Vol. 76, No. 1

The Medical Aspects of Civil Defense in CaliforniaJUSTIN J. STEIN, M.D., Los Angeles

SUMMARY

Medical care for persons injured in atomicbomb attack or other far-reaching enemyaction occupies an important place in civildefense plans that have been set up in Cali-fornia.

Preparations have been made on the basisof suppositions as to where attacks mightoccur and estimates of the number of casual-ties.

State and federal funds have been allo-cated for aid station equipment, antibiotics,plasma, blankets and litters.In the table of organization, use of all

physicians, nurses and hospitals in the stateis contemplated. Communities at the centerof attacks would borrow facilities and med-ical personnel from areas not directlyaffected.

County medical societies in California haveappointed civil defense committees to workout local plans. Each physician has a part inthese plans. If he does not know what hisassignment is, he ought to get in touch withhis county medical society headquarters im-mediately.

IT must be assumed that man is destined to'live ina state of continued conflict. Therefore, plans and

preparations must be made against wars which sud-denly break upon us without warning or which fol-low a series of so-called "incidents."We no longer live under such favorable conditions

as existed in the past, namely, a vast ocean betweenus and our enemies and the fact that allies wouldcombat the enemy while we were allowed to preparefor war.

In the future, because of the tremendous advancesin aviation, submarines, guided missiles, and otherweapons of destruction the civilians of this countrymay be the first targets and may even suffer greatercasualties than our armed forces. In fact, it mayeven be safer to be a member of the armed forcesthan to live in a critical target area. The enemy willbe able to bomb our cities just as we will be able tobomb his cities.

Civil defense plans and preparations are as impor-tant as are those of the armed forces. Each requiresthe other to survive and both are a direct responsi-Read at the Medical Civil Defense Conference given by

the American Medical Association, Chicago, Illinois; No-vember 9, 1951.The author is Chairman, Committee on Military Affairs

and Civil Defense, California Medical Association; Chair-man, Governor's Citizens Advisory Committee on Medicaland Health Services (California).

bility of the Federal government. It has been saidthat the new Secretary of Defense, Robert A. Lovett,is of the opinion that civil defense is the fourth armof the Defense Department and on a par with theArmy, Navy, and Air Force. If such be the case, thencivil defense will proceed more rapidly than it hasin the past.

Civil defense is here to stay and must become apart of the daily life of every man, woman, and childin this country. It is disheartening to note that thepublic enthusiasm for civil defense increases anddecreases with the headlines in the newspaper. Thisis understandable in a public which reads of wasteof tremendous sums of our money overseas and ofthe apparent lack of interest in Congress in appro-priating adequate money and encouraging civildefense. The public must demand of its congres-si6nal representatives that something be done aboutit if we are to survive as a free people. An enlight-ened and prepared America will effectively combatany war waged against her.The appraisal of the over-all situation and of the

need for urgency in civil defense preparations is adirect responsibility of the Federal government andwe must depend upon the appraisal as given us. Todate, considerable confusion exists, as is indicatedin the wide divergence of opinions coming from keygovernment officials regarding the urgency for civildefense. In the event of enemy action the problemof supplies, equipment, and materials beyond thefirst few hours must be a Federal responsibility.There must be a central purchasing authority andessential supplies must be stockpiled at once anddistributed to the critical target areas. Only essentialsupplies should be stockpiled, for it is impossible toprovide'for every conceivable emergency. It wouldbe easy to bankrupt us all if we attempted to covereverything. Loose thinking, such as the provision forelaborate bombproof shelters, must be eliminated.This would be a waste of critical materials and atremendous loss of manpower hours.No one can question the need for civil defense.

