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HUMAN BLOOD IN NEW YORK CITY: NOW* AARON KELLNER, M.D. Executive Vice President Community Blood Council of Greater New York New York, N.Y.
THE report of the Academy's Committee on Public Health, entitled Human Blood in New York City, contained a coldly factual and completely objective description of the blood situation in New York City as it existed in 1956. This kind of a report was precisely what was wanted and needed as a basis for the development of an effective, efficient blood organization. In simpler and more realistic terms, the report was a horror story-with New York as perhaps the worst possible example of a community's organization of its blood resources. Since 1956 that situation has changed drastically, as I shall show. We have not solved all the problems-by its very nature this is a dynamic and ever-changing undertaking-but we have created a mechanism for solving the problems. We have created something special and unique. "We" refers specifically to the Committee on Public Health of the Academy, since in a real sense the blood program we have in New York today is a child of this committee. I invite those of you who have not visited your child lately to come and see it. There is nothing like it anywhere else. To carry the story forward from where Dr. August H. Groeschel left it, in the late 1950s the Community Blood Council of Greater New York was formed. It is a private, nonprofit, membership corporation chartered in the state of New York. It has two kinds of members: delegate members and individual members. Originally there were 18 delegate members representing professional and community organizations interested in community health services, blood resources, and related activities, and an approximately equal number of individuals representing the community-people distinguished in business, banking, or medicine who were interested in *Presented at a meeting on Human Blood in New York City: Then (1956) and Now (1975) held by the Committee on Public Health of the New York Academy of Medicine November 3, 1975. Address for reprint requests: Community Blood Council of Greater New York, 310 East 67th Street, New York, N.Y. 10021
Bull. N. Y. Acad. Med.
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creating a blood center for our area. Among the organizational members was the New York Academy of Medicine, and to this day the Academy's first and only delegate to the council's board of directors has been Dr. Peter Vogel. The original charter established the Community Blood Council simply as an advisory body; so we sat around and advised for two or three years-and nothing happened. Indeed, the situation got worse. The Academy's report states that 45% of the blood transfused in New York City in 1956 was obtained from "commercial sources," a euphemism for skid row blood banks; much of this blood came from derelicts in the Bowery area. In 1962 another survey showed that 65% of the blood used in New York City came from the same commercial sources. At that time it was agreed that something had to be done; the council's charter was changed so that it could implement the Academy's second recommendation, that "the community blood organization set up and operate a community blood center." We recruited a group of eight distinguished physicians and scientists from various parts of the country and formed the council's Scientific Committee. Among its members were Richard Rosenfield from the Mount Sinai Hospital here in New York, a colleague of Dr. Vogel; Henry Kunkel; Elvin Kabat; James Tullis from Harvard University; and Scott Swisher, who was then at the University of Rochester and is now professor and chairman of the Department of Medicine at the Michigan State University College of Medicine. The Scientific Committee sat down to figure out what should be done next-and quickly decided that it did not want to establish a supermarket for blood. We recognized this as an unprecedented opportunity to create something excitingly new and different. The program obviously had to meet the needs for blood, but we wanted it to have an intellectual dimension: to be concerned with health in the broad sense. The council had to take the collection of blood out of the hands of social workers and businessmen and bring it back into the realm of medicine and science. The program had to be connected closely with the care of patients. It had to be involved in teaching at all levels and it had to be engaged in research. With those broad principles as a guide, we drew up a 10-year plan of action which is being realized progressively. With our goals clearly defined, we determined to raise the large sum of money needed to achieve them and to do the job properly. With strong community support we raised more than $6 million in 1963-1964. The Vol. 53, No. 2, March 1977
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money came from foundations in New York City such as the Commonwealth Fund, the Andrew W. Mellon Foundation, and the Rockefeller Brothers Fund, and from major corporations in New York such as the Consolidated Edison Company, the New York Telephone Company, International Business Machines Corporation, Chase Manhattan Bank, and similar large, community-minded organizations. Since 1964 we twice have gone back to these same organizations and to the community at large for additional help, raising a total of approximately $12 million. These constituted our capital resources. We then looked for a building which we could afford, close to a major medical center. It had to be where we could attract the kind of staff we would need for the innovative blood center we were committed to create for New York. It had to be close to centers of patient care and medical research, and where educational opportunities, scientific resources, and libraries were readily available. Our real estate committee looked at a number of buildings in various locations and finally recommended a building at 310 East 67th Street in Manhattan which at that time was occupied by a trade school, the Vorhees Technical Institute. We bought the building toward the end of 1963. In 1964 we moved in. We had no staff, no equipment, and not a single unit of blood. But we had some strong, resourceful, and determined support-and we had some money in the bank. I shall bypass all the storm and strife of the intervening 11 years and describe what we have today. The New York Blood Center is not merely a blood center, but a new kind of regional health facility, with a staff of more than 900 people. We are the largest collectors of blood in the world. We have a burgeoning research program, a regional transplant program, and a variety of educational activities. Our budget for fiscal year 1975 totalled approximately $35 million, and our income equalled our
expenditures. The Community Blood Council of Greater New York consists of five separate operating programs supported by a central core of administrative services. The headquarters for all of these programs and supporting services are in the New York Blood Center. These programs include: 1) The Greater New York Blood Program 2) The Blood Derivatives Program 3) The New York-New Jersey Regional Transplant Program 4) The Educational Program 5) The Research Program Bull. N. Y. Acad. Med.
