History

Modernization of Facilities and Equipment

Here, at whatever hour you come, you will find light and help and human kindness. -ALBERT SCHWEITZER.

A NEW GENERATION OF HOSPITALS

Early Plans

World War II, immediate postwar economic readjustment, and the Korean War retarded the development of a modern Army hospital system in the United States. From the end of World War II to mid-1959, only 10 of the 52 Army hospitals in the United States had been replaced, four were undergoing construction, and contracts had been awarded for the construction of an additional three.

The strong and concerted effort made by the Army Medical Department to modernize hospitals after the Korean armistice in 1953 had been defeated by lack of funds. In the meantime, modern facilities were becoming more and more essential to the full utilization of new knowledge and skills in the practice of medicine. Good medicine had been practiced in Army hospitals before 1959, but in many instances newer techniques and procedures could not be introduced because of the lack of modern facilities and equipment.

General Heaton, on becoming The Surgeon General in June 1959, urged his chief subordinates, his colleagues, and those in key positions above the Army Medical Department to join him in accelerating the program for

replacing outmoded Army hospitals and equipment in the United States. Significant advances in medicine and technology, the realization that these advances could be used to advantage in Army hospitals, increasing demands for improved facilities for outpatient care of military families, coupled with the heavy emphasis placed on internship and residency training in Army hospitals were among the many factors that gave weight to General Heaton's plea for a new generation of hospitals. Certainly of no less importance as a justification were the growing world tensions and the likelihood that large numbers of U.S. troops might be committed in conflicts around the globe.

In briefing the Deputy Chief of Staff for Logistics, General Heaton stated that equipment in Army hospitals was good, but, in many of these hospitals, it was not the best available. Because of lack of funds over a period of years, the Army Medical Department had not kept pace with innovations in technology and medicine. "Modern medicine," he continued, "can be practiced adequately only in modern facilities."

It was a prestigious and determined General Heaton who took up the leadership struggle in 1959 to bring the Army hospital system in the United States up to date. He spoke with authority and he wrote with authority for he brought to the top position in the Army Medical Department rare and rich experiences gained as a diligent practicing military surgeon and as an able administrator in commanding leading Army hospitals in the Pacific, the United States, and Europe. For the remainder of 1959, he studied the problems in the hospital system and stressed in his papers, briefings, and speeches the importance of the modernization program, which he considered a capstone to one of his five pillars of military medicine: the practice of medicine, including the art of medicine as well as curative and preventive medicine.

General Heaton's overall plan and hope was to provide the Army with well-designed permanent hospitals in

order to raise the standard of medical care in the Army to a level commensurate with the highest quality in medicine and to keep pace with the new gymnasiums, permanent barracks, and overall troop support construction program. He was strongly convinced that the sick soldier required and deserved at least an environment as adequate and attractive as that of the well soldier.

In speaking for the Army Medical Department, however, The Surgeon General did not limit himself to an expression of concern about outmoded facilities. He praised the efforts of those who had served before him, and described the superior professional care being given at obsolete and inadequate facilities. "Splendid results were achieved," he said, "despite wars, hot and cold; despite constant turnover of personnel; and despite cutbacks and shrinking budgets."

Cutting the Redtape

The process of obtaining approval for the construction of a new hospital was a long and arduous one in 1959. It started at the post, went next to the U.S. Continental Army Command, then to the Department of the Army, and ultimately to the Department of Defense for final approval.

To cut the redtape, General Heaton suggested that his office initiate requests for hospital construction and submit them directly to the Department of the Army for approval. His suggestion was approved in December 1959, and he was instructed to prepare the justifications for the construction of new hospitals to be included in future Military Construction Program documents for approval at Department of the Army level.

Army Health Facility Concept

In fiscal year 1960, the Army Medical Department made another move forward in its effort to assure the provision of adequate modern permanent buildings for the

hospitalization of patients and the treatment of increasing outpatient loads at Army medical facilities.

The concept was developed from an awareness that all new hospitals constructed a few years before were inadequate in size and design and forced the use of portions of old hospital plants. To preclude continuation of this situation, and to establish building requirements for future Army hospitals, an extensive study was made of the methods used to determine facility needs. This study resulted in the creation of an entirely new formula for measuring the space requirements of a major Army medical facility. The formula, based on statistical analysis of workloads, staffing requirements, hours of operation, and areas required for clinical elements, nursing units, and supportive activities, made it possible to predetermine the size of a building required to meet medical needs at a given installation.

As a result of this study, the Army construction program for fiscal year 1961 included an experimental project called health activity at Aberdeen Proving Ground, Md., and construction of a 75-bed hospital was begun in July 1961.

The term "Army Health Facility" heralded a new medical treatment concept which envisioned a modern permanent building to house all major medical activities of an installation under one roof. Buildings would be designed to provide inpatient and outpatient facilities, dental clinics, supportive services, and, in most instances, a troop dispensary to serve personnel in the immediate area.

The long-range practical aspects of using a logical formula to determine requirements can best be illustrated by citing certain details about the building plans for Aberdeen Proving Ground. Using the old system of computing requirements, it was determined initially that The Surgeon General would be allowed a maximum gross area of 49,350 square feet for this structure. Using the new formula, a requirement for an 84,000-square-foot structure was demonstrated. The new requirement was

presented to, and justified before, the Congress. The size-specified facility was approved for construction at the Aberdeen Proving Ground.