We have only to study the great mistakes made byGermany and Japan in assuming that they wouldnever be invaded from the air.'They suffered tre-mendous and unnecessary casualties through lackof preparation and organization. Great Britain be-gan civil defense training and organization in 1935and would not have survived without it. The numberof casualties at Hiroshima would have been greatlyreduced if the city had been prepared.DEVELOPMENT OF CIVIL DEFENSE IN CALIFORNIA

Some of the outstanding principles for good civildefense are as follows:

1. Effective, adequate legislation.2. Self-help and mutual aid.

8

MEDICAL ASPECTS OF CIVIL DEFENSE

3. Organization.4. Education (enlightenment of the public and

the medical profession).5. Assignment of capable, interested persons to do

the job.California is fortunate in that excellent legislation

has been provided for civil defense. In 1929, theCalifornia Legislature passed an act creating a StateEmergency Council (Chap. 662, Statutes 1929)whose duty it was to prepare a general plan for themeeting of any great emergency occurring in thestate, such as floods, fires, tornadoes, earthquakes,pestilence, et cetera. Some of the major cities tookaction to provide for disaster councils and to lay thegroundwork for a disaster plan. Others soon fol-lowed this example.

In 1941 the Division of State and Local Coopera-tion of the National Defense Advisory Committee tothe Council of National Defense requested the Stateto provide legislative authority for a Council of De-fense; the Legislature on this recommendation cre-

ated the California State Council of Defense Act(Chap. 561, Statutes of 1941).The California Legislature passed the State War

Powers Act (Chap. I, First Extraordinary Session,1943) in January 1943. This statute, known as "TheCalifornia War Powers Act," defined the duties andresponsibilities of the state and its political sub-divisions with respect to civil defense.On June 25, 1945, the California Legislature filed

with the Secretary of State the California DisasterAct (Chap. 1024, Statutes of 1945) which becameeffective September 15, 1945. This has proved to bea noteworthy action since it preserved the benefit ofthe experience gained and maintained a statewideorganization to meet emergencies. The title and someof the principles of the 1941 act were changed, butthe basic principle of the entire state functioning asa unit to protect lives and property was continuedunder the "California Disaster Act." The Governorand his staff were given the duties and powers of theCalifornia State War Council and of the State Coun-cil of Defense.During the period from 1945 until the outbreak

of hostilities in Korea on June 25, 1950, more than200 cities and 45 counties adopted ordinances pro-

viding for "accredited disaster councils" as calledfor in the Act. Thus California was better preparedthan most states to resume civil defense activities.

In January 1950 the aircraft observers system was

instituted in California by the Federal Government.Twelve key centers were established in the state andabout 600 posts were located. On July 7, 1950, onlya few days after the Korea hostilities began, Gover-nor Warren established the California State CivilDefense Planning Board, composed of the heads ofall state departments and the chairmen of the advis-ory committees which had been in existence for a

period of five years under the California DisasterAct. In September 1950 the Legislature passed theCivil Defense Act of 1950.

Governor Warren called a meeting of the gover-nors of the three Pacific Coast states. With General

A. C. Wedemeyer, who was commanding general ofthe Sixth Army, they met and discussed civil de-fense in California and the western states. GeneralWedemeyer agreed to send three competent trainingand planning officers to each state to assist in settingup the civil defense program. During September andpart of October 1950, the three officers assigned toCalifornia assisted in the formulation of the civildefense plans and organization for the state. Theywere of great help.

In October 1950, Major General Walter M. Rob-ertson, U. S. Army (retired), former deputy com-mander of the Sixth Army under General Wede-meyer, accepted appointment as the California StateDirector of Civil Defense. General Robertson hasbeen very active in civil defense and has an organi-zation of over 100 persons.

During the 1950 and 1951 sessions of the Legis-lature all laws with regard to civil defense recom-mended by Governor Warren were enacted, whichbrought the California statutes relative to civil de-fense into conformity with every recommendationof the Federal government. Master mutual aid agree-ments, model ordinance for city and county, shelterliability, rescue and first aid, workman's compensa-tion benefits for volunteers, loyalty oath, et cetera,were covered in the statutes.

