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In World War II, the United States was able to marshal its strength and equip its armies while protected by redoubts that are no longer effective. Without warning, the modern bomber and the fifth columist may now strike devastating blows that could destroy our potential capacity to strike back. Our factories and farms, our railroads and mines could be rendered powerless to forge the mighty machine that would be needed to retaliate in kind on the homeland of the enemy.Our armed forces would prevent much of this destruction, to be sure. Complete military defense is impossible, however, and a paralyzing blow could be dealt our military potential. We, as civilians, can prevent this paralysis. Indeed, we must, for it is our responsibility and ours alone. Not only our industrial capacity and innumerable lives but the actual success of our military operations will depend on the adequacy of our civil

• The new concepts of mass evacuation from critical target areas and of radioactive fall-out make it imperative that state plans be revised and broadened. The Public Health Service program stresses the provision of consultative services. Three types of special civil defense training courses are contemplated. One will consist of fieldtraining courses primarily for chief operating personnel at state levels and key local sites and will include public health physicians. A second will train civil defense state and local basic public health operating personnel for the tasks that will arise at operating levels. The third will prepare key operating professional specialists from states and localities to meet the specialized public health problems created by the threat of radiological, biological, or chemical warfare. Research projects are also being developed concerning the epidemiologiy related to such warfare and the disruption of normal sanitary practices by large-scale destruction and mass evacuation.

To the Editor:— "In the conduct of military operations, great illusions are born out of a poverty of information coupled with a wealth of confidence that the enemy in any case is unequal to the task of promoting a decisive change in events" (S. L. A. Marshall, Chief Historian, European Theatre of Operations). After any natural or man-caused calamity, the prime objectives are to preserve life and to restore health and the ability to work and to reconstruct, all other functions of society obviously being dependent on at least some of its members remaining alive or recovering and being able to carry on. Therefore, at no other time are the skills and the professional knowledge of the physian more urgently needed than in the time of a collective emergency—be it natural cataclysm, major industrial accident, or large-scale military operation. We suspect that, due partly to the traditional abhorrence of the

There are such a multitude of facets of this problem to be explored, if a physician desires to prepare himself for leadership in the civil defense program and to promote participation by all groups in civil defense organizations, that extreme difficulty is encountered in attempting to compartmentalize the manner in which these objectives are accomplished. Heretofore the task has been a long and tedious one. The physician entering the civil defense program for the first time at this late date will in no way encounter the many difficulties that pioneers in the program met with during the past four or five years. We now have varying degrees of efficiency in civil defense departments from the national down to the local level, and the physician can fit into these organizations readily. IMPORTANT ATTRIBUTES FOR LEADERSHIP The manner in which the physician develops the necessary leadership and encourages the required participation in

Although civil defense directives have recently been promulgated by federal authorities, local communities must work out their individual plans on the basis of the situation existing in those communities. In some states directives and coordinating plans have been drawn up. The necessity of having carefully worked-out plans cannot be overemphasized. Modern warfare, in which the conventional high explosive and incendiary bombs will be complemented by atom bombs, and in some cases by guided missiles, can cause casualties in cities that will be counted in the thousands. Because of the large number of casualties, ali available medical resources, both personnel and material, must be used in the most efficient manner possible. It must be remembered that not all personnel and facilities will be available because some of them will be among the casualties. Plans must be completely prepared before the disaster strikes, down to the last detail of assigning primary and

The national concept and philosophy of civil defense developed during World War II. It was the first time in warfare that the people at home were in danger from attack. We hurriedly set up a civilian defense organization. We developed a program while conducting the war. As the war progressed more successfully, the civil defense effort receded rapidly. It was practically abandoned by the end of the war. Civil defense contributed little to the winning of the war. Citizens in general did not then, and do not now, understand the relationship of a civil defense to the strength or survival of the nation, for this country has never experienced a crisis in which a long-sustained, supreme effort on the part of every citizen and each community was necessary for national survival. The comfortable family and community way of life has been relatively little disturbed by our last two wars. CIVIL

I know of no group that is more receptive to civil defense, no group that is more responsive to our planning, and no group with more significance to the ultimate survival of this nation, than the members of the American Medical Association. We appreciate your splendid cooperation and performance. Medical Care We proposed, some time ago, that the responsibility for health and medical care of the surviving population be delegated to the Public Health Service of the Department of Health, Education, and Welfare. We want to delegate this whole responsibility to the PHS, and, along with it, the responsibility for writing the medical portion of the National Civil Defense Plan which we have drawn and which I will discuss more fully later. At no time did we consider doing this without first bringing it before the A. M. A. The latest opportunity for full discussion came in a meeting, late