It was unfortunate that before 1961 engineer policies for new construction did not take into consideration changes in the pattern of medical treatment provided by modern hospitals, and consequently, several hospitals completed before that time were incapable of providing the kind of care desired. The matter was of such deep concern to General Heaton that he declared he would not recommend the building of a single hospital until the policy was amended. Fortunately, his views were accepted by the Congress, and the Army Health Facility concept was adopted. Aberdeen Proving Ground Army Hospital (later named Kirk Army Hospital), for which the Congress appropriated $2,745,000, was the first hospital built under the new concept. On that post, it was possible to meet all medical needs in one building. This experimental project at Aberdeen Proving Ground served as a model for other medical installations to follow.

In keeping with the new trend, the outpatient facilities in all class II hospitals went through some degree of enlargement and improvement. By 1963, each class II hospital, except Letterman General Hospital, had an enlarged, improved, and attractive outpatient facility.

Status of Army Hospitals in Mid-1959

The Army Medical Department, as noted, was operating 52 hospitals in the continental United States, including the dispensary functioning as a hospital at White Sands Missile Range, N. Mex., when General Heaton became The Surgeon General in June 1959. Under a modest renovation program initiated at the end of World War II, 10 of these hospitals had been replaced, four were under construction, and three were funded and under design.

Of the 35 hospitals not included in the initial renovation program, 25 were in dire need of replacement

through a program in which several would be constructed each year until the entire 25 were finished. Eight of the 25 hospitals were completely housed in the World War II cantonment-type structures, and the remaining 17 were simply old, outmoded, and inconveniently arranged structures in various stages of deterioration. The remaining 10 (Walter Reed; Fitzsimons; Brooke; U.S. Military Academy, West Point, N.Y.; Valley Forge; Madigan; Fort Carson, Colo.; Camp Hanford, Wash., Redstone Arsenal, Huntsville, Ala.; and Camp Irwin, Calif.) were not, with the exception of Fitzsimons, in what might be considered up-to-date shape, but the need for replacing them was not as acute as for the 25 hospitals. Renovation and expansion of the existing buildings, it was decided, would suffice until a later date.¹

On 15 September 1959, The Surgeon General submitted to the Department of the Army a list of 11 of the 25 hospitals recommended for replacement under the accelerated program. Four were recommended for construction in fiscal year 1960, and seven in fiscal years 1961 and 1962. The remaining 14 hospitals would be replaced as rapidly as possible in the years to follow.

Hospital Construction

One of the most readily understood measures of an organization's effectiveness is the tangible results achieved. During no period in the history of the Army Medical Department was so much permanent construction completed to provide for the care and comfort of the sick and wounded members of the Army as in the decade from 1959 to 1969. Each passing year was marked with progress toward a new generation of hospitals.

Fiscal year 1960.-One new hospital was completed, construction was nearing completion on two others, and contracts for an additional three were awarded dur-

¹The seven class II Army hospitals in the continental United States were redesignated "general hospitals" on 21 December 1959 by General Order No. 44, effective 1 January 1960, to distinguish them from named class I Army hospitals.

ing the year as progress under the new accelerated program gained momentum.

Under a policy initiated in 1957, all new hospitals were to be named in commemoration of medical personnel who made noteworthy contributions to the Army Medical Department.

Walson Army Hospital, Fort Dix, N.J., a 500-bed hospital with central-core medical facilities included in the construction to permit expansion to 1,000 beds, was dedicated on 15 March 1960 by Secretary of the Army Wilber M. Brucker. This hospital was named in memory of Brigadier General Charles Moore Walson, a distinguished medical officer, who was surgeon of the First U.S. Army before his retirement in 1947.

Fiscal year 1961.-Three new hospitals were completed during 1961, and work was progressing satisfactorily on the construction of hospitals at Carlisle Barracks, Pa. (p. 69), Fort Eustis, Va., and Fort McClellan, Alabama.

Munson Army Hospital, Fort Leavenworth, Kans. (fig. 6), a 90-bed unit constructed to permit expansion to 190 beds, was dedicated at Fort Leavenworth on 1 March 1961 and named in memory of Brigadier General Edward Lyman Munson, a medical officer who invented the Munson Army shoe and the Munson medical tent, and in addition, became noted for his work with the Philippine Health Service, where he served with great distinction during 1914-15 and 1922-24.

Kimbrough Army Hospital, Fort George G. Meade, Md., a 150-bed facility capable of expanding to 300 beds, was dedicated on 29 June 1961. It was named for the Army's famed urologist, Colonel James Claude Kimbrough, who retired from the Army in 1953 following a brilliant 36-year medical career.

Fiscal year 1962.-Four new hospitals were completed and placed in operation during 1962. These hospitals were constructed on the so-called standard design and were limited in clinical service areas. Bed space for inpatients was adequate, but supplementary facilities had

FIGURE 6.-Munson Army Hospital, Fort Leavenworth, Kans.
(U.S. Army photograph.)

to be built later to provide for outpatients. In addition to the four hospitals completed, the new experimental model at Aberdeen Proving Ground was under construction, and contracts were awarded for construction of new hospitals at Fort Leonard Wood, Mo., and Fort Sill, Oklahoma.

McDonald Army Hospital, Fort Eustis, Va., a 116-bed facility, was dedicated on 30 March 1962 and named in memory of Brigadier General Robert Clarence McDonald, who completed his brilliant 36-year career in 1945 as surgeon of the Fourth Service Command, Atlanta, Georgia.