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THE GREATER NEW YORK BLOOD PROGRAM
The name of The Greater New York Blood Program was adopted in 1968 when the Community Blood Council and the American Red Cross in Greater New York merged their blood-bank facilities. For the purpose of this presentation, I shall refer to it simply as the Blood Program. The Blood Program (as well as our Transplant Program) serves New York City, all of Long Island, the lower Hudson River valley, and northern New Jersey. In this area we are the principal provider of blood. We supply approximately 75% of the blood used in New York City; a dwindling number of commercial blood banks continue to operate in the city; they will probably disappear in a year or two. We are the sole suppliers of blood for Long Island and the lower Hudson River valley. In northern New Jersey we are one of four nonprofit community blood banks which provide all the blood used in that area (almost no "commercial" blood is used in northern New Jersey). In the area covered by our Blood Program the annual need for blood totals approximately 700,000 units. The Blood Program operates a number of facilities in fixed locations, including the following: The New York Blood Center on East 67th Street (our headquarters building), the headquarters building of the American Red Cross in Greater New York located on Amsterdam Avenue at West 67th Street (where many of the Blood Program's activities are located), a donor center in the World Trade Center in lower Manhattan, a facility on Long Island, and a facility in New Brunswick, N.J. However, most of our blood (approximately 75% of the total) is collected by mobile units which are set up in factories, office buildings, churches, schools, and similar locations. A great deal of painstaking effort goes into the organization of mobile blood collection. The Blood Program employs 35 full-time field representatives who visit business, labor, religious, community, and other organizations and work with their personnel to establish donor groups and make arrangements for scheduling blood collections. Mobile units vary in size from those handling 100 donors in a single operation to several thousand donors over a period of two or three days. An example of the latter is the collection at the U.S. Military Academy at West Point, where we draw blood from as many as 1,000 donors each day for three days. This operation is capable of bleeding 50 donors at a time in the military academy's large gymnasium and is accomplished with the precision so characteristic of West Point. The Community Blood Council started to collect blood in 1964; it drew Vol. 53, No. 2, March 1977
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a total of 3,000 units that year. In each of the following years blood collections increased substantially. In 1968 the Community Blood Council's blood program merged with that of the American Red Cross to form The Greater New York Blood Program, which is operated by the Community Blood Council. The Red Cross has five members on the board of directors of the Community Blood Council and a member on its executive committee. The day-to-day operation of the Blood Program and its staff are under the jurisdiction of the Community Blood Council. The merger has worked out well and the Blood Program operates to the mutual satisfaction of the two organizations-as the increase in blood collections each year since the merger shows. In 1970 the Blood Program was the second largest collector of blood in the United States. In 1971, 1972, and 1973 it was the largest collector of blood in the United States. In 1974 the Blood Program established a world record by collecting almost 450,000 units of blood. No other city in the world-not London, Paris, or Moscow-even came close to that figure. Last winter we estimated that during fiscal year 1975 (May 1, 1975 to April 30, 1976) we would collect 550,000 units. We actually collected 561,000. Most of the blood we draw is not collected in a single plastic bag, but in multiple bags; these are sets of two, three, four, or sometimes five bags connected by plastic tubing in a closed system so that the whole blood drawn in the first bag can be separated readily and without danger of contamination into its various components, including red blood cells, platelets, leukocytes, and plasma. The plasma may be utilized as such or it may be converted into derivatives such as fresh frozen plasma, clotting factors, albumin, and gamma globulin. A shuttle service is set up to rush the whole blood from the mobile collection sites to our laboratories in New York City by station wagon and, on occasion, via helicopter. This is necessary because certain components deteriorate so rapidly; for example, platelets and Factor VIII have to be separated within four hours of collection. Wherever possible, we try to get donors in Manhattan to come to the Blood Center or to the Red Cross building or to the collection station in the World Trade Center. Bleeding the donors at these fixed locations is not only more economical, it facilitates the separation of the whole blood into its many useful components. We now bleed an average of 1,500 donors per day and more than half of this blood is used for the preparation of blood components. The separation of whole blood into its components is accomplished by placing the multiBull. N. Y. Acad. Med.
