|OFFICE OF MEDICAL HISTORY AMEDD REGIMENT AMEDD MUSEUM|
ACCESS TO CARE
On July 27, 1775, the Continental Congress created a medical service for a 20,000-man army and named Dr. Benjamin Church of Boston as director general and chief physician. That year, Dr. John Jones of New York published the first American surgery text, a pamphlet titled "Plain, Concise, Practical Remarks on the Treatment of Wounds and Fractures." It was widely used in the war. Dr. Benjamin Rush, signer of the Declaration of Independence, ran a Continental Army hospital and wrote the first American preventive-medicine text for Army physicians. It was used until the Civil War. A historic first occurred in 1777, when George Washington ordered the inoculation of all Continental Army recruits to prevent smallpox. Never before had an entire army been immunized. And it worked. In 1778, Army doctors at Valley Forge published the first American pharmacopoeia, a 32-page list of medications. Dr. James Tilton built a well-ventilated, uncrowded Army hospital with isolation wards in 1779, influencing hospital design for decades.
Peace brought military cuts. In 1784, the Army had only one surgeon and four surgeon's mates. Yet there was progress: in 1812 the U.S. Army replaced smallpox inoculation with Jenner's safer cowpox vaccination. The Army began the War of 1812 with no medical department as such, but Congress created one in 1813 under Dr. James Tilton's leadership. After the war, the service shrank to five surgeons and 15 surgeon's mates, but lessons had been learned. In 1818, Congress included a permanent Army medical service in a military reorganization act. Dr. Joseph Lovell became the Army's first true surgeon general. Building on a Tilton initiative, Lovell ordered Army surgeons to keep weather records and investigate the relation of disease to climate. This was the first nationwide collection of weather data and eventually led to creation of the U.S. Weather Bureau.
In the 1820s, William Beaumont was base surgeon at Fort Mackinac near the Canadian border, an often violent frontier area. In June 1822, a Canadian named Alexis St. Martin was shot. His wound never fully healed, and for 10 years Beaumont peered into St. Martin's stomach to observe gastric digestion in progress. This was the first direct study of digestion and the first American physiological research. "Experiments and Observations on the Gastric Juices and the Physiology of Digestion" was published in 1833, to international scientific acclaim. It became a cornerstone of modern gastroenterology. In 1836, Lovell started a collection of medical and scientific books in Washington. Thus began the Army Medical Library, one of three great institutions the AMEDD created. Today it is the U.S. Public Health Service's National Library of Medicine, world's largest medical library. In 1840 the AMEDD published the country's first nationwide public-health statistics, based on records kept by Army doctors since 1819. In 1847 Congress authorized medical officers to receive military ranks for the first time. The existence of an organized medical system that crossed the nation contributed not only to creating knowledge but to its dissemination. A civilian, Dr. William T. G. Morton, demonstrated use of ether as an anesthetic at Massachusetts General Hospital in 1846. Within a year, the Army was using the gas for surgery at Vera Cruz in the Mexican War. As the country moved west, Army doctors saw the land with scientific eyes. Several made lasting contributions to the study of American birds. Not all was quiet out West. The first Medal of Honor action was by a young Army doctor named Bernard Irwin at Apache Pass, Arizona, in 1861. Irwin took command of troops and pursued Apache raiders led by Cochise. (The award was not created until 1863. Irwin received his in 1894.)
Medicine was not ready for the Civil War. Disease ravaged both sides. Improved weapons increased wound severity. Going to a hospital often meant death. There were attempts to reform the hospital system and improve hospital design. But good intentions were frustrated by a lack of information on hygiene and sanitation. Bacteriology was an infant European science. Louis Pasteur published his first paper in 1861, the year the Civil War began. George Sternberg, who later would lead the U.S. into the age of bacteriology and serve as Army surgeon general, was still just a young battlefield doctor. Yet there was progress, especially in evacuation of casualties. In early 1862 Congress expanded and reorganized the AMEDD, giving the Army surgeon general actual general-officer rank for the first time. That same year the AMEDD directed the keeping of detailed medical records, later compiled into a massive five-volume medical history of the Civil War—the first detailed history of war's medical effects. Jonathan Letterman, medical director of the Army of the Potomac, led epochal reforms: reorganized medical field supply, a system of forward hospitals, and an AMEDD-controlled ambulance corps. His field-hospital and ambulance evacuation ideas are followed in essence even today. In May 1862, Surgeon General Dr. William Hammond founded the Army Medical Museum in Washington, the second great AMEDD institution. Housed in six places over the years, including Ford's Theatre (where Lincoln had been shot), the museum was the base for Army medical research. In 1949 it became today's all-service Armed Forces Institute of Pathology. From 1864 to 1867, AMEDD officers working at the museum invented methods for taking photographs of bacteria through microscopes.