The fact that you are here today is clear evidence that you are dedicated to the proposition that America must live. The challenge that is before all of us, in this hazardous age, is to make certain that our nation and its people survive any disaster that might be directed against us. It is good to know that you are as deeply interested as I am in the problems of the nuclear age. I know of no group, no profession, that is more dedicated to the cause of civil defense than are you and all the other members of the American Medical Association. It is a good thing for all of us that you are. It is with you, and all others so strategically situated, that our civil defense effort will succeed or fail. I am sure that you mean to make it succeed. We at the national level of

If we are bombed tomorrow, any type of protection that can be given to the individual will be better than none at all. But this premise, if continually accepted, is not planning. It is improvisation, and poor improvisation at that. What is required is medical planning, for that is the only sensible manner in which our profession can discharge the new and staggeringly tremendous obligation, quietly and almost imperceptibly being thrust on us by the new fact of life, civil defense. For physicians to be disinterested in this new aspect of their professional and private lives, for them to fail to see the immensity of the problem faced by the physicians of the United States, will be to evade responsibility at a time —should atomic attack come—when the survival of our country will depend upon the American medical profession more than upon any other group of our citizens. Civil defense

In any medical preparedness program for national disaster, the development of allied medical personnel is a highly important consideration. If, as has been stated, a thermonuclear attack on the United States would involve millions of casualties and if the medical personnel itself will be decimated, it is obvious that there would not be enough duly qualified medical practitioners to meet this colossal task. It has long been recognized that there is an imperative need to develop and train all allied and paramedical personnel to assist physicians in the care of the injured in a major disaster.This premise has been recognized and approved by the Office of Civil and Defense Mobilization and by leaders in medical civil defense, many of whom are participating in this conference. But, as yet, organized medicine has made no official statement to sanction or support such allied professional training.This question has been raised by

It is just make believe, this "war" in Europe last June, but to 40 physicians of the Calcasieu Parish Medical Society, meeting in a Lake Charles, La., restaurant, it might well be the start of World War III. They are getting ready in earnest for the fourth annual U. S. civil defense exercise—planning emergency procedures, reviewing assignments for the society's 98 members, and discussing aggressions of the paper enemy. Already, the "enemy" is supposed to have invaded a friendly nation abroad. In three days, according to the exercise blueprint, the President will call Congress into session. On July 12, some 165 nuclear bombs would rain on key American targets, and tens of millions would die—all on paper. Of course it is not going to happen, but this night of Tuesday, June 25, is the last time for the medical society to plan its role in the test because the next

• Thermonuclear weapons are fully capable of destroying large cities. Dispersion is the only real protection against these weapons. By proper planning for evacuation and protective shelters, a few hours of warning may suffice to reduce the number of casualties by half. The early phase is marked by confusion and delay, since most of the radiological defense personnel will be volunteers. During this phase the normally active protective services—law enforcement, fire, utilities, and engineering services—must be active in radiation-detection and communication; meanwhile the complete over-all state civil defense plans go into effect, with the integration of all the various groups. The radiological training program has assisted in training medical personnel in monitoring functions, training radiological laboratory technicians, and training instructors for volunteer and servicemonitoring groups. More than 450 instructors and 6,000 monitors have been trained. Sixteen mobile laboratories have been designed and purchased, and 105 trailers, each for the use of a monitoring squad of 20 persons, have been equipped with radiological apparatus. Maintenance has been satisfactory.

The Civil Defense Committee of the Council on National Defense directs its activity toward the following specific objectives and projects: The Committee sponsors a one-day session on civil defense and related problems on the Saturday preceding the Annual Meeting of the American Medical Association and a two-day session on civil defense and related problems, annually, in the fall, for county medical societies. It prepares permanent reports of sponsored meetings for state medical associations, county medical societies, and those attending such sessions. The Committee accomplishes the necessary research for testimony before congressional committees concerned with civil defense. It acts in a liaison capacity between the A. M. A. and national organizations concerned with disaster preparedness. On request, it recommends physicians for membership on advisory committees, private or federal, concerned with civil defense and disaster preparedness. Resolutions are prepared by the Committee for submission to the A. M. A. Board of Trustees

I am grateful for the opportunity to address this group, but let me assure you at the outset of these remarks that I do not speak as an expert on medical subjects. So, for the sake of the medical profession and my responsibility to the federal government, I should like very simply to express to you something of the urgent problem which each of us faces as we live in this age of continuing and accelerating changes. Although I am not a medical man, I feel curiously at home in this gathering. Your concern with medical education and specialism parallels my concern over some of the major national security problems which we face today. That sounds like an enigma. Let me explain. The crux of your problem is the acceleration and proliferation of scientific knowledge and technological development. In the few years since 1940 we have made more scientific progress

