By Lincoln Cushing, Heritage writer
One of the major academic figures in American public health was Lester Breslow, MD, who passed away last year at the age of 97. Dr. Breslow was a former dean of the Fielding School of Public Health at UCLA and director of the California Department of Public Health from 1965-1968.
He was also president of the American Public Health Association from 1968 to 1969. Central to Dr. Breslow’s research was mathematical support for the premise that improving personal habits such as reducing smoking, eating better, and sleeping well could have a significant impact on life longevity and quality.
Dr. Breslow was also a pioneer in multiphasic screening and an advocate for the Automated Multiphasic Health Test developed by Kaiser Permanente’s Morris Collen, MD, an early medical informatics guru who turns 100 this November.
National Public Health Week, April 1-7, is a good time to revisit Kaiser Permanente’s role in the early recognition of preventive care as a way to address public health issues.
Breslow had developed the original multiphasic screening (the examination of large numbers of people with a series of tests for detecting diseases) during the 1940s, and Collen improved upon it with new technology. The first beneficiaries of Collen’s multiphasic process were members of the International Longshoremen’s and Warehousemen’s Union in 1951.
The AMHT was a battery of tests, administered in an efficient routine by medical professionals and supported by then-new mechanical and chemical analytic devices. The results were funneled into a powerful mainframe computer.
From a public health perspective, the ability to efficiently diagnose communicable and noncommunicable diseases not only benefitted the individual patient, it also helped to stem public health risks as well.
In Breslow’s 1973 Preventive Medicine article, “An Historical Review of Multiphasic Screening,” he noted: “Automated multiphasic screening opens the possibility of extending the health-maintenance type of health care to all groups of the population, particularly including those most likely to suffer from the conditions now responsible for the greatest amount of disability and death.”
Dr. Collen taught two semesters at UC Berkeley’s School of Public Health during the spring and fall of 1965; much of the curriculum explored the uses of multiphasic exams. Students included physicians engaged in their continuing medical education.
Final papers for the classes included such subjects as “Evaluation of Environmental Toxins Utilizing Automated Methods” by David R. Brown, “Obesity and its Measurements as it Relates to a Multiphasic Screening Program” by Clarence F. Watson, MD, and “Biological Effects of Magnetic Fields” by Earl F. White.
Although the multiphasic screening as it was developed in the 1960s has been replaced by other diagnostic methods, the efficient application of medical diagnostic tools – and the enormous Kaiser Permanente patient database that has accumulated over the years – continues to advance public health.
Also see: “Screening for Better Health: Medical Care as a Right”
By Ginny McPartland
As we wonder and worry about the fate of health care in America, it’s interesting to look back at how Kaiser Permanente physician leaders saw the future just after the 20-year-old health plan got a firm foothold in the 1960s.
Cecil Cutting, MD, executive director of The Permanente Medical Group, told of his worst fears in a talk to a group of hospital administration graduate students at the University of Chicago on Nov. 17, 1966.
“Looking ahead, there seems little doubt but that our present ‘derangement’ of providing medical care is totally inadequate to absorb the onrush of the technological revolution that is now upon us, even if the rising personnel costs can be absorbed,” Cutting lamented.
“The tempo of the hospital has changed from a relatively easy-going, low cost charity institution to a competitive, high cost one, with third parties paying the costs and becoming ever more critical of hospital management,” Cutting said.
A 1935 Stanford Medical School alumnus, Cutting joined Sidney Garfield when he established a medical care program at the Grand Coulee Dam job site in the late 1930s. During the war, Cutting also took a leading role in Garfield’s Kaiser wartime shipyard program in Richmond, California.
1960s changes threatened traditional medical care delivery
Cutting was talking about the mid-1960s climate that included newly enacted government-paid Medicare-Medicaid programs for the elderly and poor, a flood of new medical technology, health care professionals’ demands for higher pay and a proliferation of union and company health plans for workers.
With the blessing of KP founding physician Sidney Garfield, Cutting laid out the problem: “Today we have many individual, unrelated, competitive hospitals seldom organized among themselves as a team, for the most part with unorganized staffs of physicians, serving an unknown population – a population unknown both in numbers and in health requirements.
“The consequences of continuing along our present path of complete disorganization are staggering and make the need to change methods of organizing medical care inevitable,” he told the group.
Cutting warned that high technology was too expensive for an individual institution to purchase on its own. He said a system should be established in which medical facilities are designated as one of three types: a community preventive health center; a service hospital for routine care, such as trauma, appendectomy, hysterectomy, maternity, hernias, cancer surgery, pediatrics and psychiatry; and a “super-specialty” hospital.