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ple bags in special centrifuges, spinning them down, and squeezing off the plasma. The basic procedure is repeated several times with minor modifications. When a quintuple bag is used, the end result is five separate bags, each containing one of the following components: 1) red blood cells, 2) leukocyte concentrate, 3) platelet concentrate, 4) fresh frozen plasma (yielding cryoprecipitate or Lyoc), and 5) residual plasma (from which albumin and gamma globulin are derived by fractionation). The demand for various blood components has increased astonishingly during the past 10 years. For example, in 1964 the transfusion of platelets was almost unheard of. We began to prepare platelets for therapeutic use in 1965; at that time it was unusual if 50 units of platelets were required in a month. This year we shall make approximately 10,000 units of platelets per month and even that number will not meet the total demand. The demand for platelets exceeds our capacity to make them, yet no other blood center in the world produces nearly that number. This is because of our location in the middle of an area that includes 10 medical schools and numerous major hospitals where platelets are used extensively in the treatment of leukemia and other types of malignant disease. In addition, we are now facing the increasing use of granulocytes for transfusions. Our Blood Program has taken the lead in the automation of laboratory procedures involved in the processing of blood. Our Groupamatic 360 machine was the first of its kind to be put into routine operation in the United States. This automatic blood typer does the routine blood-group serology on 360 units of blood per hour, performing 12 separate tests on each unit; it records the results of these tests, interprets the data, and enters the information in the computer. The machine, which costs a quarter of a million dollars, is in daily operation at the Blood Center. Any blood center desiring to use such a machine must first obtain permission from the Food and Drug Administration (FDA). The New York Blood Center was the first to obtain that permission; any other blood center wishing to use this equipment will be able to do so on the basis of our experience and resultant certification. The machine works on a principle different from that of the well-known autoanalyzer. Whereas the latter is very effective in blood chemistry, the Groupamatic 360 is substantially superior in blood typing. We recently have obtained a second Groupamatic 360 machine to be used exclusively for further serological development. The New York Blood Center was the first to introduce routine testing of blood for hepatitis. This was initiated in 1968 as a direct result of the Vol. 53, No. 2, March 1977
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discovery of the relation between Australia antigen and hepatitis by Dr. A. M. Prince, head of our Virology Laboratory. Now such testing is accepted everywhere and is required by law. Yet, only seven years ago we were criticized for initiating such tests because it was alleged that we were putting other blood centers in medicolegal jeopardy. The story of hepatitis is an interesting one, but time does not permit me to go into it here. Another area of special interest at The New York Blood Center is the freezing of blood. Dr. Arthur Rowe, head of our Cryobiology Laboratory, pioneered the development of the liquid nitrogen method of freezing blood which now is being used in many places around the world. The Blood Program uses 8,000 to 10,000 units of frozen blood each year for a variety of clinical purposes. Some bloods are of exquisitely rare types; these are sent all over the world upon request. Some are typed extensively for use in solving unusual antibody problems; others are for use in treating patients who can be transfused only with their own blood. Because leukocytes are absent in frozen, thawed blood, it is the transfusion material of choice in treating patients needing repeated blood transfusions (such as children with thalassemia) or in patients on renal dialysis awaiting kidney transplantation. We have storage capacity for 3,000 units of frozen blood at all times, kept at the temperature of liquid nitrogen (- 1960C.). THE BLOOD-DERIVATIVES PROGRAM
The plasma which remains after separating whole blood into its components is an important source of various clinically useful blood derivatives. Presently, we salvage approximately 50,000 liters of plasma each year. Instead of selling it to a pharmaceutical company-as is done by most blood banks and blood centers-we fractionate it ourselves. We are the only blood center in the United States which has a federally licensed plasma-fractionation facility. We now have FDA licenses to make albumin, plasma protein fraction, gamma globulin, hepatitis antibody, and Factor VIII concentrate. We presently are able to supply approximately 45% of all the albumin needed in the area, and we hope within the next several years to be able to meet 100% of that need. The capacity to fractionate plasma protein is important not only because it makes albumin and other blood derivatives available at lower cost but also because it enables us to develop new, medically useful materials. For example, more than five years ago, with FDA approval, we produced a special high-titered hepatitis B immune globulin (HBIG). Extensive clinical Bull. N. Y. Acad. Med.
