History

Professional Care and Related Activities

To preserve a man alive in the midst of so many chances and hostilities, is as great a miracle as to create him.-JEREMY TAYLOR.

STANDARDS OF PATIENT CARE

General Heaton, operating on the principle that high standards for military patient care required constant reevaluation and readjustment to changes in the art and science of medicine, raised the performance of the Professional Services Directorate of his office to the highest degree of excellence in any period of the history of the Army Medical Department.

Medical care of the serviceman and his dependent became more complex with each passing year because of the sheer scope of the uncertainties of the age, the magnitude of Army worldwide commitments, and the need to keep pace with the constant advances in medicine and surgery.

To achieve the best standards for medical care, General Heaton sought to improve the quality of the Army physician as the central figure in medical care and also to balance the professional functions supporting him in the practice of medicine. He favored and sponsored the highest integration of the medical disciplines.

Whether in garrison or in field, patient care and the practice of medicine hinge primarily on the knowledge, skill, and devotion of the physician. Working in teams, supported by good nursing care and allied medical neces-

sities, the Army physician is dependent on the entire range of professional functions if he is to perform with maximum effectiveness.

General Heaton's plans for patient care throughout his administration were flexible and under continuous review. He recognized that medicine was dynamic, changing, and never static. And while he emphasized patient care in volume as the major task of the Army Medical Department, preventive medicine ranked high with him as a vital link in maintaining the strength of the Army.

Preventive medicine became more than a specialty within itself. It permeated the realms of other disciplines. Measures to prevent disease and injury and to control the environment in which troops were stationed became more effective progressively.

Preexamination and pretesting of the serviceman and his dependent ranked high in The Surgeon General's program for the prevention of more serious medical and surgical problems. In psychiatry, for example, procedures were expanded to avoid noneffective behavior. Greater emphasis was placed on the early recognition and identification of maladjustments to prevent the consequences of more serious mental illness. At no period in the history of the Army Medical Department did dentistry undergo more change. The stress was clearly on preventive dentistry.

Beyond this, General Heaton expanded the contributions of his office to the betterment of world health as a major factor in the furtherance of world peace.

General Heaton encouraged Army physicians in all of the specialties of medicine and surgery to accept invitations to speak and teach in other nations, particularly in Taiwan, Japan, Korea, and South Vietnam. Also, he fostered the reciprocal exchange of medical knowledge between nations through military assistance advisory groups. Patient care was inescapably interwoven in our foreign policy, he believed, throughout the free world. The impact of his endeavors became one of the manifestations of the universal understanding among men.

Medical personnel in global-political situations around the world responded magnificently, and their labors, especially in South Vietnam in the various provincial hospitals, villages, hamlets, and in the countryside, reaped great dividends for the free world.

Of grave concern to The Surgeon General was the growing realization that medical and public health problems resulting from major disaster or nuclear attack must be shared by civilian and military populations. Guidelines for the Army's specific role in civil defense and civil affairs were prescribed, and ways were explored in which the Army Medical Department could cooperate with, and assist in, the relief of afflicted populations.

ARMY HEALTH EXPERIENCES AND TRENDS

From 27 June 1953 (the end of the Korean War) to 30 June 1965, the Army Medical Department experienced a downward trend in the morbidity indexes used to evaluate the health of the Army in terms of rates of admission to hospital and quarters, noneffective rates, occupancy of hospital beds, and treatment of outpatients in hospital clinics.

With the escalation of military activity in South Vietnam in 1965, the downward trend in morbidity indexes was reversed, and the upward trend continued through 1968 for the third consecutive year. By 1967, however, relatively high rates for disease and nonbattle injury among growing numbers of troops stationed in South Vietnam decreased, but these decreases were offset by a corresponding rise in the admission rate for injury in hostile action.

Admissions

Admissions for all causes of disease and injury occurred at a worldwide rate of 355 per 1,000 average strength in 1959, representing a decrease of about 10 percent over the rate of 397 in 1958. Admission rates

continued to drop from 1960 to 1964 when the rate fell to 271. The rate rose to 282 in 1965 and continued to climb to 350 in 1966. By 1968, admission rates for all causes, reflecting continued activity in Vietnam, climbed to 400 per 1,000 average strength.

Noneffective Rates

A record low in average daily noneffective rates was achieved in 1959 when the 1958 rate of 12.0 was reduced to 11.4 per 1,000 average strength. During the period from 1960 through 1964, the average annual noneffective rate declined from 11.8 in 1960 to 9.4 in 1964. The rate was slightly higher in 1965 (9.8 per 1,000); then it rose about one-third to 13.4 in 1966. In 1967 and 1968, the levels were 14.8 and 19.3 per 1,000, respectively. In 1969, the rate of noneffectiveness was at the same level as in 1968.

Hospitalization Rates

In 1959, there were around 20,000 fewer initial admissions of Army personnel to hospitals than in 1958. The rate of initial admissions to hospitals declined from 226 per 1,000 average strength in 1958 to 208 in 1959. In 1960, 1961, 1962, and 1963, the rates per 1,000 average strength were 192, 183, 176, and 163, respectively. By 1966, the rate for initial admissions was 200 per 1,000 average strength as compared to 161 in 1964 and 170 in 1965. The rate rose to 250 per 1,000 in 1968. Around the same rate of admission to hospital occurred in 1969 as in the year before.

Medical Workloads

Daily average workloads in Army Medical Department facilities, worldwide, rose from 40,330 in fiscal year 1960 to 69,921 by the close of fiscal year 1968, as shown in table 1.

TABLE 1.-Trends in daily average workloads in Army Medical Department facilities, worldwide, for specified fourth quarter fiscal periods, 1960, 1963, 1966, and 1968

[Composite work units consist of the sum of (1) the average daily number of hospital beds occupied, (2) 10 times the average daily number of hospital admissions, (3) 10 times the daily average number of births, and (4) 0.3 times the total of the average daily number of dispensary and clinic visits (outpatients, quarters patients, and inpatients) and the average daily number of complete examinations]

Area and year	Forecast	Actual
1960
Worldwide:
Composite work units	40,972	40,330
Beds occupied	13,254	13,075
Admissions	1,248	1,205
Births	205	175
Clinic visits	43,963	44,859
Continental United States:
Composite work units	28,194	27,582
Beds occupied	9,201	9,122
Admissions	819	785
Births	140	115
Clinic visits	31,368	31,546
Overseas:
Composite work units	12,778	12,748
Beds occupied	4,053	3,953
Admissions	429	420
Births	65	60
Clinic visits	12,595	13,313
1963
Worldwide:
Composite work units	43,639	41,791
Beds occupied	13,327	12,317
Admissions	1,288	1,218
Births	190	190
Clinic visits	51,755	51,302
Continental United States:
Composite work units	30,318	28,957
Beds occupied	9,296	8,675
Admissions	858	814
Births	126	128
Clinic visits	37,255	36,196
Overseas:
Composite work units	13,321	12,834
Beds occupied	4,031	3,642
Admissions	430	404

TABLE 1.-Trends in daily average workloads in Army Medical Department facilities, worldwide, for specified fourth quarter fiscal periods, 1960, 1963, and 1966, and 1968-Continued

Area and year	Forecast	Actual
Births	64	62
Clinic visits	14,500	15,106
1966
Worldwide:
Composite work units	55,867	49,482
Beds occupied	20,053	16,166
Admissions	1,689	1,501
Births	141	130
Clinic visits	58,386	56,700
Continental United States:
Composite work units	35,491	32,859
Beds occupied	12,282	10,478
Admissions	1,057	950
Births	87	82
Clinic visits	39,242	40,194
Overseas:
Composite work units	20,376	16,623
Beds occupied	7,771	5,688
Admissions	632	551
Births	54	48
Clinic visits	19,144	16,506
1968
Worldwide:
Composite work units	66,195	69,921
Beds occupied	22,444	23,919
Admissions	1,964	2,121
Births	152	150
Clinic visits	75,290	77,639
Continental United States:
Composite work units	42,481	44,925
Beds occupied	14,140	15,820
Admissions	1,178	1,226
Births	108	102
Clinic visits	51,620	52,772
Overseas:
Composite work units	23,714	24,996
Beds occupied	8,304	8,099
Admissions	786	895
Births	44	48
Clinic visits	23,670	24,867

SOURCE: Comptroller's Program Progress Reports, Fourth Quarter, 1960, 1963, 1966, and 1968.