Lt. Col. John Shaw Billings was one of the most amazing people in U.S. medical history. He led the Army Medical Museum and Medical Library at the same time, publishing the first subject index to world medical literature. He later organized and directed the New York Public Library. He published writings on hospital hygiene, made recommendations that led to creation of the U.S. Public Health Service, and designed Peter Bent Brigham and Johns Hopkins Hospitals. As a Census Bureau consultant, he was first to suggest machine-sorted punched cards for recordkeeping. In 1889, he advised Herman Hollerith on the idea. Hollerith founded IBM. Later, Billings was professor of hygiene at the Ariality of Pennsylvania. True to form, he designed the building in which he taught. In 1887 Congress created the Hospital Corps for enlisted men, making the AMEDD a real enlisted career. (Earlier hospital orderlies had been borrowed from line units.) Though the Corps was abolished later, the idea of a professional enlisted medical force has continued growing. The third great AMEDD institution was America's first school of public health and preventive medicine. The Army Medical School opened in two rooms of the museum in 1893, with four part-time teachers. It later became the world-leading Walter Reed Army Institute of Research. Walter Reed, then a young officer, was one of its first teachers. Within a decade, he would be world-famous as conqueror of yellow fever. In 1896, six months after Roentgen announced the existence of X-rays, the Army Medical Museum used X-rays to find a bullet in a patient. X-rays would be used in field and hospitals in the next war, in 1898.
In the Spanish-American War, U.S. troops first crossed oceans to fight in places teeming with disease. Wounded totaled 1,581; typhoid cases, 13,770. Malaria, yellow fever and dysentery struck thousands. The war left the U.S. responsible for new lands—and their diseases. But bacteriology was now a science. George Sternberg, Civil War veteran and author of the first American bacteriology text (1892), was Army surgeon general. The AMEDD attacked the tropical diseases head-on. First Lt. Bailey Ashford showed that "Puerto Rican Anemia" was caused by hookworm. Since the same disease affected the southern U.S., his control and treatment ideas benefitted Puerto Ricans and Americans. Other Army physicians, research boards and commissions studied cholera, plague, dengue fever, malaria, beriberi and amoebic dysentery. But Maj. Walter Reed became the symbol of the whole effort. He had already led a typhoid board, which established the principle that line commanders are responsible for unit sanitation. But his great assignment was heading the 1900-1901 yellow-fever commission in Cuba. The researchers' heroic sacrifices captured the world's imagination. Officers, enlisted men, nurses and Cuban civilians exposed themselves to infection as volunteers in a human laboratory. Several died, but in only six months the team proved the disease was mosquito-borne. Soon this medical triumph had changed life in the tropics and indeed the economic and trade structure of the world. U.S. Army physician Col. William Gorgas, using Reed's research to fight malaria, made building of the Panama Canal possible. Gorgas later became Army surgeon general and received the first Distinguished Service Medal ever issued (1918).