The effects of whole-body roentgen radiation were studied in 11 patients with faradvanced neoplastic disease in order to form a picture of the typical initial response to ionizing radiations. The nominal air dose was 150 r in seven patients and 200 r in four. At this dosage level the duration of the latent period and intensity of ensuing symptoms were determined more by personal differences than by amount of radiation. During the "delay period" of one or two hours there were no symptoms. Two patients later experienced nausea, and two others remained asymptomatic. In the remaining seven, fatigue and apathy appeared abruptly from one hour to four and one-half hours after the irradiation. The onset of vomiting sharply marked the beginning of the initial reaction, which reached its climax five to eight hours after irradiation and then steadily receded. Evidently, among large groups of people exposed to radiation from a nuclear weapon, many who are capable of self-help during the first hour will become prostrated during the three hours that follow.

• Under disaster conditions, the treatment of the individual patient cannot approach the ideal. Compromises in treatment become essential, but they follow some general principles: 1. Infections under these conditions have to be treated, rather than prevented. 2. When the supply of blood is limited, it can be used most efficiently in patients in whom the hemorrhage has been controlled; a limited quantity of blood will, therefore, save more patients with injuries in the extremities than with intraabdominal hemorrhage. 3. In the treatment of thermal injuries, priority should be given to those casualties with burns of 20 to 40%. 4. Patients with wounds of the brain can be transported to fixed hospitals without greatly increasing the mortality. 5. Patients with thoracic and abdominal wounds deserve a fairly high priority. These principles were followed in "Operation Mercy." The sorting station was divided into four areas, the admission and triage section, the resuscitation section, the holding section, and the evacuation point. A mobile emergency hospital was given a thorough trial.

I would like to start with two definitions defining chemical warfare and biological warfare from a civil defense point of view. Chemical warfare is the intentional use of toxic chemicals to kill or confuse man. Biological warfare is the intentional use of living organisms or their toxic products to produce death, disability, or damage to man, animals, or crops. Note that both chemical and biological warfare are concerned only with living things. These two types of warfare have frequently been called unconventional warfare. They have nothing whatsoever to do with conventional weapons which cause physical destruction not only of humans but of equipment and facilities. Nuclear and thermonuclear bombs are conventional weapons if we consider the blast and heat effects. Fall-out, however, is in a sense an unconventional weapon since it adversely affects only living things. Chemical and biological weapons or agents are far more flexible than fall-out and offer

How well can we expect our plans to function? Many methods and techniques for testing have been used in as many places across the United States from the annual Operation Alert to local tests and drills. We are all in agreement that increasing emphasis must be placed upon the capabilities and preparation of the support areas, to which the attacked cities must look for help. These areas are the least prepared to give the required support because of their very limited resources of personnel, facilities, supplies, and equipment. Methods A test was devised for the support areas, with two purposes in mind, based upon the premise of an assumed situation of strategic evacuation—no casualties. The first objective was to determine the total medical potential of the support areas of the southern part of the state, known as Region 1. The second was to know if there was any duplication of

As a part of the Mutual Defense Assistance Program, the United States has launched a nutrition program for the purpose of assisting the developing countries of Asia and Africa in improving the health of their people. In most of these countries, the primary concern of an estimated 90% of the people is survival, dependent upon food and shelter. Food becomes the so-called first line of defense. Although the nutrition program is directed toward the armed forces of the host country, a nutritional assessment of the new recruits gives an appraisal of one segment of the civilian population and the food, dietary, and agricultural studies reflect the habits, customs, and resources of the entire population. The countries included in this program are keenly aware of the seriousness of their nutritional problems and have indicated a desire for assistance and guidance in developing national nutrition programs. However, since comprehensive surveys were not

Very briefly, I shall summarize recent congressional action affecting civil defense and outline in general terms the civil defense legislation now pending in Congress, together with a few comments on what I consider the essential elements of a workable civil defense program for our nation. First, however, I should like to congratulate the American Medical Association, and particularly the Council on National Defense, for its fine work in civil defense. The continuing support of the Association, as well as the support of the medical profession in general, has contributed significantly to the civil defense work of our subcommittee on military operations, and I am sure its support has been of immeasurable help to the Federal Civil Defense Administration. Your presence at this conference today evidences the personal interest of you gentlemen of the medical profession, and I commend you for that interest. No single group in our society can perform

