at the 118th Station Hospital in Fukuoka in railway baggage cars, three of which had been equipped with reach-in reefers (refrigerators) for this purpose. Later, air transport was used almost exclusively (p. 752).

Techniques of collection of blood in Japan generally followed those employed in Red Cross bleeding centers in World War II until donations from Japanese began to be accepted, at the end of 1950. Then, certain changes in

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procedure were necessary. For one thing, language difficulties made it necessary to employ a small Japanese staff, as well as to use nurses and volunteers supplied by the Japanese Red Cross (fig. 168). For another, Japanese medical authorities were at first reluctant to depart from their standard practice of limiting donations to 200 cc. Some concessions, naturally, had to be made to the small size of the Japanese, who could not routinely give 500 cc. of blood as did U.S. donors, and tables of maximum collections for bleeding them and others of similar stature were therefore worked out (table 34). When these standards were adhered to, there was never any evidence of immediate or delayed harmful effects from the donations.

Publicity for the blood program in, Japan was provided by the U.S. and the Japanese Red Cross, the Armed Forces radio station in Tokyo, the Pacific edition of the Stars and Stripes, and similar sources. Documentary films showing blood bank operations were made by the Army Signal Corps and by Japanese photographers for use locally as well as in the United States. Posters, pictures, and stories were provided for both local and stateside release by General Headquarters and Joint Logistical Command Public Information Offices.

On one occasion, a spectacular air rendezvous was made with the U.S.S. Boxer, then in Korean waters; her crew donated 2,407 pints of blood in 4 days. On another occasion, Gen. Douglas MacArthur publicly received a token

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shipment of blood from the German employees of a commercial airline. On 4 July 1951, the medical section of the Joint Logistical Command, at a carnival at Meiji Park, staged a complete demonstration of blood bank operations; the processing of the blood was carried out in full view of the spectators. The Gallon Club, instituted in August 1951, had almost 150 members within a few weeks.

During fiscal year 1951, a total of 43,479 donors were interviewed at the blood bank in Japan and more than 39,000 pints of blood were collected from them through the efforts of the central bank and its mobile teams. The chief reason for refusing donors was a history of disease, including malaria and infectious hepatitis, and of hypertension. Only 175 positive serologies were encountered, 0.4 percent.

The low incidence of Rh-negative blood (table 35), a Japanese racial characteristic, limited to a considerable degree any extensive use of Japanese donors if Rh-compatible blood was to be given to a recipient population composed chiefly of Americans and Europeans. In the first 2,784 Japanese

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bloods collected, there were only 19 Rh-negative bloods, 0.68 percent. The distribution according to type in 39,100 units of Japanese blood collected in 1951 is shown in table 35. Statistics for 1952 and 1953 were of the same order.

In 1951, almost 25 percent of the blood received in Japan by the blood bank was procured in that country (table 36). Something over a third of this amount was collected in Tokyo. The remainder was collected by mobile teams at various stations in the vicinity, including 6,456 pints from the U.S. Naval Hospital in Yokosuka and 3,308 pints from the U.S. Army Hospital in Yokohama.

Collections of blood by the American Red Cross for the Department of Defense began in August 1950. By the middle of 1951, those responsible for the blood and plasma program in the Department of Defense were increasingly concerned because procurement was lagging far behind requirements and commitments (2). Whole blood requirements for the Armed Forces were being met, but reserves of plasma were in alarmingly short supply because of lack of blood to process.

On 20 July 1951, the chairman of the Armed Forces Medical Policy Council, Dr. Lovelace, projecting present trends into the future, reported to the Secretary of Defense that the blood procurement program of the Department was in serious need of revision. On the basis of a report made to the Policy Council on 16 July 1951 by an ad hoc committee,⁴ Dr. Lovelace recommended that the program be referred to the newly established Health Resources Advisory Committee of the Office of Defense Mobilization for information and assistance. He also recommended that the American Red Cross Blood Donor

⁴ This committee consisted of Colonel Kendrick, Chairman; Captain Newhouser, Department of Defense; Maj. Gen. David N. W. Grant, USAF (Ret.), and Mr. Richard Swigart, American Red Cross; and Dr. F. Douglas Lawrason NRC.