As the 20th century began, the AMEDD was again restructured. New branches were added to the AMEDD, including the Nurse Corps. Women had long cared for U.S. soldiers. The 1775 law that created the AMEDD also allowed for employment of female nurses. Most were the soldiers' own untrained relatives. But they filled an important role. During the Civil War, women served in the hospitals of both armies. Dorothea Dix, famed for work with the mentally ill, was superintendent of women nurses for the Union Army. Clara Barton, founder of the American Red Cross, recruited volunteers. But the women's work remained conventional: preparing diets, housekeeping, distributing supplies. The Spanish-American War was different. Over 1,500 experienced, trained nurses signed up for war service. They were civilians with government contracts, not soldiers. But they went overseas; and those who died could be buried in Arlington Cemetery. A nurse, Clara Louise Maass, was among the volunteers who died in Reed's yellow-fever study. With the 1901 Reorganization Act, women nurses could really join the Army. Over 200 did. They still had no military rank. That wouldn't come until over 20,000 women served in the AMEDD in World War I—10,000 of them overseas. In 1922 Congress authorized "relative rank." Nurses wore officer insignia, but legally were still not commissioned officers. The same law that let women into the Army authorized appointment of contract dental surgeons. In 1908, dentists were admitted to the AMEDD; in 1911 a true Dental Corps was created; and in 1917 their status, pay and benefits were equalized with Army doctors. Later acts created the Medical Administrative Corps, Sanitary Corps and Veterinary Corps. Army veterinarians were responsible not only for military animals, but for the wholesomeness of Army food. This was preventive medicine. So was the new emphasis on sanitation. In 1910, Maj. Carl Darnall devised a way to chlorinate drinking water. Modifications of his method remain the basis of water purification all over the world today. Three years later, Maj. William Lyster invented the "Lyster bag" for field chlorination. Through the early 1900s, research boards in the Philippines studied diseases like rabies, cholera, plague, malaria, and amoebic dysentery. Working there, Lt. Charles Craig and Capt. Percy Ashburn proved that dengue, or "breakbone," fever was caused by a virus. Capt. Edward Vedder showed that eating partially milled rice could prevent beriberi. Back at the Army Medical School, Maj. Frederick Russell introduced antityphoid vaccination by injection of killed bacili in 1909. In 1911, immunization against typhoid was made compulsory for the Army. But AMEDD creativity was not limited to medicine. In the years spanning 1900, Army surgeons played vital roles in Army-wide reforms. Medical Corps Maj. Gen. Frederick Ainsworth became adjutant general of the Army and, based on methods he developed for medical records in the Office of the Surgeon General, revolutionized the Army's personnel records system. The essence of his record-jacket system survives today. Another doctor led the whole Army. Maj. Gen. Leonard Wood had earned the Medal of Honor in the Indian Wars, commanded the Rough Riders in the Spanish-American War, and been military governor of the Philippines and Cuba. Later he became Army chief of staff, developed the Officer Reserve Corps (based on the Medical Reserve Corps idea), ran for President, and ended his career as governor general of the Philippines.
Then the world blew apart. When World War One began, the AMEDD was ready as never before. And it was involved from the very beginning. The first U.S. officer killed was Lt. William T. Fitzsimons, a young doctor in a general hospital in France. Later on the same night, the first American enlisted man was killed—AMEDD Pvt. Oscar C. Tugo. Preventive medicine was a factor in victory. This was the first major war in which mortality from communicable disease was less than from battle wounds. The motor ambulance added a new level of mobility to the evacuation techniques established by Letterman. High death rates of Army pilots sparked study of aviation medicine. In World War I the Army began to treat venereal disease as a medical problem, not just a moral one. The Army had long punished VD victims. A 1778 law provided fines for soldiers hospitalized for VD. But punishment never worked. World War I policies brought the long-taboo subject into the open and laid the basis for later civilian campaigns against VD. In 1918 an AMEDD doctor, Maj. Reuben Kahn, developed the blood test for syphilis that remained the standard diagnostic tool for many years.
Between World Wars I and II, technology created new opportunities and new medical problems. The AMEDD worked to keep up with it all. In 1920, the Medical Field Service School opened at Carlisle Barracks, Penn., to train medical officers and enlisted medics in field medicine. In 1947 it moved to Fort Sam Houston, Texas, and grew into today's AMEDD Center and School. A former AMEDD officer, Dr. Hiram Orr, used World War I experience to develop a closed-cast treatment for compound fractures. Improved by a Spanish Civil War surgeon, his system saved thousands from infection. Lt. Col. C.H. Goddard's forensic-ballistic discoveries helped police (and mystery writers). He found ways to determine what make of gun had fired a bullet and whether a specific gun had fired a specific bullet. In the 1930s, Col. George Callender and MSgt. Ralph French studied the effects of high-velocity missiles. They found injury occurs beyond immediate wound sites, necessitating wider removal of tissue. Resulting improvements in surgical debridement markedly reduced gas gangrene, late infection and uncontrolled late hemorrhage. In 1922, Army dentist Capt. Fernando Rodriguez isolated the bacteria found in cavities and laid the basis for modern preventive dentistry. Veterinary Corps Maj. Raymond Kelser developed vaccines against rabies and rinderpest. An team in Panama, led by Col. Joseph Siler, performed the first controlled clinical studies of marijuana use by soldiers. Malaria was still the world's most prevalent disease, and quinine the only treatment. In the 1930s, the AMEDD tested a German synthetic drug called atabrine. It didn't prevent infection but only suppressed symptoms so long as it was taken. But during World War II, when the Japanese cut off quinine supplies, atabrine was a valuable substitute. Maj. Harry Armstrong and Dr. John Heim at the Aeromedical Lab at Wright Field, Ohio, built the first centrifuge to test acceleration effectson humans in 1936. Armstrong later published an aviation-medicine text and became the Air Force surgeon general. The Army Medical School began blood-product studies that continued through World War II. Results included kits for sterile collection of donated blood; a system for mass collection/shipment of plasma; progress on a system to collect/refrigerate whole blood for shipment overseas; and production of standardized kits for rapid blood-typing.
