Introduction
Perhaps the earliest attempt to transfuse human blood occurred in 1492 when the blood of three youths was donated in an attempt to save the life of Pope Innocent VIII. Legend hath it that this attempt ended in disaster for all four parties. The three donors died and so did the Pope. Forthwith, the use of blood as a therapeutic agent promptly fell into disrepute as an “invention of the Devil.” In the 17th Century transfusions were banned in Europe by a number of royal edicts, but the practice of blood-letting was recommended for many and varied maladies both in this country and abroad. When George Washington lay critically ill of “inflammation of the throat” at Mount Vernon in 1799 his demise was undoubtedly hastened by the then accepted practice of multiple bleedings. Today, instead of phlebotomy, transfusion would probably be employed as an adjunct to chemotherapy.
The key which unlocked the door to the modern “blood bank” was the discovery of the blood groups by Landsteiner in 1901. About 47 per cent of Americans have 0 blood, 40 per cent A, 10 per cent B and 3 per cent AB blood. Sodium citrate solution, somewhat similar to ACD, was first employed in 1915 to prevent clotting of drawn blood and thus facilitated “indirect” transfusions.
Landsteiner’s discoveries, supplemented by the clinical laboratory research of Jansky, Moss and others, gradually led to grouping or typing and crossmatching of blood before transfusion and greatly reduced the danger of reactions in the recipients. However, the problems of sterility and preservation were complex and the pitfalls in technique were many and perilous, so that transfusion of blood did not become standard procedure until several years later. Although blood transfusions were employed as emergency measures at a number of casualty stations and evacuation hospitals behind the front lines in France in World War I, at the Walter Reed Army Hospital in Washington, D. C. only 18 transfusions were administered during 1917-1918.
After the war, British physicians intensively studied their military surgical experience and in 1921 founded the British Red Cross Transfusion Service. Eight years later, in 1929, the “Blood Transfusion Betterment Association” was organized by seven hospitals in New York City. This was and continues to be a non-profit, scientific and research organization better known as the “Blood Transfusion Association,” which in 1936 implemented a number of Blood Banks in several American Cities.
Organization
Vice Admiral Cary T. Grayson was chairman of the American National Red Cross in 1937 and in June of that year, acting on the suggestion of Miss Roberta Morgan of Birmingham and the recommendation of Dr. William DeKleine, Medical Director of the Red Cross, the Admiral authorized a “few blood transfusion services on an experimental basis.” In conjunction with the Georgia State Medical School in Augusta, that local chapter of the Red Cross obtained 500 volunteer donors in a few days. Within a few months chapter donor-programs were operating in Memphis, Tenn., Aiken, S. C., Paterson, N. J., and in Baltimore. By the autumn of 1938 additional donor centers were established by Red Cross in Chattanooga, Charlotte, Cincinnati, Fredericksburg, Little Rock and Lowell. The Cincinnati chapter alone in 1939 enrolled 2770 donors and collected 2753 pints of blood.
In the spring of 1940 the German Panzer Divisions over-ran France and forced the British to withdraw from Dunkirk. The debacle and carnage beggared description. The British Red Cross was unable to cope with the sudden and almost astronomical demands for blood to treat the wounded and maimed.
Dr. John Scudder of the Presbyterian Hospital in New York City suggested that the Blood Transfusion Association collect blood from donors, process this blood to plasma at the seven cooperating hospitals in New York City and deliver the plasma to the American National Red Cross for prompt transportation to England. The response of the medical profession and the public was most encouraging. Human donors enlisted by the hundreds and the 21 chapters of the Red Cross in the metropolitan area of greater New York made 14,556 collections, from which 10,000 bottles of liquid plasma were flown to London during the Blitz.
The successful example in New York stimulated other cities to follow suit. Several Red Cross chapters were requested to organize recruitment and collection facilities. On September 9, 1940 the Southeastern Pennsylvania Chapter of the Red Cross procured its first donation of blood and inaugurated a program which grew to great size during the War and even today is of vital significance to our national security. That same year the National Research Council through its Division of Medical Sciences organized an advisory committee on Blood and Blood Derivatives to investigate and solve problems of technique, equipment packaging, preservation, handling and transportation of blood and plasma.
World War II Program 1941-1945
In January, 1941 the Surgeons General of the Army and Navy requested the American National Red Cross and the Division of Medical Sciences of the National Research Council “to provide an adequate supply of blood and blood substitutes needed by the Armed Forces.”