Considering separately the elements which make up the worldwide medical care composite work units in table 1, only clinic visits rose steadily from the beginning in 1960 and continued throughout 1968. Exceeding the forecast in 1960 by 2 percent, clinic visits, worldwide, climbed from 51,302 in 1963 to 56,700 in 1966. By 1968, clinic visits reached a record high of 77,639, 3 percent above the forecast.

Composite work units in the continental United States and overseas were close to the forecast in 1960. Good hospitalization experiences accounted for the reduction in workloads in the continental United States, while in overseas commands, lower workloads in Europe offset increases in the Pacific and Caribbean commands.

With the deactivation in the summer of 1962 of the remaining Army reservists and National Guardsmen called to active duty during the Berlin buildup, the average Army strength was 4.2 percent below the 1961 strength. This reduction in strength caused a decline in worldwide medical care composite work units for active duty Army personnel not reflected in table 1. Despite the decline in Army strength in fiscal year 1963, the volume of medical care provided dependents in Army medical facilities worldwide rose to 20,534 or more than 40 percent of the worldwide total of 51,302 for clinic visits.

Composite work units in the continental United States and overseas increased after 1965, with the buildup of trainee strength in the continental United States and the impact of casualties on the Army hospitalization ratios. In the continental United States, a change in the mixture of Army strength occurred as seasoned troops were deployed overseas and were replaced by recruits who traditionally have much higher hospitalization ratios.

Overall medical workloads in Army hospitals and dispensaries worldwide rose substantially for the third successive year in 1968, chiefly from the rising troop strength and higher casualty rates in Vietnam. During

the 3-year period, total medical care composite work units rose 55.9 percent, with all elements except births contributing to the rise.

Dental Workloads

During the last 3 months of fiscal year 1960, dental care composite work units, worldwide, averaged 39,286 daily and moderately exceeded the forecast by 2.9 percent. In the continental United States, 21,862 daily average dental care composite work units exceeded the forecast by 0.1 percent, and overseas commands averaged 15,425 or 7.9 percent above the forecast. Dependents comprised 45 percent of the total worldwide workload.

Daily average dental procedures, worldwide, climbed from 40,094 in 1961 to 42,468 in 1962, reflecting the buildup in Berlin and an availability of additional dental officers in Reserve and National Guard units called to active duty. Worldwide daily procedures for 1963 and 1964 were 38,444 and 38,657, respectively, with a moderate rise in the volume of care provided to dependents in Army dental facilities worldwide in 1964. Daily average procedures declined in 1965 to 36,203 and 37,614 in 1966, and, with increases in Dental Corps strength, rose to 44,408 in 1967. The volume of dental care furnished to dependents declined during each of the years because of the sharp rise in trainee workloads and efforts directed to qualifying active-duty personnel for duty overseas.

Continued demands for dental care for active-duty personnel in 1968 dictated reductions in dependent care overseas. The rise in volume of dental care furnished in the United States may be attributed to increases in the dependent population and restrictions imposed on accompanied overseas tours. No significant increase in dental personnel occurred in South Vietnam in 1968, but service there for active-duty personnel became stabilized and increasingly productive in semipermanent dental facilities.

HOSPITAL CLINIC CARE

Changing Concepts

Emphasis on professional care for servicemen and their dependents shifted during the 1960's from hospital bed care to treatment of more and more patients on an ambulatory basis in outpatient clinics. Although the Army Medical Department had operated outpatient services in its hospitals for many years, it became increasingly obvious to The Surgeon General that the organization, philosophy, and concepts of the outpatient clinic services should be reoriented to meet changing methods in the practice of medicine.

Several factors were responsible for the shift in emphasis from inpatient care to outpatient care. Outpatient care had become sound from a medical viewpoint and more economical in the use of personnel and facilities. Mounting knowledge of disease processes and revolutionary developments in medicine, surgery, psychiatry, endocrinology, and other specialties, coupled with new drug therapy and improvements in antibiotics, made it possible to treat many more servicemen and their dependents on an outpatient basis.

A change in the Dependent's Medical Care Program, to be discussed later, restored to Army hospitals most of the types of professional care deleted from the program by the Congress in an economy move in 1958. This restored responsibility and the soaring costs of hospital bed care made it mandatory that as many patients as possible be cared for in the hospital clinic. There were simply not enough beds in hospitals for the increasing numbers of servicemen, dependents, and retired military personnel.

Solving the Outpatient Problem

In recognition of the outpatient problem, The Surgeon General initiated an aggressive program to reorient and rehabilitate the clinic services of Army medical

treatment facilities in keeping with their expanded role in the diagnosis and treatment of disease. He launched the program by sending letters to hospital commanders and army surgeons, soliciting their opinions and recommendations on ways and means of improving hospital clinic care. In addition, he created a special committee to make appropriate recommendations after exploring all of the avenues for improving clinic care. This committee, headed by the Director, Professional Services, included professional consultants, members of the Plans and Operations Divisions, and other representatives of the Office of The Surgeon General.

The hospital clinic care committee considered the opinions and recommendations of the hospital commanders and army surgeons; discussed the various administrative, organizational, logistic, and personnel changes required to improve clinic care; and visited certain military and civilian hospitals to observe the operations of clinic services. As a result, the committee established four principles for clinic care. The first was that hospital clinic care should be the responsibility of the professional department of the hospital, and just as inpatient care, should be given on a personalized basis. A second was that it should be sufficiently varied to offset the differences in physical facilities, the quality and quantity of professional personnel, the extent of professional training, the size of the patient load, and the type of military post involved. A third was that certain provisions should be made to take care of routine physical examinations, immunizations, and emergency cases. Finally, that responsibility for integrating outpatient and inpatient treatment to ensure the best utilization of staff and facilities should rest entirely with the hospital commander.

Plans for implementing these operating principles were developed by The Surgeon General and transmitted by letter and directive to army surgeons and class II hospital commanders. To carry out the program,

it became necessary to shift professional and nonprofessional personnel from inpatient to outpatient care to preserve patient-doctor continuity. Experience in the care of ambulatory patients in hospital clinics became an essential and vital part of the intern and residency training programs, regardless of the specialty. The outpatient service was raised to the department level in line with the changing concept in patient care. The old names "Outpatient Service" and "Dispensary Care" were eliminated and replaced with the new name "Department of Hospital Clinics."

From 1 July 1959 to 30 June 1960, more than 12 million outpatients visited hospital clinics in class I and class II medical facilities, compared to about one-half million inpatients including dependents admitted to hospitals. For every admission to hospitals then, about 25 patients received treatment and care in hospital clinics.

In fiscal year 1961, the Army Medical Department treated more than 15 million outpatients in its installations worldwide and admitted approximately one-half million inpatients to hospitals during the same period. The year 1962 proved the validity of the new concept in patient care. Once again, in overwhelming ratio, the vast majority of personnel were treated in hospital clinics. The trend continued throughout the 1960's, and the Army Medical Department kept abreast by tailoring its fixed treatment facilities to meet the impact.

GENERAL MEDICINE

Teaching Hospitals

By 1960, approximately 90 percent of the teaching positions in internal medicine in Army teaching hospitals were filled by career medical officers, and The Surgeon General's goal was to raise the level to 100 percent. A genuine effort was made in 1961 to achieve balance

in the assignment of medical specialists to class II teaching hospitals.¹

Establishment of radioisotope clinics in class I teaching hospitals moved somewhat slowly at first because of the lack of trained personnel. Pulmonary function laboratories with research facilities were established at certain class II hospitals and class I teaching hospitals with full facilities to perform clinical pulmonary function studies.

By 1965, research capabilities were increased at the larger hospitals with the clear recognition that patient care, teaching, and research are all necessary elements in a successful teaching program. Research facilities were established at Walter Reed, Brooke, and Letterman General Hospitals, and at Madigan General Hospital, Tacoma, Wash. Research services at the teaching hospitals continued to grow in 1966 with units established at Fitzsimons General Hospital, Denver, Colo., and at William Beaumont General Hospital.