Abraham Lincoln stated the major problem of disaster survival succinctly when he said, "You can't escape the responsibility of tomorrow by evading it today." Although no one at present has all the answers to the problems of survival in mass disaster, it is most important that we become acquainted with the answers we do have and begin thinking of possible solutions to problems which we know may arise in our particular situations. Major Gen. James P. Cooney, deputy surgeon general, has classified people involved in disaster into five major types: the overly optimistic, the very religious, the fatalistic, the ultraneurotic, and the sensible. The optimist is convinced that whatever is going to happen to him is all for the best. The very religious type dismisses the problem, too, by declaring, "Let God's will be done." The fatalist believes he is safe until his number comes up, and there is not

The concept of biologic warfare is not new. Perhaps ever since man has known that microorganisms cause disease, there has been speculation as to the possibilities of their intentional use to harm an enemy. Writers of fiction and journalists have theorized on the subject, usually without attention to the limitations of fact. Infectious agents have been employed in a few instances to commit murders, but their intentional use against numbers of persons simultaneously has not been accomplished. There are incomplete accounts of what may conceivably have been rather crude approaches to such actions in past wars, but these are of no significance in this report. It is possible that biologic warfare may never be employed, just as chemical agents were not used in World War II. Deterrent factors would include fear of reprisals, force of world opinion and perhaps apprehension that some agents might redound to injure the user, just

President Eisenhower, in addressing the National Defense Executive Reserve Conference last November, said that planning is everything but when the emergency actually occurs plans go out the window. "The definition of `emergency,'" he said, "is that it is unexpected, therefore, it is not going to happen the way you are planning." This paradox was startling to some of us who have devoted our energies to mobilization and civil defense planning. Webster defines a paradox as "an assertion or sentiment seemingly contradictory, or opposed to common sense, but that yet may be true in fact." As we continue to try to do our part to help achieve the posture of total defense which Lewis Berry spoke to you about a year ago, we appreciate more and more the cogency of the President's paradox. It expresses on the one hand the virtue and indeed the necessity for undergoing the planning process—not once

The need for medical and health services disaster planning for the care of civilian populations became apparent during World War II when reports of the devastation wrought by explosive missiles in Britain and Germany were received. The magnitude of destruction of life and property was something never before envisioned. As was expected, civil disaster planning and services were developed to a high degree of efficiency in the countries affected by such destructive weapons. With the closing of World War II on the ominous note of the total destruction wrought by nuclear weapons, together with the growing conviction that geographical location was no longer a protection against nuclear warfare, the need for civil disaster planning, whether for "survival" in an all-out nuclear war or for the adequate medical care of casualties in a large-scale local disaster, was recognized by most state and county civil defense administrators. Noting the meager personnel that

The development of powerful new destructive weapons by our potential enemies demands realistic training for our soldiers and citizenry in the various aspects of military and civilian defense preparedness programs. To develop these programs, it has been noted that practical realistic demonstrations in the simulation of casualties must be an adjunct to comprehensive instruction on recognition, care, and treatment of casualties. The use of films, charts, graphs, and other visual aids has been highly successful, but no single medium has added more realistically to the efficient training of troops and civilians than simulations of casualties through the effective use of theatrical make-up, modeling clay, and moulages . Experience has shown that proficiency and accuracy in the skill of simulating casualties can be attained only through repetitious training by skilled technicians under the supervision of professional personnel. The Army Medical Service School at Brooke Army Medical Center has pioneered, in the United

The promotion of disaster planning in a community is, at best, difficult and, for certain, unpopular. The disinterest of the public has been attributed to a sense of hopelessness with regard to protection from atomic warfare, to irresponsible planning and inconsistent leadership by government agencies, and to a sense of apathy with respect to the infrequent occurrence of natural disasters. 1 Catastrophe never seems to be imminent. However, since the medical profession assumes a vital and responsible role in times of disaster, it behooves its membership to persist in preparing itself and in cooperating with other community agencies concerned with health and welfare prior to such catastrophic events. Although confusion has existed with regard to the functions of physicians within the structure of the civil defense program, 2 there has been no question relative to their traditional responsibilities in their respective hospitals during a disaster in the community. In general

Most of this program has been concerned with mass casualties resulting from nuclear weapons. My responsibility is to describe briefly the medical problems posed by two other methods of producing casualties; namely, chemical and biological warfare. Neither is associated with physical destruction. Using either chemical or biological warfare agents, an enemy could induce illness or death in varying numbers of personnel. Having admitted this capability, there then devolves on us, as a part of our basic medical responsibility, the requirement to be able to handle such attacks. About the only real similarity chemical and biological warfare agents have is in the method of dissemination. The most likely use of either would be with various devices capable of producing large numbers of very small air-borne particles or aerosols. The entry of these particles into the body is through the respiratory tract or, in the case of certain chemical agents, through the