In World War II, American troops fought all over the globe, exposed to every climate, disease and weapon known to man. Out of this war came tremendous medical and surgical advances. New drugs, such as penicillin, revolutionized medical practice. In 1942, at the Army Medical School, Lt. Col. Harry Plotz found a way to restore the lost potency of typhus vaccines, sparing U.S. troops from the age-old plague of armies. The U.S. Typhus Commission, a military/civilian group, attacked that plague worldwide. Under its leadership, DDT insecticide and the improved vaccine drastically cut typhus. Its most dramatic victory: nipping a dangerous epidemic in the bud in Naples in 1943. "Shell shock" and "battle fatigue" received unprecedented study, as did other psychiatric problems—with emphasis on outpatient care. Research labs studied the effects of climate and developed clothing and behavior rules to protect soldiers from cold and heat injuries. Mass penicillin production was achieved, and the lifesaving miracles of antibiotics were first proven on North African battlefields in 1943. New methods emerged for fast treatment of wounds and shock. The need for whole blood, rather than plasma, in surgery was proven. Whole blood revolutionized traumatic surgery. In 1944 Army dentist Capt. Stanley Erpf developed a lifelike acrylic-plastic artificial eye. In 1945, Capt. Edwin Pulaski established a medical research unit at Halloran General Hospital, Staten Island, N.Y., to study antibiotic use in surgery. In 1947, the unit moved to Fort Sam Houston, Texas, where—working with Brooke General Hospital (now Brooke Army Medical Center)—it would become the Institute of Surgical Research, a world-renowned burn center and pioneer of burn treatments. The Nurse Corps grew remarkably in size and prestige, peaking at over 57,000. In 1944 Congress granted nurses temporary commissions with true officer status. (In June 1947 Col. Florence A. Blanchfield become the first woman to hold a permanent Army commission.) In 1943, Congress authorized the commissioning of female military doctors for the first time, though only for wartime service. Black physicians, nurses and medics also struggled for a fair and equal opportunity to serve, and—against heavy tides of social custom—much progress was made. This helped lay the groundwork for the equal-opportunity AMEDD of the postwar world. But above all, World War II was a story of heroism, service and sacrifice by 600,000 medical men and women—an AMEDD larger in size than the entire U.S. Army today. Hundreds of thousands of soldiers owed their lives to what those men and women did.