Visits to Medical Facilities

Medical consultants or their assistants visited every Army hospital in the continental United States yearly to assist hospital commanders with local problems and to evaluate teaching hospital training programs and other local programs pertaining to professional care. This close liaison between The Surgeon General and local medical personnel resulted in better professional assignment policies and in improved patient care. During these visits, medical consultants stressed increasingly the importance of outpatient care and the integration of outpatient and inpatient care. Medical consultants also visited U.S. Army medical installations in Europe and in the Far East, in addition to class I and class II hospitals and other medical facilities in the United States.

¹Class I hospitals are those hospitals under the jurisdiction of the U.S. Continental Army Command. Class II hospitals and medical centers are the seven installations (William Beaumont, Brooke, Fitzsimons, Letterman, Madigan, Walter Reed, and Valley Forge), under the jurisdiction of The Surgeon General.

The Chief Consultant in Medicine and the Chief Consultant in Surgery visited the U.S. Army Southern Command in fiscal year 1964 to evaluate the medical aspects of the people-to-people program, particularly as it related to the Army medical units assigned to the command. At that time, the most impressive single activity was the assistance being offered by the Tropical Research Medical Laboratory in Panama in their investigations of Bolivian hemorrhagic fever. Of special interest was the medical training being given to the military personnel of a large number of Latin American countries attending the School of the Americas at Fort Gulick, Canal Zone.

With the buildup in Southeast Asia, more time was spent in determining personnel requirements and advising on the assignment of internal medicine specialists, pediatricians, and dermatologists. Career counseling and Army residency programs assumed greater importance and were strengthened during the ensuing years.

SURGERY

Open-Heart Surgery

Between fiscal years 1960 and 1964, the Army Medical Department progressively expanded its capabilities to perform cardiac catheterization and open-heart surgery. Fitzsimons General Hospital, the first U.S. Army hospital to perform open-heart surgery, maintained an active program. Similar open-heart surgery programs were instituted at Letterman and Walter Reed General Hospitals (fig. 5). Preliminary training of personnel, modification of physical plants, and acquisition of the necessary equipment for additional programs were begun at William Beaumont and Brooke General Hospitals during fiscal year 1960. In fiscal year 1963, open-heart surgery was performed in five class II hospitals where personnel and equipment were available.

During fiscal year 1964, few changes occurred in the

FIGURE 5.-Walter Reed Army Medical Center, Washington, D.C. The Armed Forces Institute of Pathology appears in the background.

type and level of specialty care offered at class II hospitals. The open-heart surgery program at William Beaumont General Hospital was eliminated because it was not needed. Hospitals overseas were referring open-heart surgery cases to four class II hospitals in the United States, and The Surgeon General did not contemplate establishing additional open-heart surgery programs because those in existence were meeting the needs.

Visits and Missions

Surgical consultants for the Professional Services Directorate fulfilled a major portion of their mission by periodic visits to continental United States hospitals and to overseas installations. The importance of consultant visits is well illustrated by the fact that surgical consultants visited 33 hospitals in the United States during fiscal year 1961 and Army hospitals in Japan, Korea, Okinawa, and Hawaii. In addition to these visits, civilian surgical consultants in the specialties of general surgery, obstetrics and gynecology, orthopedic surgery, and urology made visits to Army medical facilities in Europe and the Far East. Consultant visits by both military and civilian surgeons continued as a major effort to continue the highest quality of patient care in the Army.

Important teaching missions were sent to Colombia, Jordan, Southeast Asia, and Thailand in 1963. The teaching mission to Thailand developed a postgraduate surgical training program at the Royal Thai Hospital in Bangkok. Similarly, the teaching mission to Bogota, Colombia, set up a postgraduate training program in general surgery for the Colombian Army Medical Corps. Professional information obtained from these teaching missions contributed to medical progress.

Medical support for the care of combat wounded occupied much of the attention of surgical consultants from fiscal years 1965 to 1969. Surgical specialty support in Vietnam reached a peak around 1965 and continued at a high level into fiscal year 1970.

PREVENTIVE MEDICINE

Communicable Diseases

Since 1959, the scope of military preventive medicine has progressively broadened as U.S. forces were increasingly committed to remote and underdeveloped parts of the world. Vigilance, planning, and foresight, coupled with proper indoctrination and education of commanders and troops at all echelons, were accordingly stepped up to minimize the likelihood of epidemics of infectious and parasitic communicable diseases. Rates and ranges of movement and concentration and other circumstances of troops, as well as local populations, exposed military personnel to hazards of disease not present in peacetime civilian life. Research activity was pushed forward on the diarrheas and dysenteries, infectious hepatitis, common respiratory diseases, insectborne diseases, and other special problems in wartime military practice.

Common respiratory diseases and influenza.-Total Army rates for common respiratory disease and influenza remained relatively low between fiscal years 1961 and 1964 as a result of the introduction of the adenovirus vaccine at the beginning of the period.

Notably high incidence rates for acute respiratory disease occurred during fiscal year 1966 in recruit training centers in the continental United States. Large populations of trainees were factors in the rise of rates.

In January, February, and March, 1967, the development and administration of a new oral adenovirus vaccine contributed to a substantial reduction in cases of respiratory diseases among recruits, but later in 1967 an adenovirus organism resistant to the new vaccine emerged. Research continued into 1968 for a vaccine effective against the resistant organism.

Malaria.-Two chloroquine-resistant strains of malarial parasites were substantiated by investigation in fiscal year 1962. In both instances, the parasite was Plasmodium falciparum. Accordingly, the Army Medical

Department revised its program for malarial chemoprophylaxis in May 1962 and recommended dosage of a new tablet containing 0.5 gm. of chloroquine and 0.045 gm. of primaquine for troops in endemic areas. The problem of resistance of certain strains of malarial organisms to synthetic antimalarial drugs was further identified and resulted in expansion of activities designed to study this problem in more detail and to develop new antimalarial agents. Sufficient supplies of quinine were reserved for use in the event the malaria resistance problem gained greater magnitude. Rates for malaria decreased during the years 1963 and 1964 in South Vietnam, but malaria was a hazard of major proportions there in 1965. The peak was reached in November 1965 when the incidence rate was 109.8 cases per 1,000 average strength. During the first three quarters of fiscal year 1966, in South Vietnam, it was not uncommon for malarial patients to be absent from their usual duties for 6 to 8 weeks, but toward the end of the fiscal year, average time lost had been reduced by improved treatment regimens and increased hospitalization facilities in South Vietnam. Nearly 98 percent of malarial infection occurring among troops was caused by Plasmodium falciparum.

Efforts to resolve the malaria resistance problem resulted in the use of many different treatment regimens centering about the use of quinine alone or in combination with one or more synthetic antimalarials during 1966. Also, a great many servicemen with malaria were evacuated from South Vietnam for treatment, and special medical teams were dispatched to South Vietnam to assist in the management of severe renal complications associated with falciparum infections. Diaminodiphenylsulfone was introduced in the treatment of malaria, and this drug was found to be effective in the reduction of relapse rates. In June 1966, the diaminodiphenylsulfonecholoroquine-primaquine regimen was introduced in South Vietnam as routine antimalarial chemoprophylaxis for persons in high risk groups.

In fiscal years 1967 and 1968, better management of malarial patients contributed to the lower incidence rates and also resulted in a reduction of the number of deaths caused by the disease. A substantial decrease in malarial infections and relapse rates among malarial victims was noted because of the use of the new drug combination. Although improved training programs on personal preventive measures and greater emphasis on malaria discipline caused the malaria rate to drop by 24 percent in 1968, malarial infections and relapses remained a problem in South Vietnam. Most of the recurrences were among those with tropical vivax malaria, a less severe disease than falciparum malaria.

Enteric diseases.-Infectious hepatitis continued to be of importance as a cause for hospitalization in Korea, Southeast Asia, and Eritrea. Beginning in March 1964, gamma globulin was administered to all persons arriving in South Korea and South Vietnam for 30 or more days of duty. As infectious hepatitis rates increased among Army personnel primarily because of the worldwide deployment of large numbers of troops, the control program was expanded to include the administration of gamma globulin to personnel in Ethiopia and other areas in Africa and the Middle East. Concurrently, a long-range research project was initiated in 1966 to test the effectiveness of gamma globulin.