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studies which have been reported recently demonstrate it to be effective as a prophylactic measure in preventing the development of hepatitis in doctors, nurses, and technicians who accidentally prick their fingers with needles or scalpels which may be contaminated with the hepatitis virus, and in reducing the risk of hepatitis among patients and staff of renal dialysis units.* We expect that the FDA will license this material in the near future and permit its distribution for clinical use. From these comments on our Blood Program and Blood Derivatives Program, you will appreciate our feeling that the art and science of blood banking are changing, and that a modern blood center is much more than a drug store for blood. In addition to providing the whole blood, blood components, and blood derivatives that patients need, we receive numerous requests for consultation and other clinical services. There are nearly 300 hospitals in our area and not all have specialized personnel in this field on their staff. We have experienced physicians on call at all times to respond to requests for consultation on blood transfusions and related matters from any hospital or physician in the area. In addition, we provide back-up laboratory services to resolve difficult and unusual typing and cross-matching problems. We receive an average of 10 requests per day for such assistance and are pleased to be able to help. THE NEW YORK-NEW JERSEY REGIONAL TRANSPLANTATION PROGRAM
During the past three years the New York Blood Center has served as the regional coordinating agency for organ transplantation. We have had a tissue-typing laboratory since 1967-an outgrowth of Dr. Fred H. Allen's research. It was one of the first to be established in the United States. Tissue typing also has become important in blood transfusion, because in some patients platelets and leukocytes for transfusion have to be tissuematched to be effective. More than 600 patients in the New York-New Jersey area now are awaiting kidney transplantation. Virtually all have serum deposited with us. When kidneys become available they are sent to us from hospitals in the metropolitan New York area or are flown in from hospitals elsewhere. The appropriate patient is selected, based upon tissue type; the cross-matches are done; then the kidney is sent to the hospital where the transplantation will be done. There are 12 such transplant *Prince, A.M., Szmuness, W., and Mann, M.K.: Hepatitis B "immune" globulin: Effectiveness in prevention of dialysis-associated hepatitis. N. Engl. J. Med. 293: 1063-67, 1975.
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hospitals in this area. In May 1975 we established an organ-preservation laboratory at the New York Blood Center, with specially designed equipment to perfuse and monitor the condition of the donated human kidneys and to preserve them for transplantation for up to 72 hours. During 1974 there were 369 kidney transplants in this region; 292 of the kidneys were from cadavers and 77 were from living, related donors. The number of living donors is decreasing. We estimate that during 1976 approximately 500 cadaveric kidneys will be processed by our Transplant Program. In addition, a few patients will receive pancreas and lung transplants, principally at Montefiore Hospital; and one or two patients will receive liver transplants at Memorial Hospital. In essence, we are doing for kidneys what we have been doing for blood: providing public education, recruitment, and distribution. We expect this program to grow as more is learned about the biology of transplantation. THE EDUCATION PROGRAM
From the beginning we have felt a strong responsibility for education at all levels. As a consequence, we now conduct a variety of educational and training programs: a summer research fellowship program for college students; an advanced technicians training program for licensed technicians; a program for hospital house officers serving residencies in medicine, pediatrics, or pathology; a program for young physicians and medical scientists from foreign countries as research fellows in various research laboratories; and the blood-bank directors program, which was initiated several years ago. Prior to this last development, no such formal training had been available. Blood-bank directors such as Peter Vogel, Richard Rosenfield, and myself were taught on the job. The next generation of directors of hospital and community blood banks will have the advantage of entering the field after comprehensive and effective training in immunohematology and blood banking. Two years ago we received the first training grant for this purpose from the National Institutes of Health. Five young physicians now are enrolled in this program. They will study for one, two, or three years, depending on the amount of relevant preparation and experience they had received before coming to us. In addition to going through the various divisions of our Blood Center, they will spend at least three months at the Mount Sinai Hospital, Memorial Hospital, or the New York Hospital to receive clinical exposure which is not available at the Blood Center. Bull. N. Y. Acad. Med.
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We feel that our educational program is extremely important, not only for what it offers the trainees, but also for its contribution to the morale and spirit of our institution. An institution that does not have young people energetically involved in all levels of its operation quickly becomes sclerotic-a deterioration we hope to avoid. THE RESEARCH PROGRAM
The last-but far from the least-among the five operating programs of the New York Blood Center is the Research Program. This really expresses the Council's intellectual dimension-the hallmark which distinguishes the New York Blood Center from most other blood centers in the world. Organized as the Lindsley F. Kimball Research Institute, this program encompasses all research activities conducted at the Blood Center; it includes 13 separate research laboratories and approximately 50 full-time research people at the level of M.D. or Ph.D. These investigators enjoy the same privileges and work under the same conditions as their counterparts in university research laboratories. Among the senior investigators are many distinguished medical scientists, including Drs. B. Alexander, F.H. Allen, Jr., A.M. Prince, W. Szmuness, J.L. German, P. Rubinstein, C.M. Redman, A.O. Pogo, J. Goldstein, B. Blomback, A.W. Rowe, K.R. Woods, E. Brodheim, A.R. Neurath, and many others. Each is free to do his own work in his own way. There is no programmed research or director of research at the Blood Center. The research program has prospered, and it has contributed substantially to the blood program in such important areas as freezing of blood, testing for hepatitis, the development of HBIG, and many other equally important areas. One index of the size and scope of our research program is its annual budget; for 1975 our budget approached $4 million. All of this funding is obtained competitively; much of it comes from the federal government-and we are competing not with other blood centers but with the nation's leading universities. For example, we have one major research grant which provides $1.5 million a year. We have had this grant for 12 years and it recently was renewed for an additional five years. The dynamism of our institution and our staff lies in the spirit that says "New York needs not just a blood center, but one that will be innovative, imaginative, and creative." This is what makes the Blood Center an exciting place and has contributed to its phenomenal growth in 10 short years. Vol. 53, No. 2, March 1977
HUMAN BLOOD IN NEW YORK CITY: NOW* AARON KELLNER, M.D. Executive Vice President Community Blood Council of Greater New York New York, N.Y.