In 1946, the Army launched formal residency programs to develop its own medical and surgical specialists in an AMEDD environment. Decades of experience show that Army-trained specialists are more combat-ready and more likely to stay in the Army. Over the years more advanced training programs were established, including programs for dentists and nurses. In 1947, Congress created the Medical Service Corps to absorb the Medical Administrative Corps, Sanitary Corps and Pharmacy Corps. The MSC today is the corps of medical administrators, scientists and certain health-care specialties. The same year, Congress created the Women's Medical Specialist Corps for commissioning of dietitians and therapists. Later men were admitted and the word "Women's" was replaced with "Army." In 1947 the Air Force became an independent service. Two years later, the medical portion of the transition took effect with the creation of an independent Air Force medical service. In 1949, practical nurse training was introduced for advanced enlisted medical specialists. But "after the war" didn't last long. Within less than five years, American troops were fighting in Korea. Weather was a big enemy here. An AMEDD research team studied cold injuries and the effect of protective clothing. AMEDD and Quartermaster Corps experts together perfected lightweight body armor that reduced wound severity for ground troops. Progress was made in vascular surgery to reduce amputations, and an artificial kidney was brought to the war zone to save renal-failure victims. But the biggest advance came in the air. In 1951, the first helicopter ambulance unit began operations in Korea. Now a wounded man could reach a sterile, fully-equipped hospital in minutes. By war's end in 1953, over 17,000 casualties had been airlifted by helicopter. This spawned improvement in helicopters and further refinement of aeromedical battlefield evacuation in Vietnam. In Japan, AMEDD researchers determined that prolonged bed rest was rarely necessary for recovery from hepatitis. This reduced patient discomfort and saved resources in military and civilian hospitals. Back in the U.S., a hospital administration course began at the Medical Field Service School. Through a Baylor Ariality partnership, graduates earned a master's degree. The program continues to this day. In the late 1950s, Walter Reed Army Institute of Research experts invented a compressed-air "jet" system for needleless vaccinations. It is used for mass immunization of trainees and civilian disaster victims. In 1957 Walter Reed Army Institute of Research isolated the virus causing Asian influenza, leading to a commercial vaccine development. In 1958, the AMEDD helped publish the first issue of NATO's manual, "Emergency War Surgery." That year, Army and Navy medics collaborated on the "Able" and "Baker" suborbital flights by primates, which collected physiological data that enabled humans to travel safely in space. In 1959, Maj. Harold Williams conducted pioneering experiments on sleep deprivation. In 1960, Army researchers led by Col. Trygve Berge developed a safe vaccine for Venezuelan equine encephalitis. A decade later this stopped VEE when it spread north from Mexico, endangering horses and people. In the same year, the AMEDD field-tested a "better mouse trap" for malaria, the once-a-week combination tablet of chloraquine diphosphate and primaquine, which not only suppresses attacks but prevents relapses. In the early 1960s, the Army built 11 new and modern hospitals at posts across the country. In 1961 the AMEDD started formal aviation-medicine training at Fort Rucker, Ala.
In Vietnam, efficiency and speed were enhanced by the MUST (medical unit, self-contained, transportable), a sort of "instant" hospital that could be moved by truck or aircraft. The inflatable rubber shelter had its own electrical power, air conditioning, heating, water supply and waste-disposal system. Replacing tents, it improved patient care and comfort. The first arrived in Vietnam in 1966. Noncombatant medical people worked "under fire" in Vietnam as a matter of course. Several Vietnam medics joined their predecessors from earlier wars in winning the Medal of Honor for lifesaving heroism. Away from the battlefield, research continued. Sulfamylon, an antibacterial cream developed at the U.S. Army Institute of Surgical Research, at Brooke Army Medical Center, Texas, resulted in a 50-percent reduction in burn fatalities due to infection. Advanced procedures in physical and occupational therapy were used by the Army Medical Specialist Corps. In 1966 an Army lab developed a more dextrous and more natural-looking artificial hand. In 1966 osteopathic physicians were admitted to the Medical Corps. In the late 1960s, the AMEDD developed a new adenovirus vaccine that cut respiratory infections in trainees and field-tested the use of gamma globulin in overseas troops, finding that gamma globulin injections give significant protection against hepatitis but not most other infections. A 1967 law removed limits on promotion of Army Medical Specialist Corps and Army Nurse Corps officers, equalizing the promotion and retirement rules of these mostly female corps with other AMEDD corps. The next year, Congress ended an 18-year experiment in calling Army Medicine the "Army Medical Service," which had caused as much confusion as it cured. The historic term "Army Medical Department" was revived. In 1969-1972, the U.S. Army Institute of Dental Research modified the dental "water pick" into a sophisticated surgical tool. The tool's pulsing water jet removes (debrides) dead tissue and bacteria faster and with less damage to healthy tissue than scalpel and forceps. Later, by adding detergents/disinfectants to the water stream, the machine also became a much faster method for cleaning surgical teams' hands. In 1970, Army Nurse Corps Chief Anna Mae V. Hays was promoted to brigadier general. She was the first female general in Army history. MAST (Military Assistance to Safety and Traffic) saved civilian lives by using military helicopters to rush accident