Beginning with the acceleration of combat operations in Vietnam in 1965, large numbers of Army personnel were exposed to a gamut of diseases. Diarrheal diseases and fevers of undetermined origin were by far the most common causes of disease admission. Amebiasis was reported at various times to have accounted for between 1 and 10 percent of diarrheal diseases, but a team from the Armed Forces Epidemiological Board's Commission on Enteric Infections visited South Vietnam in the summer of 1965 and found that amebiasis was being grossly overdiagnosed. Shigellosis accounted for the majority of diarrheal diseases for which an etiological agent could be identified. Dengue fever was reported in

small numbers through 1965, and scrub typhus in fewer numbers.

Meningococcal meningitis.-Resistance to prophylactic doses of sulfadiazine was first detected in early 1963 at Fort Ord, Calif., and resistant organisms were identified with increasing frequency at other recruit training centers during fiscal year 1964. Severe concentrations of cases occurred at Fort Ord in mid-1964, and basic training was suspended until April 1965.

The number of Army cases in continental United States increased abruptly in December 1965 and reached a peak rate of 1.86 per 1,000 average strength in February 1966. The Surgeon General studied the distribution of cases between basic trainees and other groups of Army personnel, and measures to avoid overcrowding in training camps were instituted. At several posts, tentage was used for housing troops, in response to The Surgeon General's recommendations to minimize overcrowding. Passive protective methods, including progressive physical conditioning, adequate rest, early detection, and treatment, were initiated at recruit training centers in mid-1966. A decline in the incidence of meningococcal disease began in late 1966 and continued. In the spring of 1967, a 72-percent reduction over the same period in 1966 was achieved.

Melioidosis.-Melioidosis had been rarely encountered by the Army before troops were deployed in large numbers to South Vietnam. The mode of transmission of the disease is unknown, but proposed theories on the means of the organism's entry into the body include contamination of broken skin by infested soil, ingestion of contaminated food, water, or inhalation of contaminated dust. The disease, commonly manifested as an acute lung infection, also occurs as an overwhelming systemic infection or as a localized abscess. When antibiotics were administered early enough, the disease was arrested, and usual procedures to purify water and destroy melioidosis bacteria were effective.

In Vietnam, a total of 34 cases, with seven deaths,

occurred in 1966, compared to 11 cases and two deaths in 1965.

The Army Medical Department established treatment centers for melioidosis at Fitzsimons General Hospital and at Valley Forge General Hospital, Phoenixville, Pa., in 1967, and extensive research was underway at the Walter Reed Army Institute of Research and at research institutes in South Vietnam.

Immunization activities.-Numerous changes occurred in the Army immunization program early in the 1960's. Some of the most significant changes were the standardization of the hypodermic jet injection apparatus, the distribution of freeze-dried lyophilized smallpox vaccine, and the establishment of a standard dosage of immune serum globulin at 0.05 milliliter per pound body-weight for the prevention of infectious hepatitis. In October 1962, the Sabin poliovirus vaccines became available as standard supply items. The Salk vaccine was discontinued when the supply was exhausted.

Yellow fever and typhus vaccines became routine and were required for all active-duty personnel late in 1962.

Cholera immunization was required for all personnel of the Strategic Army Corps in 1962.

Third immunizing doses and re-immunizing doses of tetanus-diphtheria toxoid were reduced in fiscal year 1963, in conformity with the Army Medical Department's policy of reducing, when possible, the number of immunizing doses administered to each individual. A complete initial series of typhoid, typhus, and cholera immunizations was reduced from three to two injections.

Army Health Nursing

The Army health nurse is the public health nurse of the military community and a member of the preventive medicine team along with the preventive medicine officer, the sanitary engineer, and the entomologist. She works closely with the team in the hospital and on outpatient services.

In several Army health nursing programs, the major emphasis on teaching and counseling was augmented to include home nursing service. Continued improvement was noted in the extent and quality of health nursing services provided to the military community.

Army health nursing was monitored through consultation with participating installations, arrangement of training courses, and coordination of assignments and career planning for health nursing.

At the close of fiscal year 1967, a total of 102 Army health nurses were on active duty, an increase over the previous year's total. These nurses administered 38 nursing programs in the United States, including Alaska and Hawaii, and 18 programs in other overseas areas. Thirty-nine installations had one Army health nurse assigned; the remaining 17 participants in the program were staffed by two to 10 nurses each.

Environmental Medicine and Engineering

General Heaton's staff responsibility for management of health services of the Army included the development of programs for control of environmental factors adversely affecting the health of the Army. He coordinated the health aspects of environmental contamination (including, but not limited to, air, water, and soil pollution) with other Federal agencies and State and local authorities. He established the standards and criteria for protection of the health and welfare of the U.S. Army overseas.

Army Medical Department epidemiologists identify the areas in the world in which environmental control can contribute to the health of troops, and the sanitary engineer finds the method and accomplishes the objective. Reasons for disposal of human wastes to prevent illness are medical, and the design and operation of sewage disposal systems are sanitary engineering. With the U.S. Army at war in Southeast Asia and troubleshooting around the world, the role of the Army Medical Depart-

ment in environmental medicine and environmental health engineering covered numerous problems.

A conference of 25 sanitary engineers was held at the Walter Reed Army Institute of Research in late 1959 to review and analyze the Army sanitary engineering program. A series of staff studies on environmental control were prepared and published.

Development of an international standard for drinking water was the subject of increased activity in the early 1960's. The Assistant for Environmental Health Engineering participated as the U.S. member of the North Atlantic Treaty Organization Medical Working Group to develop an atomic, bacteriological, and chemical water standard for combat. In fiscal year 1967, an agreement was reached by the armies of the United States, United Kingdom, Canada, and Australia on standards for water potability. These countries agreed to accept specific criteria for minimum potability of water intended for human consumption under field conditions.

Field studies were conducted during the summer of 1961 on waste disposal practices on the Greenland icecap. The studies were under the joint auspices of the Walter Reed Army Institute of Research and the U.S. Army Environmental Hygiene Agency, Edgewood Arsenal, Md. Considerable difficulty was encountered in obtaining suitable core samples from the icecap. The sewage mass studied was from 160 to 240 feet in diameter and had a thickness of 30 feet. Vertical penetration of the icecap was from 85 to 100 feet. The project was completed in 1962, and results yielded information in engineering design and environmental methods to be used in large Arctic installations.

A program for the evaluation of field water purification equipment for the destruction of chemical, biological, and radiological agents was completed for the U.S. Army Mobility Command, Warren, Mich., in 1963. The U.S. Army Medical Equipment Research and Development Laboratory, Fort Totten, N.Y., and the Office of

The Surgeon General participated in the project. Tests completed during the year concerned the removal of chemical agents and biological warfare agents from water by the Erdlater and pre-treatment kit.

One of the big issues in 1964 concerned effective control of pollution originating from Federal real estate. A clean air and water quality control act was passed by the Congress which required Federal agencies to cooperate with public health agencies to prevent and control air and water pollution.

Efforts in the environmental pollution abatement program in the 1960's included Army membership on the Department of Defense Environmental Pollution Control Committee, the development of health policy guidance, and the provision of technical evaluation and investigation on programmed health protection projects. The U.S. Army Environmental Hygiene Agency conducted six general sanitary engineering surveys, 13 preliminary and detailed water pollution surveys, and 20 air pollution surveys at 39 installations in fiscal year 1968. A total of 122 recommendations for improvement were provided to appropriate commands.

During fiscal year 1966, Army Medical Department personnel conducted medicoecology studies along tentative routes of the proposed sea level canal in Panama and in Colombia, while providing dispensary care and preventive medicine support to engineering survey teams working there. The studies were completed on 31 December 1967, and the final reports, with a special report on heat stress, were submitted in 1968. In addition, the staff of the Medical Support and Research Division, Office of Interoceanic Canal Studies, Canal Zone, compiled and published a comprehensive biomedical bibliography on Central America.

Environmental engineering's top priority in 1968 was to render all possible support to preventive medicine programs in Southeast Asia. More sanitary engineers and sanitarians with intensified training were assigned to Southeast Asia, and as a result, environmental sani-

tation, particularly in the vital areas of water supply and waste disposal, was improved.