THE report of the Academy's Committee on Public Health, entitled Human Blood in New York City, contained a coldly factual and completely objective description of the blood situation in New York City as it existed in 1956. This kind of a report was precisely what was wanted and needed as a basis for the development of an effective, efficient blood organization. In simpler and more realistic terms, the report was a horror story-with New York as perhaps the worst possible example of a community's organization of its blood resources. Since 1956 that situation has changed drastically, as I shall show. We have not solved all the problems-by its very nature this is a dynamic and ever-changing undertaking-but we have created a mechanism for solving the problems. We have created something special and unique. "We" refers specifically to the Committee on Public Health of the Academy, since in a real sense the blood program we have in New York today is a child of this committee. I invite those of you who have not visited your child lately to come and see it. There is nothing like it anywhere else. To carry the story forward from where Dr. August H. Groeschel left it, in the late 1950s the Community Blood Council of Greater New York was formed. It is a private, nonprofit, membership corporation chartered in the state of New York. It has two kinds of members: delegate members and individual members. Originally there were 18 delegate members representing professional and community organizations interested in community health services, blood resources, and related activities, and an approximately equal number of individuals representing the community-people distinguished in business, banking, or medicine who were interested in *Presented at a meeting on Human Blood in New York City: Then (1956) and Now (1975) held by the Committee on Public Health of the New York Academy of Medicine November 3, 1975. Address for reprint requests: Community Blood Council of Greater New York, 310 East 67th Street, New York, N.Y. 10021
Bull. N. Y. Acad. Med.
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creating a blood center for our area. Among the organizational members was the New York Academy of Medicine, and to this day the Academy's first and only delegate to the council's board of directors has been Dr. Peter Vogel. The original charter established the Community Blood Council simply as an advisory body; so we sat around and advised for two or three years-and nothing happened. Indeed, the situation got worse. The Academy's report states that 45% of the blood transfused in New York City in 1956 was obtained from "commercial sources," a euphemism for skid row blood banks; much of this blood came from derelicts in the Bowery area. In 1962 another survey showed that 65% of the blood used in New York City came from the same commercial sources. At that time it was agreed that something had to be done; the council's charter was changed so that it could implement the Academy's second recommendation, that "the community blood organization set up and operate a community blood center." We recruited a group of eight distinguished physicians and scientists from various parts of the country and formed the council's Scientific Committee. Among its members were Richard Rosenfield from the Mount Sinai Hospital here in New York, a colleague of Dr. Vogel; Henry Kunkel; Elvin Kabat; James Tullis from Harvard University; and Scott Swisher, who was then at the University of Rochester and is now professor and chairman of the Department of Medicine at the Michigan State University College of Medicine. The Scientific Committee sat down to figure out what should be done next-and quickly decided that it did not want to establish a supermarket for blood. We recognized this as an unprecedented opportunity to create something excitingly new and different. The program obviously had to meet the needs for blood, but we wanted it to have an intellectual dimension: to be concerned with health in the broad sense. The council had to take the collection of blood out of the hands of social workers and businessmen and bring it back into the realm of medicine and science. The program had to be connected closely with the care of patients. It had to be involved in teaching at all levels and it had to be engaged in research. With those broad principles as a guide, we drew up a 10-year plan of action which is being realized progressively. With our goals clearly defined, we determined to raise the large sum of money needed to achieve them and to do the job properly. With strong community support we raised more than $6 million in 1963-1964. The Vol. 53, No. 2, March 1977
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money came from foundations in New York City such as the Commonwealth Fund, the Andrew W. Mellon Foundation, and the Rockefeller Brothers Fund, and from major corporations in New York such as the Consolidated Edison Company, the New York Telephone Company, International Business Machines Corporation, Chase Manhattan Bank, and similar large, community-minded organizations. Since 1964 we twice have gone back to these same organizations and to the community at large for additional help, raising a total of approximately $12 million. These constituted our capital resources. We then looked for a building which we could afford, close to a major medical center. It had to be where we could attract the kind of staff we would need for the innovative blood center we were committed to create for New York. It had to be close to centers of patient care and medical research, and where educational opportunities, scientific resources, and libraries were readily available. Our real estate committee looked at a number of buildings in various locations and finally recommended a building at 310 East 67th Street in Manhattan which at that time was occupied by a trade school, the Vorhees Technical Institute. We bought the building toward the end of 1963. In 1964 we moved in. We had no staff, no equipment, and not a single unit of blood. But we had some strong, resourceful, and determined support-and we had some money in the bank. I shall bypass all the storm and strife of the intervening 11 years and describe what we have today. The New York Blood Center is not merely a blood center, but a new kind of regional health facility, with a staff of more than 900 people. We are the largest collectors of blood in the world. We have a burgeoning research program, a regional transplant program, and a variety of educational activities. Our budget for fiscal year 1975 totalled approximately $35 million, and our income equalled our
expenditures. The Community Blood Council of Greater New York consists of five separate operating programs supported by a central core of administrative services. The headquarters for all of these programs and supporting services are in the New York Blood Center. These programs include: 1) The Greater New York Blood Program 2) The Blood Derivatives Program 3) The New York-New Jersey Regional Transplant Program 4) The Educational Program 5) The Research Program Bull. N. Y. Acad. Med.