‘Super-specialty’ hospital to optimize high technology use
The highly specialized treatment facility envisioned by Cutting (perhaps the precursor of a center of excellence) would be designed for handling neurological cases, open-heart surgery, megavoltage radiotherapy – the types of cases that required the most sophisticated equipment.
Here, specialists would take care of a sufficient number of patients referred from other facilities to optimize utilization of the equipment and highly skilled staff.
As it happened, Kaiser Permanente was in the process of developing such a system by this time, and Cutting could report its success to his audience. “In Northern California area the Kaiser Permanente program is working along these lines, though it is by no means a finished demonstration,” Cutting said.
“The (Kaiser Permanente) group practice-prepayment arrangement is, in itself, a step toward improving organization of medical care and undoubtedly makes accomplishment of further organization considerably easier to attain.”
Health center concept proposed
The health center concept, which Cutting called “predictive and preventive medicine,” had already been developed and was in operation in KP Northern California. “Forty thousand patients a year are being given an extensive health questionnaire (to complete), updated each year, and an automated battery of some 20 test measurements plus 18 laboratory procedures amounting to almost 1,000 different characteristics on each patient,” Cutting continued.
With this information, all recorded in a computer data base, KP physicians compiled knowledge of each patient’s changes from year to year. This information helped physicians to predict illness and to advise patients and their families about how to prevent chronic illnesses such as diabetes, heart disease and cancer.
Data compiled about whole populations, i.e. KP members, also helped researchers answer such questions as: Can treatment of asymptomatic patients with a slight increase in blood sugar prevent diabetes altogether or merely postpone the disease? With data from a questionnaire about a patient’s psychological state, researchers compared the effectiveness of psychiatric services versus medical office visits for reducing total visits for emotionally disturbed patients.
Too many specialists spoil the broth
Cutting complained to his audience that medical schools were turning out too many specialists, a trend that threatened basic medical care. “It would appear that the rush for super-specialization may be leaving behind an ever widening gap in well rounded, competent medical judgment.
“Though the individual episode of care may be superb, it certainly does little for the orderly development of efficient, economical medical care as a whole.”
In what must have surprised many, Cutting suggested that medical education should develop a new type of medical doctor: the preventive, predictive specialist. “Following the natural development of disease of entire families over long periods, alerted to early changes through the screening program, he becomes a health specialist.”
Today, both primary care and preventive medicine are specialties recognized by the American Board of Specialties.
Kaiser Permanente has advanced Garfield and Cutting’s ideas about preventive care and health appraisals in a variety of ways over the decades. KP physicians promoted healthy eating and exercise for the workers in the World War II Kaiser Shipyards, and they began offering preventive testing in the 1950s for members of the longshoremen union and other groups.
KP’s ‘Total Health’ concept emerges
In the 1970s, health education centers were established to teach patients how to stay well; Garfield’s Total Health Research Project launched in the 1980s led to the opening of special centers where healthy patients received their routine care.
Centers for preventive medicine functioned within KP for many years, largely giving way to periodic screenings for particular diseases such as breast and colon cancer, heart disease, hypertension and diabetes. Healthy Living programs, an expansion of member health education, have flourished in the past decade offering many classes in good nutrition, exercise, smoking cessation and stress reduction.
Cutting ended his talk with a few wishes for the future: community institutes to teach people to preserve their good health, easily shared electronic medical records, and above all, cooperation among health organizations to provide a broad spectrum of care – from the preventive to the most complicated.
“When (all) care, whether in super-specialty hospitals, service hospitals, extended care, office or home, is correlated . . . I will begin to see hope,” he said.
By Ginny McPartland
First in a series
In the 1960s, dubbed the “Development Decade” by the United Nations, Henry J. Kaiser’s enterprises were literally all over the map. Kaiser’s companies were mining bauxite for aluminum in Jamaica, manufacturing cars in Argentina and Brazil and working on a huge hydroelectric project and aluminum smelting plant on the Volta River in the emerging West African country of Ghana.
Kaiser Engineers were also building a dam on the Bandama River in Ivory Coast, West Africa, as well as undertaking projects in various parts of India, including construction of a dam, hydroelectric plant, an aluminum plant, a steel mill and a cement facility. Kaiser Engineers were involved with the Snowy Mountain project – construction of tunnels, aqueducts, dams and hydroelectric plants in the mountains of eastern Australia.
As in his American ventures, Henry Kaiser’s enterprises on foreign soil developed medical services for workers at the job sites and often in the community. In many places, including Australia, India, and Ghana, the government required Kaiser to build hospitals at each of the construction locations.
“In a sense, this was a recapitulation of the early experience of our domestic medical care program, which had its origins in providing health care for workmen and their families at construction sites in the Western United States,” wrote James P. Hughes, MD, Kaiser Industries vice president of Health Services in 1972.