MEDICAL CIVIL DEFENSE FUNDS

A total of $12 million was appropriated by the1951 session of the Legislature for the State CivilDefense Program and, in addition, $75 million wasearmarked as available for emergency needs in theevent of an atomic attack. Of the $12 million, theamount set aside for the purchase of medical andhealth supplies was $3,167,000, provided the Fed-eral government would contribute $2 million formatching purposes. This would provide a total of$5,167,000.To date these monies have been expended as indi-

cated below:Requisitions placed with the Federal Civil Defense

Administration on FCDA forms Number 103, datedJuly 12, 1951:

Request No. 1, Aid Station Equipment......$ 333,135.00Request No. 2, Antibiotics .......................... 82,000.00Request No. 3, Plasma .......................... 1,003,756.00Request No. 4, Blankets .......................... 250,000.00

Total ......... ................. 1,668,891.00Transportation (5 per cent of above

total) ........... ............... 83,444.55

1,752,335.55Litters to be manufactured by Cali-

fornia correctional institutions at$14.25 each ................................... 356,250.00

Total all matched funds............... $2,108,585.55This would leave a balance of $3,056,414.45 forexpenditure. This balance consists of $1,166,000 freemonies since $1,000 of the free fund had been ex-pended for the purchase of a single sample aid sta-tion to be used in studying unitizing procedures andpackaging. Matching funds of this balance consistof $1,889,414.45, of which $1,044,000 has not been

January, 1952 9

CALIFORNIA MEDICINE

previously encumbered. The balance of this moneyconsists of surpluses from the original allocationsresulting from the lower prices obtained by purchas-ing locally or changes in price quotations. In addi-tion, it is proposed by the Division of Medical andHealth Services to use approximately $30,000 forpurchase of penicillin to supply aid stations. Thismoney will come from the $1,166,000 balance offree funds.The Medical and Health Services division will

follow recommendations made by the EmergencyMedical Advisory Committee and subcommittees topurchase plasma, antibiotics, morphine. additionalaid station supplies, sanitation supplies and supple-mental materials for aid stations, and to provide forunitizing and packaging costs, transportation, in-spections, et cetera, within the state and for ship-ment by the Federal government. In addition, a one-week supply of facilities and equipment for the pro-vision of whole blood will be purchased.

FEDERAL APPROPRIATIONS 1951

In 1951 approximately $75 million for civil de-fense was appropriated by Congress before it ad-journed. This money will be allocated as follows:$11 million for operational expense, $56 million formedical and health services and engineering sup-plies, and about $7,500,000 for matching funds forcommunications, fire fighting equipment, etc. Fromthe $56 million fund it is estimated that Californiawill receive between $5 million and $6 million formedical purposes.

The formula which has been used within Califor-nia for matching funds is as follows: If the Federalgovernment provides 50 per cent, then state shouldprovide 25 per cent and the local government 25per cent.

WHAT ARE WE PLANNING AGAINST?In California, plans are being made against eight

atomic bomb strikes, two in the San Francisco area,two in the Los Angeles area, and one each in SanDiego, Riverside, Fresno, and Sacramento.The estimate of casualties (eight strikes) is as

follows:Total casualties...-----------------... ............- 378,000Total requiring hospitalization: 66 % per cent

of 378,000 252,000Maximum number in hospital at any one

time: 75 per cent of 252,000...- . 189,000These strikes are considered as having occurred

at noon on a weekday.The number of first aid stations in the strike

regions will be calculated on the basis of one stationfor each 600 casualties. Additional aid stations (upto 10 per cent more, the number depending uponthe density of population) will be allotted to coverpossible casualties in personnel and equipment in-curred at the time of the explosion. At present, onlyfive aid stations will be provided for in the non-strikeareas. Each region should be told how many casual-ties it may expect and how many beds it shouldplan for.The selection and size of improvised hospitals and

the location and method of stockpiling first aid

equipment are the responsibilities of the regionalofficials. In planning for estimated bed requirements,the state has referred to improvised hospitals interms of 500 and 1,000 bed equivalents in orderthat planning for personnel and supplies will beuniform.