The U.S. Army Environmental Hygiene Agency was assigned the task of developing and maintaining a central repository for noise evaluations of the Army's mechanical equipment. Increasing use of machine-powered equipment in recent years resulted in exposure of military personnel to potentially hazardous noise levels which could produce hearing losses and other adverse physiological effects. Noise evaluations had been conducted routinely on all Army equipment, but previously there had been no single repository responsible for the accumulated results.

Environmental engineering in the U.S. Army in Europe was strengthened in fiscal year 1968 when the staff and facilities of the Medical Laboratory's Environmental Health Engineering Service were expanded to enable the laboratory to conduct health surveys of greater scope and complexity.

Occupational Health

The Army occupational health program provided support in occupational medicine, industrial hygiene, and toxicology for both active-duty personnel and civilian employees of the Department of the Army. Reorganization of the Preventive Medicine Division in 1966 placed additional responsibilities on the Occupational Health Branch.

These included occupational health and toxicology, radiologic hygiene, liaison with the Army Reactor Committee on Health and Safety, and the functions of the Civilian Employees' Occupational Health Service. Continued cooperation with the National Academy of Science's Advisory Center on Toxicology and the U.S. Army Environmental Hygiene Agency established the exchange of information on the toxicity levels of chemicals to which Army personnel could be exposed. Particular emphasis was placed on the toxicity of algicides, defoliants,

herbicides, fungicides, fire retardants, sun-screen agents, louse powders, and cable coatings.

Entomology

Vector control operations were improved in South Vietnam by emphasizing the full use of aerial dispersal techniques and equipment in localities where mosquito-borne disease was most prevalent. Six insecticide dispersal units, allocated in fiscal year 1966 for use in helicopters, were employed without significant maintenance difficulties. In fiscal year 1967, eight more units were ordered for use in Vietnam.

Living rats were found in military cargo shipments returning to the United States in fiscal year 1967 from plague-infested areas of South Vietnam. The U.S. Public Health Service intensified its quarantine procedures at ports of entry receiving cargo from Southeast Asia, and an extensive program was initiated in South Vietnam to prevent rodents from infesting cargo being shipped from that country.

In fiscal year 1968, contaminated military air and sea cargo shipments from Southeast Asia continued to serve as potential hazards for the introduction into the United States of agricultural pests and exotic diseases of humans, animals, and plants.

NURSING SERVICE

Two problems plagued the Army Nurse Corps in 1959. One of these problems, chronic shortages of Corps members, was never completely solved, but efforts to relieve the shortages had a measure of success as the decade passed. The second problem concerned clinical competency, and here, much more progress was made. With the increasing specialization and complexity of the practice of medicine in general, it became axiomatic that Army Nurse Corps officers must advance in clinical competency in order to have the understanding, the knowl-

edge, and the skills that would enable them to give adequate nursing support. Army Nurse Corps officers who had attained the advanced clinical preparation were used to give adequate support as members of patient-care teams, to administer direct patient care, and to supervise, teach, and perform nursing research.

The Chief Nurses Biennial Conference was held in the Office of The Surgeon General On 10, 11, and 12 April 1962. The primary purpose of this conference was to bring together Army Nurse Corps officers, assigned in broad areas of responsibility, to discuss, evaluate, and consider plans which would promote maximum utilization of nursing service personnel and produce coordinated and more effective training for all levels of nursing service personnel and to analyze problems which had a bearing upon the mission of the Army Nurse Corps. In addition, presentations outlining new developments and trends influencing the Army Medical Department, as a whole, provided stimulating and thought-provoking material.

Concern has been expressed frequently that proportionately more nurses were being utilized in areas other than patient care. An informal survey of the duty assignments of all Army Nurse Corps officers and civilian nurses in the continental United States, in the first quarter of fiscal year 1961, showed that 86 percent were providing patient care either directly or supportively in the operating room, or in the central materiel section. The remaining 14 percent were in other assignments, including administration (chief nurses, assistant chief nurses, and supervisors), procurement, teaching, and study. Although the information from this survey was directly related to one time period, it was believed that assignments of nurses in any time period would not show great variance in the percentages.

As stated in the personnel chapter of this monograph, the actual strength of the Army Nurse Corps decreased from 3,367 in fiscal year 1959 to 2,971 in fiscal year 1963, while the authorized strength increased from 3,330

to 3,340 for the same period. The difference between the actual strength and the authorized strength created a critical shortage of Army Nurse Corps officers at most stations, particularly at stations in the United States. Many losses came as a result of retirements, mandatory or voluntary; 234 Reserve and Regular Army officers were in this category. With the dwindling professional resources, increased emphasis was placed on the most effective utilization of all levels of nursing service personnel. In addition, the loss of large numbers of senior officers in supervisory and administrative positions made it obvious that more emphasis should be placed on the development of younger officers.

To alleviate the continuing shortage of Army Nurse Corps officers, in 1963, certain Regular Army and Reserve officers were considered for retention. A board of officers convened in July 1963 to select for retention Army Nurse Corps officers scheduled for mandatory retirement. Of 57 Regular Army officers considered, 40 were selected, and 18 accepted retention beyond the mandatory retirement date. Army Nurse Corps officers serving in the permanent Reserve grade of major, who met the provisions for retention on active duty, were also considered. Of 14 Reserve majors eligible for retention, six were selected and three accepted. By September 1963, the request for one Regular Army nurse, lieutenant colonel, to remain on active duty beyond mandatory retirement age, was approved. The Army retention program was expanded in 1965, and this measure gave some relief to the shortages of nurses.

By mid-1965, the Army Nurse Corps had increased to 3,071, and civilian nurses were being hired to provide nursing care. Selected officers serving in the grade of major, Regular Army, who had reached mandatory retirement in 1965 were given an opportunity to remain on active duty for 3 additional years.

Chronic shortages had been partially circumvented in fiscal year 1966 when the Army Nurse Corps was in-

creased by 633 commissioned officers and 21 warrant officers, bringing the Corps strength to more than 3,700.

Male nurses and married nurses represented an increasing percentage of the Army Nurse Corps strength. In June 1965, 93 male nurses were added to the Corps, bringing the total number of male nurses to 470. The number of male nurses had been increased to 753 in June 1966, 1,032 in June 1967, and 1,054 in June 1968, at which time male officers continued to constitute about 22 percent of the Army Nurse Corps strength. About half of the male nurses were specialists in the clinical areas of anesthesiology, operating-room nursing, and neuropsychiatric nursing, but they also demonstrated an increased interest in Army health nursing.

The trend toward greater concentration in the gradesof lieutenant and captain, first manifested in fiscal year1965, continued in fiscal year 1967. On 30 June 1967, the total Army Nurse Corps strength was comprised of29 percent field-grade officers and 71 percent company-grade officers.

Concerted procurement and retention efforts resulted in an increase of more than 800 officers, and by 1968, 4,734 commissioned officers and 79 nurse warrant officers were on active duty. Scarcity in the specialty areas was particularly acute, with the most critical that of qualified operating-room nurses. These shortages were relieved to some degree by hiring more civilian nurses. Under the Voluntary Retention Program, some Regular Army majors who had reached mandatory retirement continued to be retained.

Staffing requirements for units deployed to Southeast Asia for replacement of personnel completing tours there steadily increased. Nurses serving in Vietnam increased threefold, with 390 assigned on 30 June 1966 and 610 on 30 June 1967.

The number of nurses assigned to Vietnam again expanded significantly in fiscal year 1968. More than 900 Army Nurse Corps officers were in Vietnam on 30 June 1968. Increased requirements for Southeast Asia, coupled

with a decrease in authorized civilian nursing spaces in continental United States Army hospitals because of budget limitations and manpower ceilings, created some problems in assignment and career planning. Strenuous efforts were maintained to offer progressive development patterns and educational opportunities.

DENTAL SERVICE

In working toward the objective of providing quality dentistry to every patient who is entitled to care, the Army Dental Corps reflected General Heaton's concept that the soldier must go "first class" where medical service is concerned.

During the past decade, the Dental Corps strived to achieve this objective through the aggressive pursuit of activities aimed to enhance the professional and leadership qualities of its officers and to find new and better means of detecting and eliminating oral diseases.