Kenner Army Hospital, Fort Lee, Va., a 100-bed facility, was dedicated on 16 April 1962 and named in memory of Major General Albert Walton Kenner. General Kenner, dedicated Army physician for 33 years (1916-49), served with distinction as Chief Medical Officer, Su-

preme Headquarters, Allied Expeditionary Force (1944-45), and later as Surgeon, Occupation Forces in Germany.

Noble Army Hospital, Fort McClellan, Ala., a 100-bed facility, was dedicated on 4 May 1962 and named in memory of Major General Robert Ernest Noble, who worked side by side with Major General William C. Gorgas in the eradication of yellow fever during the construction of the Panama Canal.

Dunham Army Hospital, Carlisle Barracks, Pa., a 25-bed facility, was dedicated on 16 December 1961 and named in memory of Major General George Clark Dunham. General Dunham retired in 1945 after almost 30 years as an outstanding scientist, nutritionist, sanitarian, and author. He served with distinction at Carlisle Barracks, 1926-31, as director of the Department of Sanitation, Medical Field Service School.

Fiscal year 1963.-Construction was begun on new hospitals at Fort Leonard Wood, Fort Sill, and Fort Hood, Tex., and at the White Sands Missile Range. Building design was underway for a new hospital at Fort Rucker, Alabama.

On 1 July 1962, the Army Medical Department acquired the U.S. Air Force Hospital at Fort Jonathan M. Wainwright, Alaska. On 10 April 1963, this 190-bed hospital was named in memory of Captain John Winfield Bassett, who was killed in action in Alaska in 1942.

Fiscal year 1964.-One new hospital was completed in 1964. McAfee Army Hospital, White Sands Missile Range, N. Mex., a 50-bed hospital, was completed in May 1965 and named in memory of Brigadier General Larry Benjamin McAfee, Deputy Surgeon General of the U.S. Army, 1941-43.

In June 1964, a contract was awarded for construction of the hospital at Fort Rucker. During the year, building designs were prepared for a new 550-bed Letterman General Hospital and for a new 110-bed hospital at Fort Huachuca, Arizona.

Fiscal year 1965.-Substantial progress was made in

The Surgeon General's long-range program of hospital construction in the continental United States in 1965. Two new permanent hospitals were completed.

Kirk Army Hospital, Aberdeen Proving Ground, Md. (fig. 7), a 75-bed hospital capable of expansion to 100 beds, was completed in July 1964 and named in memory of Major General Norman Thomas Kirk, Army Surgeon General, 1943-47. The new facility fulfilled the new concept in design for hospitals in the Army hospital system and revolutionized the building procedures to follow. Kirk Army Hospital was designed to provide for all patient care facilities under one roof.

General Leonard Wood Army Hospital, Fort Leonard Wood, Mo., a 300-bed hospital with outpatient facilities, specialized clinical facilities, and a 14-chair dental clinic, was dedicated in August 1965 and named in memory of Major General Leonard Wood. General Wood, for whom the Fort had been named, had many tributes paid

FIGURE 7.-Kirk Army Hospital, Aberdeen Proving Ground, Md.

to him during his life as a physician, soldier, and patriot. He served as Governor General of the Philippines where he became well known for his research in leprosy. Later 1910-14, he became Army Chief of Staff.

Fiscal year 1966.-Two new hospitals were completed in 1966, and a contract was awarded in October for construction of a new 550-bed Letterman General Hospital. Ground breaking ceremonies were held on 15 December 1965 and were attended by more than 300 Federal, State, and local military officials.

Darnall Army Hospital, Fort Hood, Tex., a 285-bed hospital with outpatient facilities, specialized clinical facilities, and a 14-chair dental clinic, was dedicated in November 1965 and named in memory of Brigadier General Carl Roger Darnall, commanding officer of the Army Medical Center, Washington, D.C., 1929-31.

Reynolds Army Hospital, Fort Sill, Okla., was dedicated on 7 October 1965. This 250-bed hospital, including outpatient facilities, specialized clinical facilities, and a 14-chair dental clinic, was named in memory of Major General Charles Ransom Reynolds, Army Surgeon General, 1935-39.

Fiscal year 1967.-During 1967, one hospital was completed. Construction continued on the new Letterman General Hospital and at several other sites. A contract was awarded in December 1966 for a new hospital at Fort Irwin, Calif. Designs were completed and approved for three additional hospitals, and hospitals were scheduled for construction at Fort Jackson, S.C., Fort Ord, Calif., and Seoul, South Korea. Construction was approved for additional beds at Walson and Kimbrough Army Hospitals and the hospital on Kwajalein.

Lyster Army Hospital, Fort Rucker, Ala., a 75-bed hospital, including clinical facilities, an outpatient clinic, and a 16-chair dental clinic, was opened in February 1967. This hospital was named in memory of Brigadier General Theodore Charles Lyster, one of the pioneers in aviation medicine.

Fiscal year 1968.-Two new hospitals were completed

in 1968, several projects were under construction, and the following hospital construction projects were scheduled for contract award: Fort Devens, Mass., U.S. Military Academy, West Point, N.Y., Fort Stewart, Ga., and an addition to DeWitt Army Hospital, Fort Belvoir, Virginia.