victims to trauma centers. Once the military had proven the concept, civilian helicopter-ambulance organizations soon developed. Malaria, still the world's leading cause of death, continued to be studied. Dapsone, a medication proved effective with strains of malaria resistant to quinine or atabrine, is one achievement of this program. Rubella vaccine to control German measles, produced by the National Institutes of Health in 1969, was derived from a virus strain isolated by Army physicians at Fort Dix in 1962. The Fort Dix doctors used techniques pioneered by Walter Reed Army Institute of Research. Dr. Malcolm S. Artenstein, one of the young Army medical officers involved in the 1962 Fort Dix effort, was a member of a 1970 team that developed a vaccine to prevent meningitis epidemics in Army camps. In 1969, the U.S. Army Medical Unit at Fort Detrick, Md. (created in 1956 to find ways to defend against biological-war agents) was renamed U.S. Army Research Institute of Infectious Diseases (USAMRIID). USAMRIID has helped defeat several famous disease outbreaks, e.g., Ebola virus. In 1971, Lt. Col. Charles Angel developed the first urinalysis lab for heroin testing. The system was later expanded to other drugs and adopted for civilian use. In 1972, Army veterinary personnel worked with Air Force vets and civilian officials to contain a dangerous California poultry epidemic. (Later the Army absorbed the DoD veterinary mission, and the Air Force ended its veterinary service. Some Air Force vets joined the Army.) In 1973, the Academy of Health Sciences (now part of the AMEDD Center and School) at Fort Sam Houston, Texas, graduated the first class of Army physician assistants. The graduates got warrant officer rank and associate of science degrees from Baylor Ariality. Baylor also certified 25 enlisted medic courses for college credit. The dental therapy assistant and advanced medical laboratory procedures courses conferred associate of science degrees from Baylor.
In 1973, as part of a massive Army reorganization, stateside Army hospitals were unified under a new entity called U.S. Army Health Services Command (HSC). This ancestor of today's U.S. Army Medical Command (MEDCOM) was headquartered at Fort Sam Houston, Texas. It had 50,000 military and civilian members and provided a single manager for the Army's entire stateside health-care delivery and education system. HSC initially had seven Army Medical Centers (MEDCENs); Valley Forge General Hospital, Pa.; and the Academy of Health Sciences. It soon took control of 37 Medical Department Activities (MEDDACs) or installation medical units (usually one hospital plus other medical elements), which ha previously been commanded by post commanders. As Vietnam wound down, HSC organized the new medical system and closed several hospitals, including historic Valley Forge. But HSC's area expanded with the addition of Tripler Army Medical Center, Hawaii, and MEDDACs in Alaska and Panama. In mid-1974, HSC launched a regional system to control subordinate hospitals through MEDCENs.
As inflation slammed the nation and the Army shrank after Vietnam, HSC endured three years of shortages in dollars and physicians, in 1976-1979. By 1978, over 20 percent of physicians were gone. When HSC was formed in 1973, it had 2,300 physicians and 2.9 million beneficiaries. By 1978, it had under 1,700 doctors serving 3.1 million beneficiaries. HSC curtailed service and closed some hospitals. It had to contract for civilian physicians, while cutting other civilian jobs. But progress was made. In 1975, Army medical laboratories were reorganized under MEDCENs. Environmental resources were assigned to the Army Environmental Hygiene Agency. A new Army Medical Center named for Dwight David Eisenhower was dedicated at Fort Gordon, Ga. There was no lack of action. In 1976, HSC filler personnel deployed to Guatemala to aid 700 victims of an earthquake. In June 1977, HSC headquarters elements, previously scattered among more than a dozen locations at Fort Sam Houston, consolidated into one building across the street from the Academy of Health Sciences. In 1978, HSC's dental system was reorganized into 37 Dental Activities (DENTACs) with commanders reporting to HSC Headquarters. A new, ultramodern Walter Reed Army Medical Center was dedicated. HSC played a key role in implementing the 1979 Panama Canal Treaty. HSC assumed responsible for supplying a total health-care system for the former Canal Zone, taking over from the old Canal Zone Health Bureau. In the 1980s, physician recruiting rose. Services were restored to a growing beneficiary population of 4.1 million. Massive construction programs replaced many outdated hospitals and clinics. HSC in 1980 established Soldier and NCO of the Year competitions. Spec. 5 Rick Bazzetta and SSgt. Paul Taylor won the initial awards. The National Training Center at Fort Irwin, California, was established and HSC assumed command of the hospital. In May 1980, HSC personnel begin providing care for Cuban refugees at Fort Chaffee, Ark.; Fort McCoy, Wisc.; and Fort Indiantown Gap, Pa. That year HSC veterinary personnel assumed a worldwide mission, as the Army began a three-year transition to become sole agent for Defense Department veterinary activities. HSC vets were now responsible for more than 500 defense agencies and activities. HSC increased its medical field training and had responsibility for the new combat casualty care course, better known as C-4, a triservice combat medical field training exercise at Camp Bullis, near San Antonio. In 1982, the Basic Medic Course expanded from six to 10 weeks. The medic career field was enhanced by creation of a course for NCOs. The civilian military contingency hospital system, later called the National Disaster Medical System, was introduced. It enlisted civilian hospitals to augment the military system in case of war. By its 10th year, HSC was maturing. In 1983, its hospitals treated patients from the bombing of a Marine barracks in Beirut and later they cared for casualties from Operation "Urgent Fury" in Grenada.