In less than one month this program was in operation and the first blood donation was processed into plasma by Sharp and Dohme, Inc., on February 4, 1941.
The speed with which Red Cross Blood Donor Service gained momentum was phenomenal, thanks to the genius for effective organization within the Red Cross. A National Director for the blood program was appointed to “procure blood on a voluntary basis only, to arrange for handling and transportation of the donated blood to pharmaceutical laboratories for processing and to inform the National Research Council of the progressive status of the over-all program.”
The Division of Medical Sciences of the NRC undertook “general supervision of the professional services involved and the provision of competent scientific personnel.” The Medical Departments of the Army and Navy and the National Institutes of Health of the United States Public Health Service collaborated with the National Research Council in “establishing and maintaining proper technical standards in blood collection and in plasma processing.”
To make a long story short, the success of this program planning during the war years of 1941 to 1945 was truly magnificent. The American National Red Cross established 35 donor centers throughout the country and 63 mobile “blood-wagons” (mobile units) which visited 3260 communities in cooperation with 1100 Red Cross chapters in the nation. One hundred thousand volunteer workers served in various capacities in the administration and operation of these chapters, donor centers and mobile blood units. Nine pharmaceutical firms (Sharp and Dohme, Eli Lilly, Lederle, Reichel, Ben Venue, Cutter, Abbott, Hyland, Parke Davis) processed 9,247,016 units of dried plasma while seven firms (Sharp and Dohme, Eli Lilly, Lederle, Cutter, Squibb, Upjohn and Armour) prepared 570,714 units of serum albumin from the 13,326,242 pints of blood collected by the American National Red Cross! In addition to all this plasma and serum albumin for use in military hospitals at home and on foreign soil and aboard ships at sea, 205,907 units of whole blood were flown to the European Theatre of Operations and 181,555 pints of fresh blood were provided our fighting forces in the far- flung combat zones in the Pacific.
Post War Period, 1945-1950
One of the greatest casualties of the conflict was the discontinuance of the war-time blood program upon the cessation of hostilities with Japan. The need for a peace-time civilian blood donor program was not fully envisioned. The war was ended. The flush of victory colored most problems with a roseate hue. Public interest in the life-line of blood ebbed. Besides, combat had ceased so suddenly that there was a considerable reserve supply of plasma. So why worry?
All of the 35 Blood Donor Centers, save one, operated by the Red Cross during the war were closed on or before September 15, 1945. The only center remaining in operation after this date was the one at Denver which remained active at the request of the Army to supply whole blood to the Fitzsimon’s General Hospital. However, widespread appreciation of the life-saving qualities of blood and plasma infusions, due to research resulting in phenomenal advances in medicine and surgery, led to the spontaneous development of individual blood banks in several hospitals. Community blood procurement and processing programs were sponsored by loyal citizens and civic-minded physicians, as witness the Greater Cincinnati Blood Bank and the Worcester County Medical Society Blood Program in Massachusetts. The Illinois Department of Health pioneered a state-wide blood and plasma program, while Michigan operated a mobile bleeding team in cooperation with the State Department of Health and the Michigan State Medical Society. Blood programs of one type or another were also organized in 1944-45 by Iowa, Massachusetts, North Dakota, Utah and Vermont.
Nor was the American National Red Cross willing to stand by idly without making available for permanent utilization the results of its experience in organizing and administering the war-time program. It therefore sponsored a peace-time blood donor program for the continuing benefit of the Armed Forces and the civilian population. This was implemented by individual chapter cooperation with state and city health departments and county medical societies in recruiting donors for plasma for civilian needs and civilian disasters.
In addition, surplus supplies of plasma were returned by the Army and Navy to the Red Cross which re-processed some of this plasma into albumin. Together with other surplus proteins from blood fractionation (immune serum globulin, antihemophilic globulin, fibrin film and fibrin foam), dried powdered plasma and albumin were provided to State and local Health Departments for distribution to civilian hospitals and emergency clinics without charge for these products. Thus, the “bread upon the waters” donated by the American public during the war returned in several beneficial forms. If the plasma from eight pints of blood is fractionated into separate proteins, it will yield two units of serum albumin to combat shock, twelve vials of gamma globulin to immunize against measles and considerable fibrin foam and thrombin to arrest hemorrhage. In addition fibrin film may be used in brain surgery since it will not produce adhesions. Fibrinogen can also be employed in kidney surgery for removal of stones from the renal pelvis. Antihemophilic globulin is another plasma protein which is administered repeatedly to control hemorrhage in patients with hemophilia. Hence, the donation of a pint of blood may save the life of not just one patient but four or five, or even more. Dr. Edwin J. Cohn and his associates at Harvard have isolated experimentally from blood some 60 different proteins, at least five of which, including serum albumin, have therapeutic value. Research scientists have good reason to believe they are on the threshold of many more vital discoveries concerning blood and blood derivatives.