Weed Army Hospital, Fort Irwin, Calif., a 24-bed facility including an outpatient clinic and a 6-chair dental clinic, was dedicated on 24 April 1968 and named in memory of Brigadier General Frank Watkins Weed, Editor in Chief, 1921-28, of the "History of the Medical Department of the United States Army in the World War."

Bliss Army Hospital, Fort Huachuca, Ariz., was dedicated on 28 July 1967. This 110-bed hospital, with an outpatient clinic, specialized treatment facilities, and a 17-chair dental clinic, was named in memory of Major General Raymond Whitcomb Bliss, Army Surgeon General, 1947-51.

Fiscal year 1969.-Contracts were scheduled to be awarded for new hospitals at Forts Devens, Stewart, Jackson, and Ord and at the U.S. Military Academy.

The first permanent Army general hospital to be completed in almost 30 years was dedicated on 14 February 1969-Letterman General Hospital, Presidio of San Francisco, Calif. (fig. 8). Returning to San Francisco to dedicate the new Letterman General Hospital was the culmination of a dream for General Heaton. He had struggled for many years to obtain funds to replace the aging structure.

A modern new teaching hospital warms the heart of every surgeon, for he knows its importance in professional care and medical education. But Letterman General Hospital had another special significance for General Heaton. He had begun his career there 43 years before as an intern in 1926, and from 1945 to 1953, he served as Chief of Surgery, Chief of Professional Services, and later as Commanding General.

The new 10-story building, with its magnificent view

FIGURE 8.-Letterman General Hospital, Presidio of San Francisco, Calif.
(Architect's drawing.)

of San Francisco Bay and the Golden Gate Bridge, was erected at a cost of $15 million.

The 550-bed Letterman General Hospital, half of which are four-bedroom suites and the other half single-and double-room units, has the latest system of intercommunication. Each room has its own television set, and each floor has completely automated cart-delivery from central supply.

The three-story block at the base of the new hospital houses all outpatient clinics. Letterman General Hospital, one of the Army's finest teaching hospitals, was named in 1911 in memory of Jonathan Letterman, the Civil War surgeon who originated the Ambulance Corps and set up a plan to evacuate the wounded from the battlefield. Letterman's system of field medical service has since been adopted by every modern army.

On completion of Letterman General Hospital, the total number of new hospitals constructed or acquired since

World War II rose to 26. Of these 26 new hospitals, 16 were constructed in the 9 years from March 1960 to February 1969, almost doubling the rate of construction in the 14-year period from 1945 to 1959, when 10 hospitals were built.

General Heaton, with his sense of history, concluded his dedicatory speech at Letterman General Hospital with a challenge for the future when he said "* * * it will require decades for people to finish what we have begun here this day in this new Letterman General Hospital" (fig. 9).

FIGURE 9.-Lieutenant General Leonard D. Heaton, The Surgeon General; Major General Charles H. Gingles, Commanding General, Letterman General Hospital; and Major General George E. Armstrong, USA (Ret.), former Surgeon General, attended dedication ceremonies at Letterman General Hospital. The new hospital building was dedicated in February 1969.

Equipment Planning

Equipment planning and coordination of placement with the architect-engineers were accomplished for 10

hospitals, laboratories, and dental clinics in fiscal year 1965. Much of the specialized equipment was designed for the proposed new Letterman General Hospital because of its teaching mission. New innovations included a 2MEV deep therapy unit, Bi-Plane X-ray, central sterilization, and central distribution through a clean and soiled tray conveyor system.

Engineer Manual No. 1110-3-212, "Criteria for Design and Construction of Army Medical Facilities," was revised by the Chief of Engineers, in coordination with The Surgeon General, to update all necessary portions in line with modern hospital standards and was published as Department of the Army Technical Manual 5-838-2.

Equipment planning and coordination of placement with the architect-engineers was accomplished for four hospitals, laboratories, and dental clinics in fiscal year 1966, three hospitals and dental clinics in fiscal year 1967, and one hospital in fiscal year 1968. Equipment planning was prepared and presented to the architect-engineers for incorporation into three dental clinics and one hospital in fiscal year 1966, and for seven hospitals in fiscal year 1967. In fiscal year 1968, equipment and planning was prepared and presented to the architect-engineers for four hospitals, two dental clinics, and one community services facility.

Utilization and Requirement Studies were completed in fiscal year 1967 for two hospitals, four dental clinics, one veterinary and preventive medicine facility, and an addition to the Armed Forces Institute of Pathology. In fiscal year 1968, these studies were completed for 16 projects, eight of which were dental clinics and the remaining eight were hospitals, including additions and alterations.

Hospital Equipment Program

Plans for a hospital equipment program were developed late in fiscal year 1959 to assist commanders in reducing long-standing essential equipment backlogs and

to procure specialized equipment for diagnostic and therapeutic procedures to keep pace with new trends and advances in medicine and technology. This program was an important element of the Army Medical Department's mobilization preparedness. Medical equipment items to be procured under the program included pump oxygenators (heart-lung machines), high vacuum sterilizers, image intensifiers, automatic X-ray film processors, deep therapy apparatus, ballistocardiographs, electroencephalographs, auto-analyzers, automatic audiometers, oximeters, X-ray units, anesthesia apparatus, dental operating units, dental operating chairs, and operating tables.

Continuous effort was made by The Surgeon General late in fiscal year 1959 to elicit Congressional support for funds to replace wornout and obsolete equipment in medical facilities. Lack of sufficient funds in prior years had not permitted an orderly acquisition of replacements for wornout and obsolete equipment or for the purchase of newly developed diagnostic and therapeutic devices.