Disparity between total number of casualties and the medical means available for their treatment will be the problem facing us in the event of thermonuclear warfare. It is probable that millions of casualties will then be simultaneously produced throughout the length and breadth of the country. In fact, for the first time since the Civil War our country and our civilian population will be just as susceptible to destruction and injury as are our military forces. It has been estimated that the disaster in such a situation can develop to the point to which each physician will have to provide simultaneous care for as many as 500 casualties and that this care will have to be provided with grossly inadequate supplies and equipment. Medical Management The medical management of large numbers of sick or injured involves the establishment of an organization which takes into consideration every essential of proper care.

• Assembly of 200 improvised hospitals for federal stockpiling was undertaken in order to provide focal points for medical care in the event of attack on our country's vital areas. It is likely that more than 6,000 hospitals ought to be kept available. There is a need for training of professional nurses in mass casualty care techniques; a civil defense nursing program is concerned with this and related problems. The dentist can also play a vital role, and the American Dental Association has cooperated in stimulating dentists to train for emergency casualty services. Training courses are necessary for personnel at all levels, including first aid. Many problems arise in this area, especially that of evacuating hospitals. Preparation for radiological defense includes five distinct training programs and the purchase of much indispensable apparatus. For defense against chemical and biological warfare, systems of detection as well as of treatment are necessary; the attack may be not only on people but also on animals and farm crops. The sanitation program is especially concerned with mass evacuation of target cities, radioactive fall-out and shelters, and the restoration of damaged facilities. In addition to a program for blood and plasma expanders, there must be a stockpiling of other medical supplies, the goal for 1956 being sufficient supplies for a 3,500,000 casualty level.

A realistic point of view must permeate all local tactical planning and the logistics of civil defense. The development of guided missiles, long range bombers and the atomic bomb places every area in this country within range of a possible enemy attack. Thus, the philosophies and concepts of civil defense that were developed in the United States during World War II must be radically altered. Instead of plans being made in terms of incidents and disasters involving scores or hundreds of casualties, the medical divisions of civil defense organizations have to be organized and supplied in some way so that, if called on, they will be able to cope with many thousands or even hundreds of thousands of casualties. In World War II, civil defense organizations were concerned primarily with their role in disaster relief of various types in their own community. Now, it appears definite that a properly centered

GENERAL CONSIDERATIONS Should there ever be an atomic attack on this country, the public generally would want something done to ascertain whether there was any danger from radioactive contamination. They would probably not be satisfied unless this were done, and they would probably blame the responsible authorities in local government if it were not done. The assurance that radiological surveys had been carried out, and that they revealed no danger from any residual radioactive contamination, would probably go far toward reducing confusion and perhaps even minimizing that phase of a tendency to panic which may be based on fear of radioactivity. It is difficult for the person who is not technically trained to understand the phenomena of radioactivity. It is difficult for the average person to visualize the significance of radiological hazards because they are not readily detected by the senses, their presence being made known at the time only

If we accept the premise, as we must, that the primary objective of civil defense under disaster conditions is to save life, the effective organization of our medical resources is imperative. Technical or professional knowledge, however important and precious it may be, is not enough. It must be organized in order that it may be fully utilized. A civil defense director cannot be concerned with technical and professional details of the treatment of casualties. That is the business and the responsibility of the physicians and members of other segments of the combined medical professions. But he is, and must be, concerned with the organization of every particle of the medical resources, with which America is blessed so abundantly. In his mind, the major questions are: Is our plan as perfect as we can make it? Does it provide for the fullest possible utilization of our medical resources? Have we organized

• Help for survivors in a nuclear blast area must come from the periphery. Consequently it depends on organized mobile groups from the surrounding region. Such a unit, planned to include first aid for 250 casualties, was given a field trial in "Operation Mercy." Four hospitals willingly agreed to supply equipment for the four operating teams, three resuscitation teams, the sorting station, and the burn and postoperative ward. The local civil defense organization called on volunteer sources in the community, and physicians, nurses, medical technicians, and medical students were mobilized. Transportation for equipment and personnel was by means of private cars, buses, laundry trucks, and small vans. Boy Scouts and high school students cooperated by acting as casualties to the number of 250. The sequence of events, from the unannounced surprise alert until the "pack up and return" signal, lasted nine and one-half hours into the night. There was much confusion, but no one was hurt. Cooperation was found to be enthusiastic when people are asked to participate in a specific activity. The organizing and implementing of even a modest disaster unit was found to require a tremendous amount of attention to detail, but the results were gratifying.