By 1946 it became obvious to doctors and hospitals and health officials, according to Alton L. Blakeslee writing in Public Affairs Pamphlet No. 145 of the Public Affairs Committee, Incorporated, that “blood should be a pillar of national health.” “In rural areas, more and bigger blood banks are required. Networks of banks are needed across the nation to meet emergencies, whether from fires, floods, storms or war.”
Early in 1947 when the available reserve supply of plasma started to dwindle, doctors and hospital authorities began urging the American National Red Cross to resume collection of blood on a national scale because only 20 per cent of hospitals over the country conducted blood banks and most rural communities had no organization or system for obtaining donors in emergencies. Accidents in the home, on the farm, along highways, and among industry were killing and maiming annually hundreds of thousands of citizens, many of whom perished for lack of blood. Most of the nation lay as innocent prey to the next disaster.
The deep and troubled concern over our utter lack of preparedness two to three years after the war was reflected in the thinking and action of American Public Health Association, the United States Public Health Service, the American Dental Association, the American Medical Association, the Association of State and Territorial Health Officers, the Catholic Hospital Association, the American Hospital Association, the Armed Forces, the National Research Council, and the Veterans Administration—all of which recommended that the Red Cross “serve the entire nation with a coordinated blood and blood derivatives program.” The Board of Governors of the American National Red Cross responded in June 1947 and authorized the organization of the National Blood Program. The first regional program opened in Rochester, New York on January 12, 1948.
The National Blood Program
The purpose of the National Blood Program can be simply stated: “To help provide blood and blood derivatives to physicians and hospitals, without charge for the products, for use in the care of their patients.” This entails a three-fold responsibility in the following order: Community Programs, Department of Defense quotas and Civil Defense requirements. These responsibilities are met in three phases by procuring, processing and delivering whole blood and blood derivatives to physicians through regional Red Cross centers and State health departments for current civilian needs. The preparation of irradiated plasma, serum albumin, immune serum globulin and other derivatives is undertaken for the Red Cross by various pharmaceutical laboratories. The fractionated products are forwarded to health departments for appropriate distribution in order to provide an adequate reserve of plasma and plasma derivatives for civil defense in the event of war or other national catastrophe. The Red Cross acts as a coordinating agency for all independent blood banks cooperating in the national procurement program and assists in registration of donors for the Armed Forces. Red Cross regional blood centers and defense centers are licensed by the National Institutes of Health. All technical and laboratory procedures conform to the highest standards. The Red Cross is a charitable organization. It receives no Federal monies, no funds or grants from Congress, but is supported entirely by voluntary contributions. It is primarily responsible for coordination of blood procurement. It never administers blood or plasma or their by-products. From August through November, 1950, the American National Red Cross procured 30,144 pints of whole blood and 80,000 units of serum albumin for our combat forces in the Far East at no cost to the Government.
The Department of Defense in the summer of 1950 in an agreement with the Red Cross established the Armed Forces Blood Donor Program, authorized by the Secretary of Defense and administered by the Armed Services Medical Procurement Agency. Thirty-four blood collection centers were organized and operated by the military at major Army, Navy and Air Force installations. A nation-wide publicity program was launched on September 10, 1951 and the entire country was informed of the urgent need for more blood to meet military requirements. Through Red Cross facilities and cooperating civilian and military blood banks 59,394 pints of blood were obtained in August, 1951; the next month 129,421 and in October 286,324 units. The Armed Forces Blood Donor Program is not directed to the current needs of the civilian population nor to the future requirements of Civil Defense because, under existing directives, the military may not participate in civilian defense programs, which are the sole responsibility of the Federal Civil Defense Administration.