Preventive Dentistry

With the introduction of a vigorous preventive dentistry program, in November 1960, prevention became the prime consideration in the practice of dentistry in the Army. This practice of preventive dentistry proved its value in several large-scale studies and had a notable impact on all phases of dental operations. In this regard, a most important advance in preventive dentistry in recent years was the introduction of an anticariogenic prophylactic paste, which may be used by the hygienist or be self-applied by the individual. Preliminary studies indicated that the paste, when used with an effective stannous fluoride dentifrice, had a caries reduction potential equal to that resulting from a regimen of oral prophylaxis and topical fluorides.

The preventive dentistry program fostered the widespread use of established procedures and, importantly, determined the degree of accomplishment of assessing

the amount of disease prevented. The expanding developments in the practice of preventive dentistry reflected the progressive nature of the Dental Corps, which was the first major segment of the dental profession to organize and implement a significant preventive dentistry program.

New methods of programming and analyzing dental workloads were adopted, and these methods assured accurate forecasts for staffing and operating costs. As discussed previously, dental workloads were presented in terms of daily average dental care composite work units instead of total procedures.

Dental Resources

General Heaton's deep personal interest in all aspects of medical research had a profound impact on the dental research program throughout his decade as The Surgeon General. The orderly and progressive pattern of dental research and development resulted in programs which were oriented to the needs of military dentistry. Notable among these were improvements in dental materials and casting procedures, advances in techniques for treating oral and maxillofacial defects in combat zones, and development of the hypodermic jet injection technique for local anesthetizing, the first basic change in injection technique in the history of dentistry. These and other studies and programs in progress or planned for the future were all directed toward accomplishing the dental mission under any military condition or circumstance.

Through a "total program concept," the Dental Corps endeavored to achieve its objective of bringing the Army to a state of optimum dental health. All available resources of educational and inservice programs, leadership, and research related to military and combat operations were directed toward attaining this objective.

RADIOLOGY

Radiology services underwent considerable change in

1964. Arterial and vascular catheterization was initiated in most of the class II installations, and radioisotope clinics were active in new diagnostic procedures.

A 2-year course in radiological physics was organized at Walter Reed General Hospital to furnish physicists to Army Medical Department installations where radiation therapy and radioisotope procedures were practiced. Students applying for the course were required to have a bachelor's or master's degree in physics, radiobiology, or mathematics.

The X-ray Technicians Course at Brooke General Hospital was changed to provide on-the-job training of technicians by board-certified radiologists. Technicians completing the course qualified for certification by the American Registry of Radiological Technologists.

PSYCHIATRY AND NEUROLOGY

Army psychiatrists continued to strengthen and expand their efforts to prevent noneffectiveness for psychiatric reasons among personnel, with the result that admissions to hospitals declined to a new low rate.

Expanded care for active-duty personnel and their dependents was indicative of the progress made in the field of psychiatry and neurology. Through inservice programs in social and preventive psychiatry and in current trends in Army clinical psychology at Walter Reed General Hospital, members of psychiatric teams reviewed their methods of operation to establish effective ways of preventing noneffectiveness. Residencies flourished in fiscal year 1960, with 37 medical officers in some stage of work. Study of child psychiatry was initiated, with the cooperation of Walter Reed and Letterman General Hospitals; Children's Hospital, Washington, D.C.; and the Langley Porter Neuropsychiatric Institute, San Francisco, California.

Significant improvements were made in the psychiatric treatment and management of the chronic alcoholic and the psychotic female dependent. A number of psy-

chiatrists developed new methods of treatment for the problem drinker.

Psychiatric treatment centers were opened during fiscal year 1967 at Fort Gordon, Ga., and at Fort Ord, Calif., to cope with problems occurring in recruits. The majority of referrals for treatment were trainees rather than returnees from Vietnam.

SUPPORT ACTIVITIES

Pathology and Laboratory Activities

As research and development activities increased throughout the world, need for pathologists became apparent. Board certification was encouraged, and by 1961, of all the pathologists on duty with the Army, Regular Army, and Reserve, over 50 percent were board certified. Assignments were made in Alaska, Germany, France, Japan, Malaya, Switzerland, Jordan, Thailand, Okinawa, Iran, and Egypt, as well as in Korea and Vietnam.

The buildup of military forces in South Vietnam brought an expansion of laboratory activities there and in the continental United States.

On 30 June 1967, 288 pathologists were on active duty, the largest number since World War II. A total of 69 pathologists were in overseas assignments, including 17 in South Vietnam. Fifty-seven medical officers were enrolled in 4-year residency programs in pathology at the seven class II hospitals in fiscal year 1967. The residency program continued to be the major source of new pathologists for the Army Medical Department.

Pharmacy

As part of the effort to modernize the drug components of field medical assemblages, action was taken during 1961 to develop better packaging methods for drugs, chemicals, and pharmaceutical equipment. Plastic containers, instead of glass, were used to improve the logistic capabilities of field medical units.

On 27 March 1963, the Army Medical Department, in cooperation with the Food and Drug Administration of the U.S. Department of Health, Education, and Welfare, took action to participate in the program of collecting and disseminating information pertaining to adverse reactions from drugs. Adverse drug reaction reporting programs were initiated at the seven class II hospitals.

The Army Investigational Drug Review Board was established in January 1965. It considered proposals from within the Army Medical Department, or from contractors or grantees, which involved the use of human subjects in the clinical investigation of new drugs. During fiscal year 1966, the Drug Review Board considered 65 proposals for clinical investigations. Of these 65 proposals, 57 were approved and confirmed by The Surgeon General.

The Drug Abuse Control Amendment passed by the Congress in 1965 became effective in February 1966. The amendment provided for stronger regulation of the manufacture, distribution, and possession of depressant and stimulant drugs, including barbiturates, amphetamines, and other psychotoxic drugs. In compliance with this law, all Army activities were directed to inventory depressant and stimulant drugs. On 17 May 1966, additional drugs were added to the list of controlled drugs, and later, other drugs were added.

In fiscal year 1967, in response to a memorandum from the Secretary of Defense on the use of graduate licensed pharmacists in military pharmacies, the Department of the Army, in cooperation with The Surgeon General, issued guidelines. These guidelines specified that, at fixed military installations where the range and variety of drugs dispensed were complex and required a high degree of professional skill, only registered pharmacists should supervise pharmacy activities. At installations where the use of a full-time pharmacist was not justified, part-time military or civilian pharmacists or physicians should be utilized to supervise pharmacies.

PHYSICAL STANDARDS

One Directive for Medical Fitness

In cooperation with the Surgeons General of the Navy and the Air Force, The Surgeon General of the Army initiated plans in late 1959 to simplify, clarify, and consolidate the multiple and complex regulations and directives composing the standards for medical fitness. At that time, four Army regulations and around 200 other directives covered medical fitness standards for the Armed Forces. In volume alone, not to mention the complexities in interpretations, these directives affected adversely the triservice handling of medical examinations and the administrative processing of examinations.

The most significant development in physical standards in 1959 was the establishment of the Consolidated Medical Fitness Standards Project. This project was authorized to revise and to combine medical fitness standards into one regulation, completely indexed, to be filed in looseleaf binder form to allow for later additions, changes, and corrections. The first part of the regulation, dealing with medical fitness and examinations, was drafted in 1959 and was approved by the Department of the Army. The regulation was forwarded to the Department of Defense for review, because induction standards were included.

During fiscal year 1961, it became more evident that a clear-cut distinction had to be made between the two terms "medical fitness" and "physical fitness." Interchangeable use of these terms had resulted in false interpretations of medical statistics by the press and several Government agencies. The impression had been given that when an individual was rejected from military service because of a medical condition, he was also physically unfit, and this was not generally true. For example, it is possible that a star football player might have an illness or defect which would disqualify him for military service. Thus, he may be medically unfit for military service but physically fit for his sport.

Definitions were published in the regulation to avoid having a corollary drawn between the terms when it did not apply.

Two problems faced the Armed Forces as deterrents to the preparation of clear-cut standards for examining inductees and processing the results of examinations. One problem involved the lack of statistical data on which to base realistic policy, particularly for conditions and diseases termed "the gray areas-asthma, diabetes mellitus, herniated nucleus pulposus, myocardial infarctions and coronary occlusions, malignant tumors, otitis media, epilepsy, and peptic ulcer. An initial survey, conducted by Surveys and Research Corporation, Washington, D.C., designed to improve understanding of these "gray areas," demonstrated that a larger survey of the problem was both desirable and feasible. In fiscal year 1961, the Surveys and Research Corporation conducted a project on "Effectiveness of Discharged-to-Duty Patients in Selected Diagnoses" and presented valuable data regarding performance of men returned to duty after observation and treatment for a "gray-area" condition or disease.