With maturity came scrutiny. Some unfortunate medical misadventures gained national notoriety. HSC took a close look at itself and resolved to change. In 1984, leaders published a formal strategic plan including a set of command values and innovation goals to give everyone in HSC something to focus on. Seminars, videotapes and pamphlets enhanced health workers' awareness of customer service. Innovation became a byword. HSC became a forward-thinking command, setting its own destiny with strategic planning at all levels. HSC engaged in cooperative efforts with other services. In 1987, Brooke Army Medical Center joined Wilford Hall Air Force Medical Center to form San Antonio Joint Military Medical Command under DoD control. (This experiment ended in 1991, and BAMC returned to HSC control.) Other joint-service efforts were initiated in the Delaware Valley (affecting the Fort Dix, N.J., MEDDAC) and the San Francisco Bay area (affecting Letterman Army Medical Center). But these were cooperative ventures that did not remove Army facilities from Army control. Contract care hit a new level in 1987 with creation of 10 PRIMUS (Primary Medical Care For Uniformed Services) clinics under HSC control. These were civilian-staffed clinics in areas where Army families lived. Military medicine was searching for better ways of doing business and serving beneficiaries. Ideas for improving CHAMPUS (Civilian Health and Medical Program for the Uniformed Services) were tested. A four-year CHAMPUS Reform Initiative began in California and Hawaii in mid-1987. Regional contractors assumed financial responsibility for all CHAMPUS care for a fixed price. A year later, MEDDACs at Fort Carson, Colo., and Fort Sill, Okla., launched a different kind of CHAMPUS reform test called catchment-area management. In this system, military hospital commanders managed CHAMPUS funds for their areas and got more leeway in how to spend money. In 1988, a contract was let for the first Composite Health Care System (CHCS) test site at Fort Knox, Ky. CHCS is a comprehensive computer system for military hospitals, a step toward the goal of a paperless hospital. CHCS is now in all military hospitals. As the AIDS epidemic continued, HIV testing became routine for Army members in the 1980s. In the late 1980s, Army Medicine responded to natural disasters. When the east coast was severely damaged by Hurricane Hugo, when San Francisco was rocked by a devastating earthquake, HSC facilities responded promptly with medical and veterinary support. HSC continued to push innovation. The command received the prestigious civilian 3-M Health Care Forum Award for Innovation.