Donations of whole blood by and for military personnel are sent to the Armed Forces Central Processing Laboratory at Travis Air Force Base in California, where they are checked and prepared for immediate shipment by air to our combat forces in the Far East. Blood collected in sodium citrate is processed by eight commercial laboratories to provide a critical reserve of plasma, albumin and other blood derivatives for national defense. Whole blood obtained for current civilian requirements is distributed to physicians and hospitals through Red Cross regional centers within one to two weeks after donation.
The magnitude of the National Blood Program and its significance to our security, both foreign and domestic, has been grasped by the Executive branch of Government which authorized in 1950 a Health Resources Advisory Committee, Chairman Dr. Howard A. Rusk of New York, within the Office of Defense Mobilization. This Committee has a broad frame of reference in matters pertaining to the health of the nation during the present emergency.
The appointment of a special Sub-Committee on Blood was recommended by the Armed Forces Medical Policy Council of the Department of Defense with the concurrence of the Division of Medical Sciences of the National Research Council, the American National Red Cross, the Federal Civil Defense Administration and the United States Public Health Service. All of these agencies are involved in various phases of the blood program and recognize the need for authoritative coordination of the over-all problem. The Committee began work in September, 1951.
On December 10, 1951, the President issued a directive to the heads of executive departments and agencies in which he charged the Director of the Office of Defense Mobilization with the responsibility for “authoritative coordination of an integrated and effective program to meet the nation’s requirements for blood, blood derivatives and related substances.” The Sub-Committee on Blood of the Health Resources Advisory Committee “will be concerned with the development of a single National Blood Program, encompassing all phases of the problem.”
On March 5, 1952 Mr. Charles E. Wilson, then Director of Defense Mobilization stated: “An effective blood program is of major national importance at all times. Coodination of such a program for the duration of the national emergency is essential in order to meet the blood needs of the country without unnecessary duplication of effort or conflict of interests. . . . The American National Red Cross shall continue to be designated as the blood collecting agency for the defense needs of the National Blood Program and will cooperate with affiliated blood banks in carrying out this designated responsibility.” Mr. Wilson also announced that a Committee on Blood and Related Problems would be established by the National Research Council “to serve as a clearing house for the exchange of information related to research on blood, blood derivatives and plasma expanders and to formulate, stimulate and evaluate programs of research.” This Committee, promptly appointed by the Division of Medical Sciences of the NRC, held its first meeting on March 18, 1952 under the chairmanship of Dr. Joseph T. Wearn, Professor of Medicine and Dean of the Faculty of Medicine at Western Reserve University in Cleveland.
As pointed out by Dr. Howard A. Rusk in the New York Times on March 23, 1952, the National Blood Program is not “new” from the standpoint of the thousands of donors who have and will participate in the Red Cross, Department of Defense and community blood bank programs. (Indeed, the National Blood Program has been in effective action for the past four years.) Nor will the picture change as far as the recipients of whole blood, plasma or other blood derivatives are concerned. “By the coordination of policies at top level, however, the ‘new’ program will insure sufficient blood, blood derivatives and plasma extenders to meet basic civilian, military and civil defense needs for immediate use and for necessary reserves.”
During the emergency, “first priority will be given to the allocation of blood to the Armed Forces for whole blood transfusion and second priority to the allocation of whole blood and derivatives for civilian needs. All remaining blood collected is to be allocated to the production of plasma and blood derivatives ... to meet immediate needs and to establish an adequate national reserve by the Department of Defense and the Federal Civil Defense Administration.”
Perspective
In the event the reader is confused and dismayed by this long and perhaps somewhat tedious recitation, let him look at the perspective offered by the Health and Special Weapons Defense Division of the Federal Civil Defense Administration, which is charged with preparation for civilian catastrophes.
According to Dr. John B. Alsever who is consultant on Blood and Shock Therapy to the Civil Defense Program, an integer of the National Blood Program, the magnitude of the task is stupendous. To illustrate the probable requirements for blood, plasma and plasma expanders for civilian casualties in the event of an all-out atomic attack by the enemy, assume that 10 of our major cities have been hit. The estimated casualty rate, based on factual evidence from Hiroshima and Nagasaki, will be at least 100,000 per city—a total of one million or more killed and injured in a few hours!