The second problem was inherent in the need for improvement of the quality of medical examinations and profiling at Armed Forces examining stations and medical facilities. A program begun in previous years to solve this problem was intensified, and included basic courses at the Army Medical Department School at Fort Sam Houston, Tex. The program also included instructional inspections, visits, lectures, and conferences to guide examiners at all stations. Inspections were programmed at least once every 2 years for the 73 Armed Forces examining stations.

In fiscal year 1961, a consolidated regulation covering the standards for medical fitness was published. The regulation, Army Regulations No. 40-501, was designed to cover all standards for medical fitness, with separate chapters for specific areas.

Throughout the decade, the regulation was refined by

additional changes, including a change in medical examination techniques. The purpose of this change was to provide standardized procedures for detecting the presence of diseases, injuries, or residual conditions, and for recording the findings in medical records. This standardization was achieved without affecting the quality of examinations or infringing upon the professional training or judgment of the examiner.

Medical and Physical Evaluation Boards

Action was taken in fiscal year 1960 to improve the policies and procedures of the medical and physical evaluation boards, particularly in the disposition of patients and the separation of Army personnel for physical disabilities. The Surgeon General was concerned by the sharp increase in the workloads of these boards during the next few years because of the large numbers of individuals who were becoming eligible for retirement. Approximately 120,000 persons were already on the retired list, and it was expected that 85,000 more would be retired between fiscal years 1961 and 1965.

The Surgeon General suggested methods of improving the physical disability procedures at a briefing of the Deputy Chief of Staff for Personnel on 13 July 1959. The suggested methods included improvement in training and disposition procedures, the assignment of the best qualified medical officers to boards for disability procedures, a more critical review of board procedures by appropriate medical officers before transmittal to higher authorities, and a continuing effort to ensure that patients were well informed about their rights and privileges.

Representatives of the Physical Standards Division participated in a meeting of an interservice committee established by the Secretary of Defense to prepare uniform disability separation procedures for the Armed Forces. Although the three services operated their own disability separations under the Career Compensation Act of 1949, the implementing of directives was not

uniform. The committee made specific recommendations to the Assistant Secretary of Defense (Manpower) which would make uniform the procedures for all three services.

Armed Forces Examining Stations

The Physical Standards Division concentrated heavily on resolving problems regarding the medical processing of inductees and enlistees through examining stations when the Secretary of the Army expressed concern about adverse conditions which could create unfavorable initial impressions of the military service. Improvement in all aspects of processing inductees and enlistees was emphasized to help create a favorable impression of the Army. Army surgeons and commanders of class II general hospitals were urged by personal letter from The Surgeon General to lend their support to examining stations.

Visual testing was the most criticized test at examining stations in fiscal year 1962. To correct this weakness, enlisted men were trained at the U.S. Army Medical Optical and Maintenance Activity, St. Louis, Mo., as optical laboratory specialists, to become proficient in vision testing with the Armed Forces vision tester and to measure lens prescriptions on the lensometer.

Until fiscal year 1961, the audiometric test for hearing loss had not been a routine test at examining stations. The addition of the test was expected to save the Government a substantial amount of money, and eventually, savings were measured in millions of dollars a year. Audiometric readings became routine when they were incorporated in the medical fitness standards. Because audiometric tests had not been given routinely, the Government's position had been placed in jeopardy in the adjudication of claims for hearing loss. The level of hearing taken at the time of entry into service has the double effect of protecting both the individual and the Government.

A triservice committee was established by the Depart-

ment of Defense in fiscal year 1965 to investigate the possibility of automating routine medical examinations at examining stations. The chief of the Physical Standards Division was appointed chairman, a position which he held for the rest of the decade. In fiscal year 1968, the committee made extensive progress in the development of an automated system which would incorporate the latest techniques of recording, evaluating, and analyzing examination results. The automated system, designed to conserve manpower, was also expected to increase accuracy and quality and to improve records storage and retrieval.

The Philadelphia Armed Forces Examining and Entrance Station was selected in fiscal year 1968 as the site for the pilot project for automation, and the Department of Defense assigned the task of acquiring and testing the system to the Air Force School of Aerospace Medicine. With the first phase of the program well underway, the committee anticipated the prototype system would be ready for evaluation by June 1971.

The Medically Remedial Enlistment Program

Results of examinations of youths for military service were significantly affected by the remedial enlistment program established under Department of Defense Project No. 100,000. Initiated in October 1966, the program was designed to accept for military service men with easily correctable medical defects and men previously disqualified for failure to meet mental standards.

To qualify for the remedial program, an applicant had to accept corrective treatment for his medical defect and be otherwise eligible for enlistment. Originally limited to applicants for enlistment, the program was extended in August 1967 to include inductees.

The Surgeon General supported the Medically Remedial Enlistment Program by providing general criteria to examiners at Armed Forces examining stations on which physical conditions were considered remedi-

able and by reviewing 614 questionable cases referred to him by examiners.

Project No. 100,000 resulted in the acceptance of 118,163 youths who would have been disqualified for physical or mental reasons before the initiation of the program.

THE MILITARY BLOOD PROGRAM AGENCY

The Military Blood Program Agency, jointly staffed by the Army, Navy, and Air Force, was established on 17 July 1962, to coordinate and manage the blood program of the Department of Defense.

In its seventh year of effective administration and management, in 1969, and under the continuous leadership of an Army Medical Corps officer, the Military Blood Program Agency for the three services had demonstrated its worth in carrying out the national military blood program.

During its first year of operation, the Military Blood Program Agency responded to its mission by completing and distributing a mobilization plan approved by the three services and the Deputy Assistant Secretary of Defense (Health and Medical). The plan detailed the means by which whole blood, under a series of emergency conditions, would be procured, processed, and distributed to a requesting unit. Working with Army, Navy, and Air Force elements, the Agency maintained emergency needs for whole blood on a continuing basis. Close working relationships were established with the U.S. Public Health Service, the Office of Emergency Planning, Executive Office of the President, and the American National Red Cross to effect the Agency's participation in blood activities in the civilian defense effort. The mission of providing the Defense Supply Agency with technical and professional guidance in natural and synthetic expanders led to positive ways to evaluate stockpile materials for retention and disposition.

In fiscal years 1963 and 1964, the Military Blood

Program Agency developed plans for whole-blood requirements under thermonuclear warfare conditions, coordinated the triservice collection and transportation of blood for Exercise Desert Strike, and participated in simulated blood shipments for Exercise Key Chain. In keeping with its mission for reviewing whole-blood mobilization needs, a working relationship was established with the newly organized U.S. STRIKE Command/ Middle East, Africa South of the Sahara, and Southern Asia. Whole-blood needs were determined for these regions, and blood collection potentials of military and civilian donor centers in the U.S. STRIKE Command were reexamined and recorded.

Continued and increased use of immune serum globulin for hepatitis control in Southeast Asia led to the development of a staff study by the Military Blood Program Agency in September 1965. The purpose of the study was to determine the procedure for building up and maintaining Department of Defense reserves of the immune serum globulin to meet peacetime and mobilization needs. Results of the study were modified when the Armed Forces Epidemiological Board, with triservice concurrence, recommended a reduction in the dosage of immune serum globulin. The decision to reduce the dosage and the occurrence of certain events made it possible to meet the demands for immune serum globulin without going into a nationwide or servicewide bleeding program at the time.

One of the events which reduced substantially the need for immune serum globulin was a highly successful program initiated among college students and later supplemented by the National Guard Association Blood Donor Program to increase the supply of whole blood for fractionation. The program was begun at the University of Illinois, Urbana, Ill., as a countermeasure to draft-card burning. The American National Red Cross joined the effort and, with personnel from the Department of Defense, visited college campuses in the interest of voluntary blood donations. The donor program was

concluded in November 1966 after almost 225,000 students and National Guardsmen had contributed enough blood for approximately 45,000 liters of plasma.