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THE GREATER NEW YORK BLOOD PROGRAM
The name of The Greater New York Blood Program was adopted in 1968 when the Community Blood Council and the American Red Cross in Greater New York merged their blood-bank facilities. For the purpose of this presentation, I shall refer to it simply as the Blood Program. The Blood Program (as well as our Transplant Program) serves New York City, all of Long Island, the lower Hudson River valley, and northern New Jersey. In this area we are the principal provider of blood. We supply approximately 75% of the blood used in New York City; a dwindling number of commercial blood banks continue to operate in the city; they will probably disappear in a year or two. We are the sole suppliers of blood for Long Island and the lower Hudson River valley. In northern New Jersey we are one of four nonprofit community blood banks which provide all the blood used in that area (almost no "commercial" blood is used in northern New Jersey). In the area covered by our Blood Program the annual need for blood totals approximately 700,000 units. The Blood Program operates a number of facilities in fixed locations, including the following: The New York Blood Center on East 67th Street (our headquarters building), the headquarters building of the American Red Cross in Greater New York located on Amsterdam Avenue at West 67th Street (where many of the Blood Program's activities are located), a donor center in the World Trade Center in lower Manhattan, a facility on Long Island, and a facility in New Brunswick, N.J. However, most of our blood (approximately 75% of the total) is collected by mobile units which are set up in factories, office buildings, churches, schools, and similar locations. A great deal of painstaking effort goes into the organization of mobile blood collection. The Blood Program employs 35 full-time field representatives who visit business, labor, religious, community, and other organizations and work with their personnel to establish donor groups and make arrangements for scheduling blood collections. Mobile units vary in size from those handling 100 donors in a single operation to several thousand donors over a period of two or three days. An example of the latter is the collection at the U.S. Military Academy at West Point, where we draw blood from as many as 1,000 donors each day for three days. This operation is capable of bleeding 50 donors at a time in the military academy's large gymnasium and is accomplished with the precision so characteristic of West Point. The Community Blood Council started to collect blood in 1964; it drew Vol. 53, No. 2, March 1977
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a total of 3,000 units that year. In each of the following years blood collections increased substantially. In 1968 the Community Blood Council's blood program merged with that of the American Red Cross to form The Greater New York Blood Program, which is operated by the Community Blood Council. The Red Cross has five members on the board of directors of the Community Blood Council and a member on its executive committee. The day-to-day operation of the Blood Program and its staff are under the jurisdiction of the Community Blood Council. The merger has worked out well and the Blood Program operates to the mutual satisfaction of the two organizations-as the increase in blood collections each year since the merger shows. In 1970 the Blood Program was the second largest collector of blood in the United States. In 1971, 1972, and 1973 it was the largest collector of blood in the United States. In 1974 the Blood Program established a world record by collecting almost 450,000 units of blood. No other city in the world-not London, Paris, or Moscow-even came close to that figure. Last winter we estimated that during fiscal year 1975 (May 1, 1975 to April 30, 1976) we would collect 550,000 units. We actually collected 561,000. Most of the blood we draw is not collected in a single plastic bag, but in multiple bags; these are sets of two, three, four, or sometimes five bags connected by plastic tubing in a closed system so that the whole blood drawn in the first bag can be separated readily and without danger of contamination into its various components, including red blood cells, platelets, leukocytes, and plasma. The plasma may be utilized as such or it may be converted into derivatives such as fresh frozen plasma, clotting factors, albumin, and gamma globulin. A shuttle service is set up to rush the whole blood from the mobile collection sites to our laboratories in New York City by station wagon and, on occasion, via helicopter. This is necessary because certain components deteriorate so rapidly; for example, platelets and Factor VIII have to be separated within four hours of collection. Wherever possible, we try to get donors in Manhattan to come to the Blood Center or to the Red Cross building or to the collection station in the World Trade Center. Bleeding the donors at these fixed locations is not only more economical, it facilitates the separation of the whole blood into its many useful components. We now bleed an average of 1,500 donors per day and more than half of this blood is used for the preparation of blood components. The separation of whole blood into its components is accomplished by placing the multiBull. N. Y. Acad. Med.