In fiscal year 1960, the Hospital Equipment Program was established to aid in accomplishing the objectives of the Army Medical Department equipment modernization and replacement program. Measured on the basis of replacement costs, medical equipment in use in medical facilities throughout the Army in fiscal year 1963 was estimated at $60 million. Although the standard for civilian hospitals established by the American Hospital Association was based on an equipment replacement rate geared to a 12-year turnover cycle, the Army had an austere program designed to achieve equipment replacement within a timespan of 16 years. On the basis of the 16-year cycle, a minimum of $3.7 million was required annually to maintain the status quo.

The Surgeon General decided that the bulk of the funds which would be made available by the Congress would be controlled centrally at his level to assure an equitable distribution, to meet priority requirements, and to save money whenever possible through centralized buying in gross lots.

On the basis of a survey completed in June 1961, the requirement for modern equipment was established at $9,050,000. These funds included worldwide requirements for medical treatment facilities and Armed Forces examining and entrance stations. One million dollars was made available by the Congress for the program in fiscal year 1962, with a backlog of $8,050,000 at the end of the fiscal year. Fiscal year 1963 was an austere year with only $700,000 being made available to reduce the equipment backlog.

Despite this central funding which alleviated the most critical requirements, unfinanced requirements for hospital equipment being submitted exceeded the funds provided. It was evident, therefore, that the backlog in this program was accruing at a faster pace than it could be reduced with the limited funds available.

Three million dollars was programmed for central procurement for each of the next 5 years in the Five-Year Force Structure and Financial Program, which would have drastically reduced, if not eliminated, the backlog. However, the fiscal year 1965 program was reduced to $1.5 million, which meant that another year would pass without any improvement in the status of hospital equipment.

The Hospital Equipment Program remained a vitally important program, with direct bearing on patient care, and every effort was made to obtain all the funds programmed. The Army Medical Department activities entered fiscal year 1965 with an unfinanced equipment backlog of more than $7.3 million. An additional $4 million was required to replace obsolete and uneconomically repairable equipment generated during the course of the year, resulting in a net fiscal year 1965 equipment requirement of $11.3 million.

During fiscal year 1965, approximately $5.2 million in central Hospital Equipment Program funds were distributed worldwide, and additional funds were provided by local commands. This was the first year in which sufficient funds were made available to have an impact on

the longstanding backlog. These expenditures resulted in a reduction of the equipment backlog to approximately $4.7 million at the year's end.

By fiscal year 1966, the 16-year replacement cycle previously utilized proved unrealistic because it did not provide the Army Medical Department the means of keeping pace with minimum modernization necessary to support good medical practices. With the realization that functional and economic obsolescence in medical service oriented facilities must take precedence over physical deterioration, the replacement cycle was changed late in fiscal year 1966 to 12 years (8.33 percent per year of capitalized assets). This replacement cycle was in line with other military services and with the American Hospital Association equipment replacement and modernization rate. Further, capital equipment procurement was expanded to include all medical support equipment, as opposed to medical only equipment. This was necessary to realize the full benefits from future procurement under any replacement and modernization program.

During fiscal year 1966, a series of equipment management objectives had been formulated. The purpose of these objectives was to provide commanders with a means to obtain professional, technical, and financial assistance to achieve these goals: reduce existing unfinanced equipment backlogs; procure essential equipment to accomplish diagnostic and therapeutic procedures; accomplish technological modernization to keep pace with new medical treatment, analysis, and monitoring procedures; and make available professional, technical, and supply support evaluation of program and item requirements.

Army Medical Department activities entered fiscal year 1966 with an unfinanced equipment backlog of over $4.7 million. An additional $5.2 million was required to support incremental replacement and modernization which would be generated during the course of the year from approximately $83.1 million capital equipment in use.

This resulted in a net equipment requirements of $9.9 million.

During the year, approximately $4.4 million in Hospital Equipment Program funds were distributed worldwide. These funds plus local command funds provided for equipment replacement and resulted in a reduction of the equipment backlog to approximately $3.1 million at the end of the year.

During fiscal year 1967, The Surgeon General distributed almost $8.6 million to the major commands, almost twice as much as the $4.4 million allocated in fiscal year 1966. Army Medical Department activities entered 1967 with an unfinanced equipment backlog of about $3.1 million, and an additional $11.9 million was required during the year for replacement, modernization, and the purchase of additional equipment. The net equipment requirement then amounted to approximately $15 million.

Hospital Equipment Program funds plus local command moneys were provided to procure equipment in the amount of $11.4 million, resulting in a slight increase in the backlog of $3.6 million at the end of the fiscal year.

During fiscal year 1968, the Hospital Equipment Program materially contributed to the accomplishment of the objectives of the Army Medical Department's Equipment Replacement and Modernization Program. Central funding was utilized in order to manage the complexities encountered due to the high dollar value, nonstandard categorization, and major item mix of unfinanced requirements projected by fixed medical facilities worldwide.

Army Medical Department activities entered fiscal year 1968 with a requirement for $15.3 million dollars to finance medical equipment replacement and modernization. During the year, approximately $9.2 million in Hospital Equipment Program funds were distributed worldwide. These funds, plus local command funds provided for replacement, resulting in a reduction of equipment backlog to approximately $1.3 million at the end

of the year. Funds were distributed in accordance with priorities established by individual medical activities as modified by the urgency of need recommended by command surgeons.