KP executives tapped to develop health facilities abroad
Clifford Keene, MD, Kaiser Permanente president at the time, was thrilled to participate in the launching of medical care projects in foreign lands.
“I went to Australia several times because Kaiser Engineers were involved in the Snowy Mountain Project and I was involved in the location and construction of hospitals there. . .I went to India twice, once for a period of almost a month. I found myself in places with exotic names, Uttar, Pradesh, Mysore, and Jamshedpur.
“So all of this was going on and it was just a big, spreading, challenging, wonderful, exhilarating kind of existence. While we were having all the troubles in the Permanente Medical Program (in California), getting reorganized, I was involved in these other challenges, which gave me satisfaction and sort of balanced the scales against the frustrations of dealing with the Permanente program.”
Ernest Saward, MD, medical director of Kaiser Permanente’s Oregon Region, traveled to Argentina in 1960 to help establish a medical care program for Kaiser automobile workers in Cordoba and Buena Aires. Saward said the Argentines didn’t trust the Kaiser organization initially and expected the company to superimpose a foreign health system on the community.
“The reaction back from Argentina was, ‘You folks in California put some millions in this and build us a hospital and everything will be all right.’ From what I’d already learned, I saw that if (Kaiser in partnership with the Argentines) put any millions in a hospital it would be confiscated within months. That was the nature of Argentina at the time. They play rough. Now I never personally got shot at; I was only threatened with a saber,” Saward said with a laugh in a 1986 oral history.
Saward and his artist wife managed over time to infiltrate the Argentine culture and make essential contacts for Kaiser. “They saw that we were somebody they could relate to, that (we) wanted to understand them and to understand what I would call their general, cultural events, and not be an isolated colony.
“They began to entertain us, and I spent hours lying on the living room floor, drinking red wine in front of a fireplace with these guys, until they finally understood what it was we were trying to do, and once they really got a feeling for what we wanted to do, they said, ‘Let’s do it’. We did it with the best medical group in town and with the best hospital in town, and it’s still going (1986) and it cost us in toto, $55,000.
“What had to be done in Argentina was to make an indigenous plan and not a foreign plan and (to make it go) it had to be done as an indigenous plan by what were respected elements in the community. (That’s how) we did it,” Saward said.
Requests for help from international community multiply
As Kaiser Industries continued to work abroad into the 1960s and 1970s, the challenges for providing health care kept coming.
This was a period when African nations were gaining their independence, and the international community was interested in promoting industrial development to improve the economies of all underdeveloped countries. With new industry and its attendant growth, the budding nations were struggling to provide essential services to their citizens, both natives and newly arrived workers and their families.
To address these issues, seven hundred industrialists from 70 nations gathered in the San Francisco Bay Area in September of 1969 to figure out how to close the gap between the “have” and “have not” nations.
“There was much talk about the responsibilities of private enterprise in developing countries; about the need for more effective allocation of resources; about the need for business to interact with the society in which it finds itself,” noted KP President Clifford Keene in a talk to the Industrial Council for Tropical Health at the Harvard School of Public Health in Boston in 1969.
Kaiser’s people learned the hard way what this meant. In Ghana on the Volta Dam project, Kaiser leaders discovered pretty quickly that – despite the government’s well-laid plans – the company needed to initiate environmental programs to ensure safe water and pest-control measures to protect workers from the spread of debilitating disease.
Once the dam was completed, Kaiser began construction on a smelter plant to manufacture aluminum. “. . .the first responsibility was to provide care for the work injuries, since the existing health care facilities in the town were grossly overburdened,” wrote Hughes.
Health planners forced to improvise
For these foreign projects, many necessitating brand new cities or towns, Kaiser’s goal was to establish health care facilities for its workers, their families and often for the community at large. Hughes said in most countries where Kaiser had developments health care services had to be introduced in waves, depending on available services. Often, sanitation and safe water needs and the dire need for training of locals in basic care methods were the first priorities.
To provide health services, Kaiser Industries initially engaged the Kaiser Permanente Medical Care program. By 1964, however, Kaiser leaders realized the need for a separate entity and established the not-for-profit Kaiser Foundation International (KFI) to administer the foreign medical care programs. With Kaiser Permanente’s reputation on the rise, requests for consulting help started to come from places where Kaiser Industries didn’t already have a presence.
Between 1964 and 1969, the international group was engaged for medical care projects in 15 African countries. By 1975, KFI had been hired and paid for projects in 30 countries around the globe, including rural locations in California, Utah and West Virginia.
Next time: Kaiser Foundation International gets contracts to resurrect a hospital devastated by the Nigerian civil war, to train Peace Corps workers for African rural health projects and to consult on many foreign health care projects.