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ple bags in special centrifuges, spinning them down, and squeezing off the plasma. The basic procedure is repeated several times with minor modifications. When a quintuple bag is used, the end result is five separate bags, each containing one of the following components: 1) red blood cells, 2) leukocyte concentrate, 3) platelet concentrate, 4) fresh frozen plasma (yielding cryoprecipitate or Lyoc), and 5) residual plasma (from which albumin and gamma globulin are derived by fractionation). The demand for various blood components has increased astonishingly during the past 10 years. For example, in 1964 the transfusion of platelets was almost unheard of. We began to prepare platelets for therapeutic use in 1965; at that time it was unusual if 50 units of platelets were required in a month. This year we shall make approximately 10,000 units of platelets per month and even that number will not meet the total demand. The demand for platelets exceeds our capacity to make them, yet no other blood center in the world produces nearly that number. This is because of our location in the middle of an area that includes 10 medical schools and numerous major hospitals where platelets are used extensively in the treatment of leukemia and other types of malignant disease. In addition, we are now facing the increasing use of granulocytes for transfusions. Our Blood Program has taken the lead in the automation of laboratory procedures involved in the processing of blood. Our Groupamatic 360 machine was the first of its kind to be put into routine operation in the United States. This automatic blood typer does the routine blood-group serology on 360 units of blood per hour, performing 12 separate tests on each unit; it records the results of these tests, interprets the data, and enters the information in the computer. The machine, which costs a quarter of a million dollars, is in daily operation at the Blood Center. Any blood center desiring to use such a machine must first obtain permission from the Food and Drug Administration (FDA). The New York Blood Center was the first to obtain that permission; any other blood center wishing to use this equipment will be able to do so on the basis of our experience and resultant certification. The machine works on a principle different from that of the well-known autoanalyzer. Whereas the latter is very effective in blood chemistry, the Groupamatic 360 is substantially superior in blood typing. We recently have obtained a second Groupamatic 360 machine to be used exclusively for further serological development. The New York Blood Center was the first to introduce routine testing of blood for hepatitis. This was initiated in 1968 as a direct result of the Vol. 53, No. 2, March 1977
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discovery of the relation between Australia antigen and hepatitis by Dr. A. M. Prince, head of our Virology Laboratory. Now such testing is accepted everywhere and is required by law. Yet, only seven years ago we were criticized for initiating such tests because it was alleged that we were putting other blood centers in medicolegal jeopardy. The story of hepatitis is an interesting one, but time does not permit me to go into it here. Another area of special interest at The New York Blood Center is the freezing of blood. Dr. Arthur Rowe, head of our Cryobiology Laboratory, pioneered the development of the liquid nitrogen method of freezing blood which now is being used in many places around the world. The Blood Program uses 8,000 to 10,000 units of frozen blood each year for a variety of clinical purposes. Some bloods are of exquisitely rare types; these are sent all over the world upon request. Some are typed extensively for use in solving unusual antibody problems; others are for use in treating patients who can be transfused only with their own blood. Because leukocytes are absent in frozen, thawed blood, it is the transfusion material of choice in treating patients needing repeated blood transfusions (such as children with thalassemia) or in patients on renal dialysis awaiting kidney transplantation. We have storage capacity for 3,000 units of frozen blood at all times, kept at the temperature of liquid nitrogen (- 1960C.). THE BLOOD-DERIVATIVES PROGRAM
The plasma which remains after separating whole blood into its components is an important source of various clinically useful blood derivatives. Presently, we salvage approximately 50,000 liters of plasma each year. Instead of selling it to a pharmaceutical company-as is done by most blood banks and blood centers-we fractionate it ourselves. We are the only blood center in the United States which has a federally licensed plasma-fractionation facility. We now have FDA licenses to make albumin, plasma protein fraction, gamma globulin, hepatitis antibody, and Factor VIII concentrate. We presently are able to supply approximately 45% of all the albumin needed in the area, and we hope within the next several years to be able to meet 100% of that need. The capacity to fractionate plasma protein is important not only because it makes albumin and other blood derivatives available at lower cost but also because it enables us to develop new, medically useful materials. For example, more than five years ago, with FDA approval, we produced a special high-titered hepatitis B immune globulin (HBIG). Extensive clinical Bull. N. Y. Acad. Med.