In spite of the relative success in reducing the medical equipment backlog, medical care equipment replacement and modernization problems were not abated during fiscal year 1968. The inability to eliminate equipment problems was primarily due to the expansion of medical facilities to support the increased Army mission plus complications arising from increased equipment costs, range, and complexity. In addition, there was the ever-present problem of continually modernizing and replacing in excess of 170 million dollars' worth of medical care equipment plus changes brought about by the Department of Defense Resources Management System. It was therefore apparent that the Army Medical Department Hospital Equipment Program must encompass all equipment management responsibilities under a single homogeneous program.

Accordingly, the Army Medical Department developed a Medical Equipment Programming and Reporting System (MEPRS). MEPRS was designed to provide the necessary planning, programming, and budgeting data to project equipment requirements and the tools to manage equipment expenditures for fixed medical facilities worldwide. The basic objective of the system was to provide fixed medical facilities with the latest equipment which incorporated technological advances in keeping with modern medical practices. The equipment management objectives under MEPRS provided commanders assistance by furnishing professional, technical, and financial support. In order to accomplish these objectives, MEPRS included four elements to be utilized to project medical support equipment requirements in future years. These elements included the-

1. Medical Equipment Program for Requirements Projection, which was a 5-year supply program for projecting all capital equipment requirements, irrespective

of funding, developed by fixed medical facility commanders worldwide.

2. Medical Equipment Program for Unfinanced Requirements, which was utilized to project medical care capital equipment requirements developed under the Medical Equipment Program for Requirements Projection which could not be procured with available command resources.

3. Medical Equipment Program for New Facilities, which was utilized to project unfinanced noninstalled equipment requirements necessary to support new and expanded construction for medical and dental facilities worldwide funded by Military Construction, Army.

4. Medical Equipment Program for Investment Requirements, which was a pilot program utilized to develop and project capital equipment investment type requirements for medical items of equipment for potential application under the Resources Management System.

Unfinanced capital equipment requirements in excess of $16 million were reported by worldwide medical facilities under this program during fiscal year 1969. The item and dollar requirements as reported, plus additions and substitutions requested by submitting activities, were evaluated and reviewed by the Medical Equipment Review Board.

Of the $16 million unfinanced requirements reported, $15 million were reported under the Medical Equipment Program for Unfinanced Requirements. Of this amount, $12.5 million was approved by the Medical Equipment Review Board. The sum of $4.9 million was provided by operation and maintenance, Army, during fiscal year 1969. In addition, procurement was initiated for approximately $600,000 worth of equipment for delivery in fiscal year 1970.

Unfinanced equipment requirements of more than $984,000 funded by operation and maintenance, Army, were reported under the Medical Equipment Program for New Facilities in fiscal year 1969. Of the program total, $530,000 was funded, with the balance being de-

ferred to fiscal year 1970 based on revised contractor requirements. In addition, procurement was initiated for approximately $45,000 worth of equipment for 1970 delivery.

Although the equipment replacement and modernization objectives of the Army Medical Department Hospital Equipment Program were not completely met, the program was of inestimable value in balancing funds with high priority and emergency equipment requirements.

Accreditation of Army Hospitals

Recognizing the need for maintaining the highest degree of professional medical care and treatment throughout the entire system of Army medical treatment facilities, The Surgeon General in fiscal year 1959 focused attention on obtaining accreditation of Army hospitals in the continental United States and overseas.

Every eligible Army hospital in the United States surveyed in fiscal year 1959 received a certificate of accreditation from the Joint Commission on Accreditation of Hospitals.

The Surgeon General attained an important objective during fiscal year 1960 when the Joint Commission circled the globe from Okinawa to Germany and surveyed and accredited 15 eligible Army hospitals.

Accreditation of Army hospitals was especially significant because of the strong emphasis placed on maintenance of the highest degree of professional care throughout the entire system of hospitals. The Joint Commission represents the four most influential groups dealing with health in the United States: The American College of Physicians, the American College of Surgeons, the American Hospital Association, and the American Medical Association.

By 1 July 1963, 43 Army hospitals in the continental United States and 23 Army hospitals overseas had been accredited. Receiving the coveted accreditation rating was a tribute to the high quality of medical care avail-

able to Army personnel and their dependents. Each Army medical facility inspected received the rating, and by 30 June 1967, every eligible Army hospital had gained accreditation.

Membership in the American Hospital Association

The Surgeon General proposed in 1962 that all overseas Army hospitals become institutional members under the governmental group plan of the American Hospital Association. Army hospitals in the continental United States already enjoyed membership status. Overseas commanders and the American Hospital Association were equally receptive to the proposal, and negotiations were completed and arrangements became effective on 1 July 1963.

RESEARCH AND DEVELOPMENT COMMAND

Minor Construction

Funding problems.-The Research and Development Command minor construction program was seriously hampered in fiscal year 1962 and for several years afterward from the rigid restrictions imposed by the Congress on research, development, test, and evaluation funds in August 1961.

Application of the $25,000 limitation, which had previously only applied to new minor construction, resulted in a large number of needed projects being deferred because of the requirement for submission under the Military Construction Appropriation program to the Congress. The full impact of this restriction was not felt at the close of 1961, but it was readily apparent that extended continuation of the restriction in the future would have a serious effect on the research effort.