Donor Motivation

Realizing that no blood program can be successful without donor motivation, the Military Blood Program Agency prepared and distributed a basic public information package consisting of ten 35-millimeter slides portraying graphically the collection, processing, and distribution of whole blood and its use in treating casualties. (Printed materials were distributed.) Military communications media used the information package to promote the program at Department of Defense installations throughout the United States.

Response from servicemen, their dependents, and from Department of Defense civilian employees was outstanding. Recruit training centers of the Army, Navy, Air Force, and the Marine Corps achieved outstanding records in support of the blood program.

Conferences and Meetings

During fiscal year 1968, Military Blood Program Agency personnel participated in various conferences, seminars, and meetings of regional, national, and international medical organizations engaged in blood banking and blood therapy for the purpose of promoting mutual understanding between its program and civilian blood programs. Particularly significant in 1967 was the Agency's participation in the International Working Conference on Long Term Preservation of Blood, held in London, England, in November and December. The conferees studied, analyzed, and discussed the problems of developing better frozen blood techniques, a topic of vital concern to the three services.

Whole-Blood Support in Emergencies and Crises

Dominican Republic.-During the greater part of

1965, the Military Blood Program Agency made periodic shipments of whole blood, obtained by triservice effort, to support U.S. Forces deployed to the Dominican Republic. By October 1965, when U.S. Forces became self-sustaining for whole-blood needs, no further shipments were made.

Southeast Asia.-On 10 June 1966, the Military Blood Program Agency received a request from the Commander in Chief, U.S. Army, Pacific, to ship 1,000 units of low-titer group O blood to the 406th Medical Laboratory in Japan. At the time, it was estimated that 1,000 units per week would be needed to augment the whole blood provided by the Pacific Command. Continental U.S. Armies collected and forwarded to the Agency 22,000 units of whole blood, thus demonstrating their sustained ability to supply approximately 40 percent of the blood needed in Southeast Asia.

From 1 July 1967 to 30 June 1968, the need for whole blood in Southeast Asia tripled because of the high casualty rates during the enemy's Tet offensive and the expanded combat operations in Vietnam. The Defense Department's weekly quotas of whole blood increased from a weekly quota of 2,500 units in July 1967 to a weekly quota of 7,500 units by June 1968.

Blood was collected in the United States at 42 donor centers located at Army, Navy, and Air Force installations, and shipped through the Armed Services Whole Blood Processing Laboratory, McGuire Air Force Base, Fort Dix, N.J., to Japan.

The commanding officer of the 406th Medical Laboratory served as blood program officer of the Pacific theater. His laboratory maintained and managed the input of whole blood into Southeast Asia. Department of Defense personnel in Japan, Taiwan, Okinawa, and Korea donated blood to make up any difference between needs and amounts shipped from the United States. Approximately 80 percent of the blood was shipped in and the remaining 20 percent donated in the theater during fiscal year 1968.

Blood was transported from the 406th Medical Laboratory to South Vietnam, where a central blood bank received the shipments and distributed the blood as needed to hospital laboratories and field units throughout the country.

DEPENDENTS' MEDICAL CARE PROGRAM

From Medicare to CHAMPUS

The medical care program for the dependents of uniformed servicemen completed 12 years of operation on 7 December 1968. The number of dependents of active-duty personnel eligible for medical benefits under the program had grown from 2,772,800 in fiscal year 1956 to about 6,000,000 in fiscal year 1968. Expenditures in fiscal year 1968 totaled approximately $170 million compared to about $75 million spent during the program's first year of operation.

The Dependents' Medical Care Program, commonly referred to as Medicare, was enacted by the Congress on 7 December 1956 to provide inpatient and outpatient medical care through civilian facilities to the dependents of uniformed members of the Army, the Navy, the Marine Corps, the Air Force, and the U.S. Public Health Service.

During its controversial and evolutionary period of growth, Medicare underwent three major changes. The first and second changes were the result of economy moves in the Congress, and the third change culminated a 6-year struggle of the top medical chiefs of the uniformed services to improve the program, with the Army Surgeon General leading the way from Medicare to CHAMPUS. The Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) was 3 years old in 1969, and as a vital morale and strength builder for the Armed Forces of the United States, it had no counterpart.

The Congress made the first of the three changes in

Medicare on 1 October 1958 by placing restrictions on the types of medical care available from civilian facilities to dependents of active-duty personnel. This change also eliminated partially the freedom-of-choice provision for those dependents residing with their sponsor until a permit or declaration of nonavailability of a military medical facility was first cleared with the appropriate military authorities. Under the provisions of the 7 December 1956 law, the Congress established the right of the patient to choose between medical care in military hospitals or civilian facilities, the right of hospitals and physicians to choose not to accept patients under the plan, and the right of the patient to choose the civilian physician desired.

By 1959, mounting concern in the Congress over the soaring cost of Medicare and the reality that many dependents were using civilian medical facilities when military medical facilities were available led to the second change in the Medicare program.

The second change, on 1 January 1960, restored most of the types of care deleted by the Congress in 1958, but retained the permit system and the partial restriction on freedom of choice. The deletions were made not only to comply with the expressed desires of the Congress to effect economy in the operations of Medicare but also to ensure optimum use of the military medical facilities.

The Military Medical Benefits Amendments of 1966, signed by President Lyndon B. Johnson on 30 September 1966, represented a major augmentation of Medicare. Effective on 1 October 1966, the law created CHAMPUS and greatly expanded the program of inpatient and outpatient medical care through civilian facilities for dependents of active-duty military personnel. Retired military personnel and their dependents were also made eligible for civilian medical care, effective on 1 January 1967. At the same time, a new program of institutional care, rehabilitation, and special education in civilian facilities was instituted for the physically handicapped

and the mentally retarded dependents of active-duty personnel.

The new law removed the restrictions on treatment of mental disorders and eliminated the 1-year limit on hospitalization in civilian or military hospitals imposed under the Dependents' Medical Care Act of 1956. Retirees and all dependents were given free choice between military and civilian facilities for outpatient treatment. Retired members, dependents of retired members and deceased retired members, and dependents living apart from their sponsors also were given free choice between military and civilian facilities for hospitalization. But dependents of active-duty personnel residing with their sponsors still were required to use military hospitals, except when no military hospital was available. The new law provided that reservists who were entitled to retired military pay, regardless of the number of years served on active duty, along with their dependents, would be eligible for medical care in both military and civilian facilities, effective on 1 January 1967.

For the first time, family planning outpatient services became available to dependents at either civilian or military facilities. Dependents could be furnished artificial limbs and artificial eyes at military facilities, and both retirees and dependents could obtain these items from civilian facilities. Retirees and dependents could procure durable equipment, such as wheelchairs and hospital beds, on loan from military facilities or on rental from civilian facilities. Other civilian outpatient benefits included prescription drugs, the use of civilian ambulances, services of Christian Science practitioners and nurses, and hospitalization in Christian Science sanitariums.

Administration and Financing

CHAMPUS, under the general direction of the Departments of Defense and the Army, was administered by the Office for the Civilian Health and Medical Program of the Uniformed Services (OCHAMPUS), a class II

activity under the Army Surgeon General, located in Denver, Colo. Medicare was administered in the same way and was also located in Denver. The Army Surgeon General, as Deputy Program Director of CHAMPUS, received the monthly reports from the Air Force, the Navy, and the U.S. Public Health Service.

CHAMPUS was administered under a single year's funds appropriated by the Congress and made available to the executive director of the medical care program. Payments for authorized medical services were made to participating physicians, hospitals, and other authorized civilian sources of medical care, primarily through claim procedures established by contracts between the Government and various health insurance companies or State medical societies.

Two independent and yet interrelated types of contracts were encompassed in the contract program, one for payment to physicians and the other to hospitals and other authorized civilian medical care facilities. Including the District of Columbia and Puerto Rico, 52 geographic areas were covered by contracts. Hospital claims were paid by the Blue Cross Association in 33 States, the District of Columbia, and Puerto Rico, and for the remaining 17 States, claims were paid by Mutual of Omaha Insurance Company.

Administration of the medical care program abroad had been the responsibility of overseas military commanders, and information about payment for dependent care had been furnished to The Surgeon General of the Army by these commanders. In June 1967, OCHAMPUS was given the task of paying civilian health benefits for retired and active-duty dependents living in countries within the U.S. European Command. A branch of OCHAMPUS was located at the 9th Hospital Center in Germany.