It has been recommended by the Medical Sub-committee of the Governor's Citizens Medical Advis-ory Committee that the minimum professional per-sonnel for these hospitals would be 35 physicians for500 patients (55 for 1,000), eight dentists for 500beds, and 70 nurses for 500 beds.The number of hospital beds and aid stations to

be assigned is as given below:Number of Hospital Beds To

Region* Be Provided by Each Region Aid Stations1 (non-strike) . 1,500 52 (non-strike) 1,500 53 . 70,500 2554 .- 11,000 395 (non-strike) ------------- 3,000 56 - 7,500 287 (non-strike) . 4,500 5

8 .5,000 189. 81,500 276

10 .13,500 47

10 - 199,500 683Total beds (strike regions) . 189,000Total beds (non-strike regions) 10,500

THE CALIFORNIA MEDICAL ASSOCIATION INCIVIL DEFENSE

The fundamental problem in civil defense is aquantitative one. Preparations must be made tomobilize and transport great numbers of medicaland allied personnel and enormous quantities ofmedical supplies to any major disaster area, and totransport, hospitalize, and furnish prompt treatmentto a tremendous number of casualties. Environmen-tal sanitation must be maintained as well as thesafety of the water, food, and milk supply. All thiswill have to be done under adverse conditions sincethere will be many professional casualties and muchmaterial damage. Also, plans must be made to dealwith radiation injury and chemical and bacterio-logical warfare.The proposed plan for the Medical and Health

Services Division in the California Civil DefenseOrganization assumes that it is the division's task toprovide for the augmentation of the services of theregularly constituted medical and health organiza-* Region 1.-Del Norte, Humiiiboldt, L,ake and AlendocinoCounties.

Region 2.-Butte, Glenn, Lassen, MIodoc, Plumiias, Shasta,Siskiyou, Te laiima, and Trinity counties.Region 3. Alameda, Contra Costa, 'Marin, Napa, San

Fi-ancisco, San AMateo, Santa Clara, Solano, an(d Sonomacounties.

Region 4.--Alpine, Ainador, Calaveras, Colusa, Eldorado,Ne\ d-a, Place, Sacramento, San Joaquin, Sierra, Stanis-laus, Sutter, Tuolunine, Yolo, and Yuba cotunties.Region 5.- Sonterey, San Benito, and Santa Cruz coun-

ties.Region 6.-Fresno, Kern, Kings, Madera, Mlariposa, Mcei-

ced, and Tulare counties.Region 7.-San Luis Obispo, Santa Barbara, and Ven-

tuira counties.Region 8.-Inyo, 'Mono, Rivet-side, and San Bernaidino

counties.Region 9.-Los Angeles and Orange counties.Region 10.-Imperial and San Diego counties.

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MEDICAL ASPECTS OF CIVIL DEFENSE

tions in order to make available on short notice theexpanded force of medical service and facilities thatwill be needed during the period of emergency. Thisplan outlines in detail the steps to be taken withregard to the emergency medical services, emer-gency public health services, and radiological safetyservices.

In June 1950, the National Security ResourcesBoard recomiiended to state governors that they ap-point their state health commissioners to be theirstate civil defense health service directors. It wasfurther recommended that local health commission-ers be placed in charge of local civil defense healthservices. Accordinugly, Governor Warren appointedDr. Wilton L. Halverson, the director of the Cali-fornia State Departmient of Health, as Director of theMedical and Health Services, and his agency vasgiven responsibility for development of the medicaland health plans of the State Civil Defense Program.

Shortly after the appointment of Dr. Halverson,the Governor appointed a Citizens Advisory Com-nmittee on Medical and Health Services to the StateDisaster Council. The State Disaster Council is thepolicy-making board in civil defense for the Stateof California and the board to which the Governorlooks for advice and recommendations.The appointment of the Citizens Medical Advis-

ory Committee greatly accelerated the civil defenseprogram, and information of the over-all state med-ical picture and unification of plans and procedureswas obtained in this way. This Medical AdvisoryCommittee is composed of representatives of theCalifornia Medical Association, the osteopathic,dental, hospital, nursing, and veterinary associa-tions, the drug trades, state and national publichealth services, American National Red Cross, fune-ral directors, water works, sewage disposal systems,the Sixth Army, Western Sea Frontier, Fourth AirForce, the universities, and others. This committeehas subcommittees and also an executive committeeto facilitate and coordinate its activities.The state of California has been divided into ten