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Program be stimulated with the assistance and cooperation of the Department of Defense, as follows:

1. There should be a continuously active advertising campaign for donors.
2. Additional collection centers should be established.
3. Blood procurement should be stimulated on the local level in every possible way, especially when blood banks were located in heavily populated areas and within reasonable shipping distance of existing plasma plants.
4. The Red Cross should be requested to establish priorities for blood for the Department of Defense.

In addition to these steps, which should be taken jointly with the American Red Cross, Dr. Lovelace recommended that the Department of Defense:

1. Should establish a military blood collection program to reach military personnel and civilian employees on military bases.
2. Should institute a policy of purchasing plasma from civilian commercial laboratories which met NIH specifications.

On 2 August 1951, in a DOD directive, the Acting Secretary of Defense, Mr. Robert D. Lovett, announced the establishment of an Armed Forces Blood Donor Program, "to provide a continuous and vigorous campaign, in conjunction with the Red Cross, to persuade the civilian and military population to contribute whole blood to the Armed Forces" (16). The program would be launched on 10 September 1951.

The Director of Information, Office of the Secretary of Defense, would be responsible for directing publicity and information concerning the program. Policy guidance would be provided by the Armed Forces Medical Policy Council, Office of the Secretary of Defense. All programs would be coordinated through the Armed Services Medical Procurement Agency.⁵

The success of the military program was immediate (figs. 169-172). Within a few months there were more donors than facilities to handle them. The attitude of the Air Force was typical of all the Services. On 6 September 1951, the Air Adjutant General directed that "every level of command of the Air Force give its whole-hearted cooperation to insure the success of the program." Effective on 10 September, the date of initiation of the program, or as soon thereafter as possible, Air Force collection centers would be established at Lowry Air Force Base, Denver, Colo., Lackland Air Force Base, San Antonio, Tex., and Sheppard Air Force Base, Wichita Falls, Tex. Tentative sites were also selected for other collection centers, to be activated as necessary later.

⁵ The National Advertising Council worked closely with the Director of Information, DOD, and deserves much of the credit for the outstanding success of the program.

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One of the major problems of blood procurement was the necessity of providing blood for civil defense as well as for combat needs. It was studied by Dr. Rusk, Chairman, Health Resources Advisory Committee, and his staff; on their recommendation, on 10 December 1951, President Truman issued an Executive order to the effect that the Director of the Office of Defense Mobilization would provide, within his office, "a mechanism for the authoritative coordination of an integrated and effective program to meet the nation's requirements for blood, blood derivatives and related substances" (17). In this order, it was pointed out that a subcommittee on blood had been appointed within the Health Resources Advisory Committee, to develop "a single National Blood Program encompassing all phases of the problem." It was the President's desire that the activities of all departments and agencies in the field be coordinated "through this mechanism."

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On 18 February 1952, the Subcommittee on Blood (the Cummings Committee) submitted a statement of basic principles upon which the reorganized program should be based. The substance of this report, which was immediately transmitted to the Secretary of Defense, Mr. Lovett, was as follows (18):

1. The program created to meet the blood needs of the nation in the time of national emergency and to be known as the National Blood Program would represent a coordination of the blood programs already in existence.
2. No agency would duplicate the efforts of another agency unless the task could not otherwise be performed adequately. Before such a duplication occurred, there must be agreement for it among the agencies involved and the Office of Defense Mobilization.
3. The recruitment program for volunteer donors would emphasize the National Blood Program as a whole and not any specific part thereof.
4. The Department of Defense and the Federal Civil Defense Administration would be authorized to establish and maintain separate plasma reserves.
5. The Red Cross would continue to be the blood collecting agency for the National Defense Program except for the facilities (then 34) of the Department of Defense in Armed Forces installations located in areas not covered by the collecting facilities of the National Red Cross. These collecting facilities now included 44 regional programs covering 1,540 local chapters and cooperating blood banks.