The cost limitation of $25,000 on in-house medical research laboratories required inclusion of all scientific equipment and other equipment related to the project. The additional stipulation that only $25,000 worth of

research and development minor construction projects could be accomplished in any one year, or on any one post, virtually forced each major research laboratory to revamp its laboratory construction requirements and submit them to the Department of Defense for approval as urgent minor construction projects or as items to be sent to the Congress in future Military Construction, Army, programs. This time-consuming process took away from in-house laboratories the potential flexibility and capability to respond to rapidly changing medical research needs.

Master Planning Board.-On 9 September 1965, a U.S. Army Medical Research and Development Command Master Planning Board was established by Memorandum 15-8. The Board was responsible for reviewing the overall, long-range construction requirements for the Command and for determining, at 5-year intervals, the needs required to meet research missions.

Eleven projects providing for medical research and development facilities were funded or completed in 1966 and 1967.

Major Construction

Walter Reed Army Institute of Research.-Construction of a new wing, main building, was begun in June 1959 and completed in 1961. The new wing houses a 50,000-watt nuclear reactor for use in biological research and medical treatment. This reactor is the largest one available in general hospitals and produces gamma rays, neutrons, and radioisotopes.

Consolidation and centralization plans.-In calendar year 1966, the Research and Development Command submitted to The Surgeon General the short-range and intermediate-range construction proposals for fiscal years 1967-71. The proposals called for $42,129,000 for construction of research and development facilities for the Army Medical Department Research and Development Command over the 5-year period. The major line item

proposed was a Western Medical Research Laboratory for $13,925,000. Guidance directed that thought be given to the consolidation of Army Medical Department research and development laboratory missions within the continental United States (exclusive of the medical units at Fort Detrick, Md., and Natick, Mass.) into one major new installation, located strategically in the western half of the United States, and another, the Walter Reed Army Institute of Research, in the eastern portion of the country. Increasing costs, limited availability of scientific personnel, and urgent needs for improving the responsiveness and coordination of Army Medical Department research efforts were believed to warrant consolidation and centralization.

The major development in research facilities and construction planning during fiscal year 1967 was the approval by the Secretary of the Army of the long-range plan for the improvement of medical research and development activities. This plan was then forwarded to the Department of Defense for further review and approval. The Department of Defense approved the plan on 7 November 1967. The approved plan proposed to consolidate the 14 current activities of the Research and Development Command into six research facilities. The six facilities were to consist of three major research and development laboratories; Walter Reed Army Institute of Research, supporting the Atlantic area at Walter Reed Army Medical Center; a Central Medical Research Laboratory at Brooke Army Medical Center; and a Western Medical Research Laboratory, adjacent to Letterman General Hospital, supporting the Pacific area. In addition, three specialty research laboratories were to continue specific Army mission-oriented research: The U.S. Army Research Institute of Environmental Medicine, Natick, Mass.; the U.S. Army Aeromedical Research Unit, Fort Rucker, Ala.; and the Medical Research Unit, Fort Detrick, Md. Ultimately, the in-house research and development capacity will be expanded by

almost 40 percent, and it will require additional staffing of 765 scientists, researchers, and technicians.

Construction of the new laboratory building for the Army Research Institute of Environmental Medicine was 90 percent complete on 30 June 1967. The estimated cost of this facility was $3,297,200.

The final design of phase I of the U.S. Army Medical Biological Defense Facility at Fort Detrick, Md., was completed. Funding problems postponed temporarily the awarding of a contract for phase II of this project and, it remained in a deferred status at the end of June 1967. The facility will provide 126,800 square feet of research space at an estimated cost of $8,865,000.

Other Major Construction or Projects

Brooke General Hospital.-Modernization of phase II at the main building to provide total air conditioning was completed in fiscal year 1960.

Walter Reed ArmyMedical Center.-The installation of air conditioning in 31 buildings was completed in 1960, and construction of a substation and electrical distribution system was also completed in 1960. A project for modifying and altering ward 33 to provide a thoracic clinic, and an addition to the X-ray building, was funded and a contract awarded in 1960. A new noncommissioned officers' club and an addition to the germ-free laboratory propagation unit at the Forest Glen Section was funded and a contract awarded in June 1959.

William Beaumont General Hospital.-A new eye, ear, nose, and throat clinic was completed in May 1960.

Fitzsimons General Hospital.-A contract was awarded in June 1960 for the construction of a 19-bed recovery ward, and work began in May 1960 on a new incinerator.

Numerous other construction projects for the Army Medical Department, funded under the Military Construction, Army, program, were underway in fiscal year 1961. One of the most interesting of these projects was the conversion of a former hospital after 10 years' use

as an administrative building at Redstone Arsenal to a hospital facility.

In 1961, a dispensary was completed at Fort Allen, P.R., and one at the U.S. Army Security Agency. Additional quarters were built for nurses at Fort Monmouth, N.J. Fort Belvoir Army Hospital, Va., was air conditioned, and modification was completed on the medical facility at Sandia Base, N. Mex. Another project worthy of note was the completion of the new building for the Second U.S. Army medical laboratory, the first modern medical laboratory constructed by the Army Medical Department since World War II.

Throughout Army medical installations in the continental United States and overseas, other construction projects too numerous to list by type and location were completed during the remainder of the decade to mid-1969. These major construction projects included the installation of multiple-chair dental clinics, additions and alterations to hospital clinics and dispensaries, the building of new quarters for female officers, family housing units, and barracks for enlisted personnel.