regions for purposes of planning mutual aid. Six ofthese ten regions have been designated as target re-gions, and plans have been made accordingly. Underdisaster conditions but with less than a state of ex-treme emergency the line of command and controlextends from the Governor through the State Direc-tor of Civil Defense and stops at regional coordina-tors. The state civil defense organization will act toadvise, to assist and to coordinate disaster activitiesonly to the extent that lower political governmentsrequest such action. In a state of extreme emergencvthe line of command and over-all control extends tothe directors of civil defense of cities and counties.One of the main functions of the California Med-

ical Association in civil defense is to correlate itsactivities with those of the state and federal govern-ments and then to pass this information on to thelocal county medical societies.

In March of 1950 the Emergency Medical ServiceCommittee of the California Medical Associationwas reactivated. The chairman of this committee at-

tended the course on the medical aspects of atomicwarfare and the medical conference on civil defensegiven by the American Medical Association. The daybefore the outbreak of hostilities in Korea, this com-mittee adopted a planned course of action. On July11, 1950, the chairman was appointed as chairmanof the Citizens Advisory Committee on Medical andHealth Services by the Governor. On March 31,1951, the California Medical Association sponsoreda refresher course for all county medical societycivil defense committees. This meeting included rep-resentatives from the Federal government as well askey personnel from the state and local organizations.Additional refresher courses are planned.

In summary, it can be stated that the CaliforniaMedical Asspciation has:

1. Participated in atomic energy training coursesregarding medical aspects of atomic warfare.

2. Kept abreast of civil defense activities in thestate in meetings with the Citizens Medical AdvisoryCommittee and with the California Disaster Council.

3. Sent representatives to medical civil defenseconferences sponsored by the Council on NationalEmergency Medical Service of the American Med-ical Association.

4. Correlated its activities with those of dental,nursing, veterinarian, and other such organizationsthrough membership in the Citizens Medical Advis-ory Committee.

5. Scheduled lectures on civil defense at medicalmeetings.

6. Planned civil defense exhibits (soon to beavailable) for use at civil defense meetings.

7. Helped in the planning and organization of ablood and blood derivatives program. (The Califor-nia Medical Association has been very active in thisphase of civil defense.)

8. Taken part in radiological safety advisory com-mittee planning.

9. Arranged to conduct refresher courses forcounty medical civil defense committees.

10. Assisted in the preparation of the followingmanuals:

Manual for Emergency Field Treatment ofCasualties. This manual outlines standardizedtreatment procedures for use in the field. It willbe 4 x 6 inches in size and circulated to allinterested groups.

Hospital Disaster Plan Guide for ExistingHospitals. Recommendations for the organiza-tion of hospital facilities and personnel aregiven in detail.

Plan for Operation of a First Aid Station.Hospita.l Plan of Operation for Improvised

Hospitals.At no time has the California Medical Association

received any Federal funds for civil defense activi-ties nor is it planned to request any funds. Organ-ized medicine will do its job as it has always doneas a civic duty and as a representative of the freeenterprise system.

January, 1952 11

CALIFORNIA MEDICINE

In 1951 the House of Delegates of the CaliforniaMedical Association abolished the Emergency Med-ical Service Committee and formed a new standingCommittee on Military Affairs and Civil Defense.

INDIVIDUAL PHYSICIAN IN CIVIL DEFENSE

In California the county medical organizationshave appointed civil defense committees. These localmedical civil defense committees are working closelywith civil defense authorities in their area and can

expect help as needed from the California MedicalAssociation.

It is the responsibility of every physician:1. To be cognizant of the civil defense plan of his

local community and of the exact part he is to playin it. He must find out at once where he is to beassigned if a disaster occurs during the day or nightand how he will be notified. He should also be uti-lized according to his capability and his assignmentstation should be as close to his home or office as

possible.2. To assist actively and cooperate in the devel-

opment and execution of the civil defense program.

Many physicians seem unaware that there are localdefense plans in which they have a vital place. Aphysician who has not been assigned a civil defenseduty should immediately get in touch with his localmedical society.