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6. Priorities for allocation of blood would be as follows:

a. The Armed Services, for whole blood transfusions.
b. Civilian needs for whole blood and blood derivatives.
c. Allocation of the remaining blood collected for the production of plasma and blood derivatives to meet immediate needs and establish national reserves.

7. In the event of enemy action, the total reserves of plasma, blood derivatives, and plasma expanders would be allocated as necessary by Executive order.
8. The Red Cross would continue to operate, for military use only, 15 centers serving 258 local chapters and would participate in a cooperative program with 35 civilian blood banks which would coordinate supply.
9. Research on blood and related problems would be coordinated through a committee set up by the National Research Council and composed of experts in the field, including liaison representatives from the Department of Defense. Funds would be provided for the research projects by the participating agencies.
10. There would also be a continuing effort to train personnel in the laboratory and clinical phases of blood supply and to foster and provide for research, so that, in the event of another emergency, any blood bank system setup would be operated by well-trained medical officers thoroughly versed in all phases of military blood banking and logistics.

These recommendations were put into effect and the national blood program was successfully operated according to them for the remaining years of the war.

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The Korean War began on 25 June 1950, and active fighting ended on 27 July 1953, with the signing of an armistice. The formal Zone of Interior blood supply program for Korea began on 15 August 1950, with a radio request from the Far East Command for shipments of blood from the Zone of Interior to augment the quantities collected and distributed by the 406th Medical General Laboratory in Tokyo (15). The first blood shipped in response to this message, which had been requested for 30 August, left the temporary laboratory at the U.S. Naval Hospital in Oakland, Calif., for Japan on 26 August 1950. On 8 February 1954, a dispatch from the Far East Command recommended that the service be terminated, and the last blood was flown to Japan on 13 February 1954 from the Armed Services Whole Blood Processing Laboratory, Travis Air Force Base, Calif. Between the dates of the first and last shipments, this laboratory had received and handled 397,711 pints of whole blood, of which 340,427 pints had been shipped to Japan for transshipment to Korea for distribution to the various medical units of the United Nations there. The Travis laboratory was placed on a standby basis on 13 February 1954 and was deactivated a month later. This program was the largest operation of its kind in the history of military medicine in the United States.

The important steps in the development of the administrative background of the airlift of blood in the Korean War have been described in detail elsewhere (p. 713). Many of the most important actions, it will be remembered, were taken after fighting had commenced.

In order that the military might have a central processing facility in which to receive blood collected by the American Red Cross, perform necessary laboratory tests on it, package it, and ship it to Japan for transshipment to Korea, a processing laboratory was established at Travis Air Force Base (then Fairfield-Suisun Air Force Base), Calif., where a Military Air Transport Service group of the Pacific Division was located. The building selected had to be renovated and converted for this purpose, and until it was ready, on 25 September 1950, a temporary laboratory was set up and operated in the U.S. Naval Hospital at Oakland, Calif., about 50 miles away.

⁶ Unless otherwise specified, the material concerning the airlift is derived from the history of the Armed Services Whole Blood Processing Laboratory, Travis Air Force Base, Calif., 25 August 1950-15 March 1954 (19).

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During the war, a number of attempts were made to establish a blood processing laboratory on the east coast, but no definitive action was ever taken, though supplies and personnel were earmarked for an emergency standby facility at the U.S. Naval Hospital, Chelsea, Mass. This facility was not called upon, but it was expected that, if it had been, it could have begun to ship blood to Japan within 24 hours after activation.