Minor Facilities

Under the Research and Development Command class II construction program, all new construction and modification projects costing more than $25,000 were halted in 1961 at the direction of the Congress. Until 1965, projects costing more than $25,000 and less than $200,000, for which an urgent need could be justified, were funded from "Urgent Minor Construction" at the Department of Defense level. New construction projects and modification projects costing more than $25,000, but for which urgency could not be justified, were turned over to the Military Construction, Army, program. New construction and modification costing less than $25,000 was approved by The Surgeon General and funded by the local installation.

Marked progress was made during fiscal year 1966 in the number of minor construction projects completed

at all class II Army Medical Department installations and activities, with a resulting decrease in the backlog of programmed minor construction projects. This decrease in backlog was a result of the buildup of the Army and the increased activity in Southeast Asia.

In the course of fiscal year 1967, the number of minor construction projects at all class II installations increased further as a result of the buildup in Southeast Asia. To aid in orderly and efficient construction, the facilities master planning program was followed at all installations. Maps, building information schedules, analysis of existing facilities, and other basic information comprising phase I of the master plan were reviewed and approved by the Department of the Army.

The number of urgent minor construction projects requested by class II medical installations and activities continued at a high level throughout fiscal years 1967, 1968, and 1969. The Army's buildup in Southeast Asia, and casualties sustained there, generated requirements for the maximum use of existing medical treatment facilities and action for improvements and additions to these facilities.

Expansion of Continental U.S. Army Hospitals

Increases in troop strength and the expansion of operations in Vietnam in fiscal year 1967 exerted a direct influence on continental United States hospital capacity. At the end of fiscal year 1966, 14,767 beds were in operation in the continental United States hospital system, including 7,968 beds in class I hospitals and 6,799 in class II hospitals. By the end of 1967, the number was increased by almost 25 percent to a total of 18,418 beds, 10,498 in class I hospitals and 7,920 in class II hospitals.

To implement the Department of Defense policy of placing the wounded and injured returnee from South Vietnam in the hospital nearest his home of record, it was necessary to augment the seven class II hospitals with seven class I hospitals. These class I Army hospi-

tals (DeWitt, Ireland (Fort Knox, Ky.), Fort Campbell (Ky.), Martin (Fort Benning, Ga.), Womack (Fort Bragg, N.C.), Darnall, and Reynolds) were well staffed professionally and were participating in the Pre-Specialty Surgical Training Program of The Surgeon General. By 30 June 1967, the designated class I hospitals had absorbed the additional patient load without any decrease in the quality of medical care.

Later in 1967, the continental United States hospital system was further augmented by the designation of Army hospitals at Forts Gordon (Ga.), Ord, and Devens as class I specialized hospitals. These three hospitals added 1,300 specialized beds to the medical capability of the Army Medical Department and gave additional coverage to the Southeastern, Northeastern, and Pacific Coast areas.

As a result of this expansion, and the inherent capability of other Army hospitals to treat small numbers of the wounded and injured returnees from South Vietnam, the continental United States hospital system retained the ability to support other overseas areas.

A major increase in the number of patients evacuated from Southeast Asia imposed a severe strain on hospital facilities in the continental United States, and this problem became even more acute during the Tet offensive in February 1968.

The Surgeon General initiated a number of actions to meet this crisis and to prevent a deterioration in the quality of medical care. Hospital commanders were directed to analyze conditions on long-term patients who were medically disqualified for retention on active duty and to expedite their transfer to Veterans' Administration hospitals. At the same time, both class I and class II hospitals were directed to expand as much as available resources would permit. In many hospitals, military and civilian personnel worked overtime to handle increased patient loads. As an additional measure to aid hospitals, The Surgeon General formed a professional team headed by a general officer. This team visited most

hospitals to advise and to assist commanders with their expansion problems.

In April 1968, The Surgeon General submitted a Program Change Request to the Department of Defense, asking for increased funding and manpower authorizations to support a proposed expansion of the continental United States hospital base during the remainder of fiscal year 1968 and for fiscal year 1969. Included in this request were requirements for an additional 1,579 civilian manpower spaces and 1,939 military manpower spaces. The Department of Defense responded by allowing only 10 percent of the manpower authorizations requested for fiscal year 1968 and deferring fiscal year 1969 manpower and funding requests until additional reports on hospital workloads were available.

On 10 May 1968, The Surgeon General forwarded a hospital expansion plan to the Commanding General, U.S. Continental Army Command, as advance information and budget guidance for fiscal year 1969 and for implementation of as much of the plan as possible. The plan provided for a 4,000-bed expansion in the continental United States, including four additional class I specialized hospitals at Forts Riley (Kans.), Campbell, Bragg, and Lee. Military and civilian personnel space requirements for support of this expansion were included in the plan.

A change in the Department of Defense Resources Management System, published on 14 July 1967, triggered a total administrative reorganization of medical activities at class I installations in fiscal year 1968.

Under the new program, an organizational entity termed "Medical Service Activity" was established at military installations with Army hospitals. The Medical Service Activity, under the direction of the hospital commander, integrated all medical facilities at the installation with offpost facilities in the area, such as dental clinics, dispensaries, and food inspection detachments.

This service activity affected 37 major class I Army

hospitals in the United States and most medical service activities in their locale, and the goal of the service activity was to improve and expedite the delivery of medical care by making available specialized treatment where and when it was needed.