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studies which have been reported recently demonstrate it to be effective as a prophylactic measure in preventing the development of hepatitis in doctors, nurses, and technicians who accidentally prick their fingers with needles or scalpels which may be contaminated with the hepatitis virus, and in reducing the risk of hepatitis among patients and staff of renal dialysis units.* We expect that the FDA will license this material in the near future and permit its distribution for clinical use. From these comments on our Blood Program and Blood Derivatives Program, you will appreciate our feeling that the art and science of blood banking are changing, and that a modern blood center is much more than a drug store for blood. In addition to providing the whole blood, blood components, and blood derivatives that patients need, we receive numerous requests for consultation and other clinical services. There are nearly 300 hospitals in our area and not all have specialized personnel in this field on their staff. We have experienced physicians on call at all times to respond to requests for consultation on blood transfusions and related matters from any hospital or physician in the area. In addition, we provide back-up laboratory services to resolve difficult and unusual typing and cross-matching problems. We receive an average of 10 requests per day for such assistance and are pleased to be able to help. THE NEW YORK-NEW JERSEY REGIONAL TRANSPLANTATION PROGRAM
During the past three years the New York Blood Center has served as the regional coordinating agency for organ transplantation. We have had a tissue-typing laboratory since 1967-an outgrowth of Dr. Fred H. Allen's research. It was one of the first to be established in the United States. Tissue typing also has become important in blood transfusion, because in some patients platelets and leukocytes for transfusion have to be tissuematched to be effective. More than 600 patients in the New York-New Jersey area now are awaiting kidney transplantation. Virtually all have serum deposited with us. When kidneys become available they are sent to us from hospitals in the metropolitan New York area or are flown in from hospitals elsewhere. The appropriate patient is selected, based upon tissue type; the cross-matches are done; then the kidney is sent to the hospital where the transplantation will be done. There are 12 such transplant *Prince, A.M., Szmuness, W., and Mann, M.K.: Hepatitis B "immune" globulin: Effectiveness in prevention of dialysis-associated hepatitis. N. Engl. J. Med. 293: 1063-67, 1975.
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hospitals in this area. In May 1975 we established an organ-preservation laboratory at the New York Blood Center, with specially designed equipment to perfuse and monitor the condition of the donated human kidneys and to preserve them for transplantation for up to 72 hours. During 1974 there were 369 kidney transplants in this region; 292 of the kidneys were from cadavers and 77 were from living, related donors. The number of living donors is decreasing. We estimate that during 1976 approximately 500 cadaveric kidneys will be processed by our Transplant Program. In addition, a few patients will receive pancreas and lung transplants, principally at Montefiore Hospital; and one or two patients will receive liver transplants at Memorial Hospital. In essence, we are doing for kidneys what we have been doing for blood: providing public education, recruitment, and distribution. We expect this program to grow as more is learned about the biology of transplantation. THE EDUCATION PROGRAM
From the beginning we have felt a strong responsibility for education at all levels. As a consequence, we now conduct a variety of educational and training programs: a summer research fellowship program for college students; an advanced technicians training program for licensed technicians; a program for hospital house officers serving residencies in medicine, pediatrics, or pathology; a program for young physicians and medical scientists from foreign countries as research fellows in various research laboratories; and the blood-bank directors program, which was initiated several years ago. Prior to this last development, no such formal training had been available. Blood-bank directors such as Peter Vogel, Richard Rosenfield, and myself were taught on the job. The next generation of directors of hospital and community blood banks will have the advantage of entering the field after comprehensive and effective training in immunohematology and blood banking. Two years ago we received the first training grant for this purpose from the National Institutes of Health. Five young physicians now are enrolled in this program. They will study for one, two, or three years, depending on the amount of relevant preparation and experience they had received before coming to us. In addition to going through the various divisions of our Blood Center, they will spend at least three months at the Mount Sinai Hospital, Memorial Hospital, or the New York Hospital to receive clinical exposure which is not available at the Blood Center. Bull. N. Y. Acad. Med.
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We feel that our educational program is extremely important, not only for what it offers the trainees, but also for its contribution to the morale and spirit of our institution. An institution that does not have young people energetically involved in all levels of its operation quickly becomes sclerotic-a deterioration we hope to avoid. THE RESEARCH PROGRAM
The last-but far from the least-among the five operating programs of the New York Blood Center is the Research Program. This really expresses the Council's intellectual dimension-the hallmark which distinguishes the New York Blood Center from most other blood centers in the world. Organized as the Lindsley F. Kimball Research Institute, this program encompasses all research activities conducted at the Blood Center; it includes 13 separate research laboratories and approximately 50 full-time research people at the level of M.D. or Ph.D. These investigators enjoy the same privileges and work under the same conditions as their counterparts in university research laboratories. Among the senior investigators are many distinguished medical scientists, including Drs. B. Alexander, F.H. Allen, Jr., A.M. Prince, W. Szmuness, J.L. German, P. Rubinstein, C.M. Redman, A.O. Pogo, J. Goldstein, B. Blomback, A.W. Rowe, K.R. Woods, E. Brodheim, A.R. Neurath, and many others. Each is free to do his own work in his own way. There is no programmed research or director of research at the Blood Center. The research program has prospered, and it has contributed substantially to the blood program in such important areas as freezing of blood, testing for hepatitis, the development of HBIG, and many other equally important areas. One index of the size and scope of our research program is its annual budget; for 1975 our budget approached $4 million. All of this funding is obtained competitively; much of it comes from the federal government-and we are competing not with other blood centers but with the nation's leading universities. For example, we have one major research grant which provides $1.5 million a year. We have had this grant for 12 years and it recently was renewed for an additional five years. The dynamism of our institution and our staff lies in the spirit that says "New York needs not just a blood center, but one that will be innovative, imaginative, and creative." This is what makes the Blood Center an exciting place and has contributed to its phenomenal growth in 10 short years. Vol. 53, No. 2, March 1977