The Armed Services Whole Blood Processing Laboratory at Travis Air Force Base performed the following functions:

1. It received whole blood from the American Red Cross, performed appropriate laboratory tests on it, and shipped it to the Far East Command for use in Korea.
2. It maintained a record of all bloods received in the laboratory and their disposition.
3. It coordinated whole blood requirements with the Armed Services Blood and Blood Derivatives Group and the appropriate representatives of the American Red Cross.
4. It maintained a close working arrangement with the medical supply section of the Travis Air Force Base in requisitioning and drawing of supplies required in the day-to-day operations of the laboratory.
5. It maintained liaison with other military organizations and civilian agencies as necessary for efficient accomplishment of its mission.
6. It prepared and submitted to the chairman of the Armed Services Blood and Blood Derivatives Group routine reports and such special reports as were requested.

Structures of the permanent laboratory included a building of 3,400 sq. ft. and two warehouses, respectively 2,786 and 800 square feet. All buildings, office equipment and supplies, housekeeping items, heat, electricity, gas, communication services, and motor vehicle transportation were furnished to the laboratory and maintained by the Travis Air Force Base. Billeting and messing facilities for laboratory personnel were also furnished by Travis Air Force Base. A Navy panel truck, on loan from Oakland Naval Hospital, was assigned to the laboratory for general use.

The building at Travis Air Force Base that was converted into a laboratory was an old hospital messhall. The conversion required the installation of lighting fixtures, water-distilling apparatus, refrigerators, sinks, laboratory counters and workbenches, and natural gas fixtures. The precooling room and warehouses were not completed until about 8 months after the laboratory was occupied. When the converted building was taken over, however, on 25 September 1950, everything else was in such good order that a shipment of blood could be sent to Japan the same day.

Initial medical supplies and equipment were procured directly from the Oakland Naval Medical Supply Depot. Later, by agreement among the three Services, the requirements and stock control section of the Supply

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Division, Office of The Surgeon General, U.S. Army, was given the responsibility of furnishing medical supplies and equipment to the laboratory. All requisitions went through the Travis Air Force Base medical supply section to the Alameda Army Medical Supply Depot.

The operational cost of this laboratory was estimated at over $1 million a year. It cost approximately $17.83 to procure and process a pint of blood and transport it from the United States to the Far East Command in Japan, this sum including $6.56 paid to the Red Cross for processing services, $9.40 for laboratory expenses, and $1.87 for transportation costs.

Four Navy blood bank technicians arrived from the east coast at the laboratory on 23 August 1950. Office, laboratory, and cold storage spaces were made available to them at once, and supplies and equipment were procured from the hospital and from the U.S. Naval Medical Supply Depot in Oakland. As a result, 48 hours after these technicians had arrived, the first whole blood shipment (1,488 pints) was received, processed, and delivered to the Military Air Transport Service at Travis Air Force Base for transshipment to Japan.

Requests for additional laboratory personnel were at first handled very slowly, and, by the middle of September 1950, the staff working in the Oakland laboratory included, in addition to the four original technicians, only one Navy Medical Service Corps officer and three laboratory technicians. Laboratory technicians were borrowed from Oakland and Mare Island Naval Hospitals and from Letterman General Hospital, San Francisco, Calif. Clerical and some general duty helpers were borrowed from Travis Air Force Base and the Oakland Naval Hospital. Additional duty corpsmen and convalescent patients aided on a day-to-day basis. All of these men were returned to their duty stations when additional permanent personnel began to arrive about the middle of October. In spite of its personnel difficulties, the laboratory handled over 7,000 pints of whole blood during the weeks of its operation at the U.S. Naval Hospital in Oakland.

In the approximately 42 months of its operation, an average of 35 persons were regularly attached to the laboratory, including an average of 11 from the Army, 10 from the Navy, and 14 from the Air Force (fig. 173).

Training.-A quick, efficient blood bank technique can be acquired only by experience, and most of the personnel assigned to the Travis laboratory were inexperienced. All therefore worked long hours while they were receiving individual instruction. A formal training program was set up a few months after the laboratory was activated, and 59 persons completed the course of instruction, including 14 Air Force Medical Service Corps officers, 34 Army enlisted men, and 11 Air Force enlisted men.

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