3. To keep abreast of current civil defense litera-ture, particularly as it pertains to medicine. Physi-cians should study special simple treatment methodsfor burns, fractures, general first aid measures, prob-lems of radiation injury, etc.

4. To attend special lectures on civil defense sub-jects and keep in close touch with his local medicalcivil defense committee.

5. To encourage his patients to take first aidcourses. The minimum objective in California is forone member of each family to be trained in first aid.

A COUNTY MEDICAL CIVIL DEFENSE COMMITTEE

An excellent example of how medical civil defenseplanning has developed and is being carried out isthe work of the Los Angeles County Medical Asso-ciation Civil Defense Committee under the chair-manship of Dr. Frank Schade.

In 1947 a group of doctors who were members ofthe Medical-Dental-Nursing Veterans Association ofLos Angeles formed a special committee to considercivil defense problems in the event of war. Membersof the committee, who had seen havoc and destruc-tion during the past war and were alarmed becausenothing was being done in this country at the time,decided to meet once each month to discuss civildefense.

In July 1950, after the outbreak of hostilities inKorea, this committee was appointed as the civildefense committee for the Los Angeles County Med-ical Association. It began meeting for two hoursthree times a week to develop and coordinate civildefense activities in Los Angeles County. Specialnight meetings were also held. This committee was

also officially recognized by the county health officer,the city health officer, and the county director ofcharities as an advisory and coordinating committee.

Los Angeles County has been divided into areasand an area medical director with two alternates hasbeen assigned to each. First aid stations on the basisof one for each 5,000 population, and casualty col-lecting posts on the basis of one per 1,000 popula-tion have been set up. Approximately 400 first aidstations have been planned for.Upon the recommendation of the Los Angeles

County-Cities Civil Defense Regional PlanningBoard, a committee on public health and medicalservices was appointed. In addition to the Los An-geles County Medical Association there are represen-tatives from the Los Angeles County Dental Associa-tion, Osteopathic Association, Nursing Association,Southern California Pharmaceutical Association,Veterinary Association, Hospital Association, De-partment of Charities, County Health Departmentand City Health Department. This committee meetstwice each week at the headquarters of the Los An-geles County Medical Association. Transportation,sanitation, communications, improvising of hospi-tals, nursing problems, medical supplies, et cetera,are discussed in detail.

STATE DEPARTMENT OF PUBLIC HEALTH INCIVIL DEFENSE

There has been splendid cooperation and goodwill between the California State Department ofPublic Health and the California Medical Associa-tion in civil defense.Upon direction of Dr. Halverson, staff members

of the State Department of Public Health were as-signed on a full-time basis to develop medical andhealth planning for civil defense. In 1949 and 1950the major work was done by Dr.. Philip K. Conditassisted by Dr. James Ellis. Later Dr. Robert Dyar,Dr. Arthur W. Hollister, Jr., Dr. John Dement, Dr.Lester Breslow, Mr. Floyd Hartmen, Mr. Arve H.Dahl, and Mr. Frank V. Jones, Jr., Dr. James 0.Culver, Mr. Bohn Lendemann and Miss NormaWhiteside were and have been very active in fur-thering civil defense plans. X

At present, the staff of the Division of Medicaland Health Services consists of Dr. Frank L. Cole,Brigadier General, M.C., U. S. Army (ret.) as chief;Dr. W. Dalton Davis, Rear Admiral, M.C., USN(ret.), assistant chief, Medical and Hospital Branch;Dr. Byron J. Peters, Colonel, M.C., U. S. Army(ret.), assistant to Dr. Davis; Jack Kirkpatrick,hospital consultant, assistant to Dr. Davis; Arve H.Dahl, chief of Sanitation Section and executive offi-cer; Frank V. Jones, Jr., assistant chief of Medicaland Hospital Supply Branch.

Both Major General Walter M. Robertson, U. S.Army (ret.), the Director of Civil Defense in Cali-fornia, and Mr. Burton Washburn, executive secre-tary of the California Disaster Council, have beenmost understanding and sympathetic to organizedmedicine and of its work in civil defense.

1407 South Hope Street.

12 Vol. 76, No. 1