Yet, as the Berlin Wall fell and the nation sought a peace dividend, innovation was no guarantee of survival for HSC. In 1990, the defense budget proposed transferring HSC's mission to Forces Command. That plan ignored painful historical lessons on the need for medical people to manage Army Medicine, the very lessons that had created HSC. A worried Army surgeon general sought and received permission to propose alternatives that would preserve medical control of medical assets. Meanwhile, HSC again faced personnel shortages, especially nurses. But, in December 1989, all else took a back seat as HSC supported Operation Just Cause in Panama. HSC sent 58 people to help Gorgas Army Community Hospital and field medical units. For the first time, some wounded men were flown straight from the battlefield to Army hospitals in the U.S., arriving still in their muddy battledress. In August 1990, Operation Desert Shield kicked off and Army Medicine responded with speed and dedication. HSC medically processed deploying troops and sent 4,000 of its medical people overseas to help, under the Professional Officer Filler System (PROFIS). Some of them helped fill medical units deploying to the Gulf, while others served in Europe to "backfill" hospitals there that had sent people to the Gulf. Despite these burdens, the Army chief of staff ordered that care for soldiers' families not be cut. People were shuffled among HSC hospitals to balance staffing. Hundreds of Reservists and retirees came on active duty to backfill overloaded HSC facilities. The challenge was met. HSC was poised to handle thousands of casualties. Fortunately, the rapid victory over Saddam Hussein produced few American wounded. In the early 1990s came BRAC (Base Realignment and Closure), a system to cut the post-Cold War military infrastructure. Letterman Army Medical Center in San Francisco was downsized, then closed. Other medical facilities followed as historic posts like Fort Sheridan, Ill., and Fort Devens, Mass., closed or converted to Reserve Component use. The Army hospital at Fort Dix, N.J., was transferred to the Air Force. The early 1990s resembled the late 1970s, with budget cuts, a civilian hiring freeze, and Army downsizing. Yet modernization continued. Madigan Army Medical Center at Fort Lewis, Wash., moved into a state-of-the-art, high-technology facility. In 1992, Maj. Gen. Alcide M. LaNoue became the first HSC commander named as Army surgeon general and was promoted to lieutenant general. Brig. Gen. John J. Cuddy became interim HSC commander, the first dental officer to lead a medical command.
As the post-Cold War Army shrank, it was time for a new way of doing business and business was the way. HSC would operate like a corporation. In 1992, HSC launched Gateway To Care, a businesslike approach to health-care delivery. It was localized managed care, intended to give quality care with better access and less cost. In a design based more on catchment-area management than CHAMPUS Reform Initiative, Army hospital commanders got more responsibility and managerial authority. Eleven Gateway to Care sites opened in spring 1992. By fall, all HSC facilities had submitted business plans. Initial results were excellent. Starting in 1994, Gateway To Care was gradually absorbed into a new regional Defense Department triservice managed-care plan called TRICARE, which was modeled on the CHAMPUS Reform Initiative. Meanwhile, healing work continued. Hurricane Andrew slammed south Florida. Army troops moved to assist and Army Medicine was there. From early 1993 to early 1994, HSC people participated in Operation "Restore Hope" supporting American troops in Somalia. Now the AMEDD's effort to "heal itself" by becoming more efficient and forestalling the break-up of medical unity bore fruit. In August 1993, the Army chief of staff approved a plan to reorganize the AMEDD. Heart of the plan was to merge several medical elements into a new, expanded medical major command under the command of the surgeon general. In October 1993, the U.S. Army Medical Command (Provisional) began a one-year process of replacing HSC and absorbing other AMEDD elements. Surgeon General Lt. Gen. Alcide M. LaNoue commanded the provisional MEDCOM, while Maj. Gen. Richard D. Cameron continued as HSC commander. In November 1993, U.S. Army Dental Command (DENCOM) and U.S. Army Veterinary Command (VETCOM) were formed as provisional commands under the MEDCOM, to provide real command chains for more efficient control of dental and veterinary units—the first time those specialties had been commanded by the same authorities who provided their technical guidance. Next month, seven MEDCEN commanders assumed command and control over care in their regions. The new Health Service Support Areas, under the MEDCOM, had more responsibility and authority than the old HSC regions. In March 1994, a merger of Medical Research and Development Command, Medical Material Agency and Health Facilities Planning Agency created the Medical Research, Development, Acquisition and Logistics Command, subordinate to the provisional MEDCOM. The command shortly got a new and less formidable moniker: Medical Research and Materiel Command. Then in June 1994, an additional HSSA was formed to supervise medical care in Europe, replacing 7th Medical Command which inactivated. That summer, the Army Environmental Hygiene Agency formed the basis of the provisional Center for Health Promotion and Preventive Medicine. Bit by bit, Army Medicine was coming together in a new home under the command of the same man who was the surgeon general—unifying the leadership and management of Army Medicine more than ever before. Except for the field medical units commanded by combat commanders, virtually all of Army Medicine as now part of the MEDCOM. The MEDCOM became fully operational, dropping the "provisional," in October 1994. In 1996, the HSSAs were renamed Regional Medical Commands.