Planning on minimum requirements, the needs for transfusion will average 5000 pints of whole blood and 26,000 units of plasma in each city. This amount of trans- fusible material might meet the requirements for immediate care of these casualties during the first 8 to 10 hours, The peak demand period would continue for some 72 hours after each attack, During this interval an additional 40,000 pints of blood and 20,000 units of plasma would be required in each city, the victim of atomic war. During the three weeks following such an enemy attack, the survivors in each urban area would require 55,000 more units of whole blood and 54,000 additional units of plasma.
One single successful enemy attack on our great metropolitan centers could readily kill or injure a million persons before breakfast. Of the 66 per cent surviving the initial holocaust, average needs per casualty are at least three transfusion units: 1 ½ pints of whole blood and 1 ½ units of plasma or plasma expanders. In other words, it is estimated that 1,000,000 casualties will require 1,500,000 units of whole blood plus 1,500,000 units of plasma. If the latter is not available in adequate amounts, recourse must be had to plasma expanders, as suggested by the NRC, such as dextran, polyvinyl pyrollidone (PVP), Gelatin (P-20), oxypolygelatin or other biological, chemical or fermentation products for intravenous infusion. Such “substitutes” first must be approved for human administration by the Division of Medical Sciences of the National Research Council and conform to the highest standards of purity and sterility as promulgated by the Food and Drug Administration.
A “critical target area” may be defined as a city of over 40,000 with essential industries and excellent transportation facilities. The aggregate population of such “key” cities in the United States is in the neighborhood of 75,000,000. Should these critical “targets” be destroyed one by one during the course of an Atomic War, one half of our manpower and 95 per cent of our industry would be rubbed out as far as our national potential is concerned. Even a fraction of this total damage could be cataclysmic to our commonweal.
Small wonder your Federal Government for the past four years has been striving to mobilize our industries, our manpower, our natural resources, and our military strength to be prepared for any emergency and thereby to prevent World War III.
Summary
The current National Blood Program coordinated by the Office of Defense Mobilization within the Executive Office of the President of the United States is implemented by the joint efforts of the Federal Civil Defense Administration, the Department of Defense and the American National Red Cross. Technical and scientific guidance are provided by the National Research Council and the National Institutes of Health. The Red Cross continues to serve as the official collecting agency for the civilian, military and civil defense quotas.
At the present writing, procurement facilities consist of 46 Regional and 15 Defense blood programs, 150 mobile units and 4 railroad donor cars specially equipped for use as mobile blood units in remote areas. In addition, there are 34 cooperating civilian blood banks and 34 military collection centers participating in the National Blood Program. The Armed Forces blood procurement quota has already passed the two million mark.
As stated by Doctor Rusk, “seventy per cent of the nation’s population from 18 to 60 years of age now have the opportunity of giving blood for the welfare of our country.” From 23 August, 1950 to 1 November, 1952 the American public donated through the Red Cross, 2,971,000 pints of blood for military use in addition to 3,291,000 pints for civilian use. Moreover, during this same period 661,500 pints were provided by 26 cooperating community civilian blood banks —a grand total of 6,923,500 donations! This is an admirable record in its own right and one that demonstrates splendid cooperation on a national scale.
Implementation of this broad, over-all planning is of necessity complex and costly. Yet, it is vital to our American way of life and our democratic form of government. What sacrifices are essential to preserve freedom and maintain our national security? Who can quote the price of Liberty? If you feel that you are “bleeding” when you pay your taxes and donate your blood for your country, remember the old Chinese proverb: “The more you sweat in peace, the less you bleed in war.”*
* The writer is indebted to the following persons and agencies for their cooperation in providing data for inclusion in this article and for their courtesy in reviewing the manuscript:
Brigadier General A. F. Schwichtenberg, USAF and Captain Raymond Murray (MC) U. S. Navy of the Armed Forces Medical Policy Council, Office of the Secretary of Defense; Dr. John B. Alsever of the Federal Civil Defense Administration, Dr. Samuel T. Gibson of the American National Red Cross, Dr. W. H. Aufranc of the Office of Defense Mobilization, Dr. Douglas Lawrason of the National Research Council, Dr. Workman of the National Institutes of Health, Dr. Geoffrey Edsall of the Army Medical Service Graduate School (Walter Reed Army Medical Center), and Lt. Cdr. Harry Browdy (MSC) USN of the Bureau of Medicine and Surgery, Navy Department. The author is particularly grateful for the kindly encouragement, the impeccable precept and the quiet example of Dr. Howard T. Karsner, Research Advisor to the Surgeon General, United States Navy.