By Ginny McPartland, Heritage writer
Kaiser Permanente founding physician Sidney Garfield caught on early that changing people’s habits would have positive results for their health. Urging his patients to avoid accidents by following safety guidelines and eating right to avoid health problems was a no-brainer for Garfield. Everyone would be happier and healthier, and the need for costly medical care could be minimized.
Voila! Prepaid care with an emphasis on prevention. Garfield adopted this theme in 1933, and Kaiser Permanente leaders have held this as a predominant tenet ever since.
Garfield’s interest in nutrition and exercise programs for shipyard workers in the 1940s, multiphasic examinations (annual physicals) in the 1950s, data processing of patient records in the 1960s, health education centers in the 1970s and the Total Health Project in the 1980s all fed into the push to promote healthy lifestyles and prevent illness.
Newsletters in the World War II Kaiser shipyards constantly reminded workers to eat three square meals a day and avoid too much fat and sugar. “Are you starving?” one article asked. “You can be starved without being hungry. . . Are you aware: 24 million man-hours per month (nationally) are lost through minor illnesses preventable by better nutrition?”
The Kaiser child care centers served healthy meals, and parents could buy nutritious family dinners to take home when they collected their offspring at the end of the day. Shipyard management sponsored intramural sports teams to help workers blow off steam and stay fit.
Screening workers for unhealthy habits
In 1950 Dr. Garfield responded to labor leader Harry Bridges’ request for a preventive care screening program for the members of his longshoremen’s and warehousemen’s union. The examinations, union-mandated for all workers, highlighted lifestyle problems and educated the men on how to avoid heart disease and other chronic illness.
In the 1960s, the first computer technology recorded the examination results so physicians could track their patients’ progress electronically and identify trends that could aid in the care and treatment of other patients, even in subsequent decades.
The 1970s saw the debut of the health education centers in which patients could seek disease prevention information and partake in groundbreaking programs to help them maintain healthy lifestyles and a healthy weight. (This was the beginning of Kaiser Permanente’s Healthy Living centers that offer a myriad of programs designed to preserve good physical and mental health and help patients manage chronic conditions.)
Health appraisal gains momentum
Health appraisal programs were established in a number of Kaiser Permanente locations, and healthy members were encouraged to visit the clinic when they were well, not just when illness struck. They filled out questionnaires and discussed their health status with practitioners who tracked their lifestyles and gave advice on staying well.
In the 1980s, Dr. Garfield conducted the Total Health research project in which he expanded the health assessment theme and had new well members diverted to a Total Health Center in which the emphasis was on promoting healthy lifestyles.
In the 1990s, Kaiser Permanente researchers participated in studies to test the success of a dietary regimen meant to reduce blood pressure and help prevent heart attacks and strokes. The Dietary Approaches to Stop Hypertension approach called for a healthy diet rich in fruits, vegetables, whole grains, low-fat dairy, fish, poultry and nuts.
The participants who followed DASH experienced a significant reduction in 24-hour blood pressure. The others, who continued to eat red meat, sweets and sugary soda, saw no improvement in blood pressure. Following the study, the DASH approach became the basis of Kaiser Permanente’s teaching about the prevention of hypertension and related conditions.
Also in the 1990s, Kaiser Permanente physician Vincent Felitti discovered while running a health appraisal clinic in the San Diego area that some patients needed help overcoming childhood trauma before they could change unhealthy behavior. Felitti conducted the Adverse Childhood Experience study and urged the consideration of psychological as well as physical issues in assessing a patient’s ability to adopt a healthy lifestyle.
Thriving in the 21st century
In 2004 Kaiser Permanente launched its Thrive advertising campaign, which spotlighted the health plan’s continuing emphasis on healthy living to help patients stay well. In the 20-Teens, the organization gave birth to other behavior change modalities, including online healthy lifestyle programs, Healthy Eating and Active Living community programs and free classes open to the public.
In 2012, Kaiser Permanente launched “Every Body Walk!” a campaign to get literally everyone up on their feet to take the first small steps that can lead to success in achieving a healthy lifestyle.
Today, patients who choose to alter their habits to achieve better health can get help in Kaiser Permanente’s Healthy Living classes, by enrolling in online Healthy Lifestyle programs, and by accessing the bonanza of health information on kaiserpermanente.org.
By Lincoln Cushing, Heritage writer
The image of Kaiser Permanente founding physician Sidney R. Garfield as a hammer-wielding workplace safety diehard has been passed down through the decades from his early days as a desert doctor. But is the legend true? Did Garfield really charge out into the dust and dirt himself and pound down rusty nails, shore up tunnels to prevent rock showers, and insist workers wear hard hats?
This story of Dr. Garfield’s passionate preventive practice on the Colorado River Aqueduct project has endured for eight decades, since about 1933. The oft-told tale conveys the young doctor’s commitment to worker safety and preventive care once he instituted the unconventional prepaid model of health care that saved his little hospital from extinction.
Garfield was certainly committed, but his allegedly active role in the cleanup of aqueduct work sites is a stretch of the imagination. And he was not alone in promoting workplace safety.
Fact or fiction?
The story has sometimes been presented as fact:
“There was a funny little story that Dr. Garfield, on the first day in which prepayment began in the desert, got up early in the morning with his hammer, and went around the worksite pounding down nails. . . The notion is that if you can keep the patients healthy, then it’s a good thing not only for the patient, but it’s a good thing, financially, for the program.” [i]
Sometimes it’s told as legend:
“There (in the Mojave Desert) he also discovered the importance of preventive medicine, and he strove to remove potential health hazards for the workers – although it is only legend that Garfield would go to the construction sites and pound down any protruding nails himself.”[ii]
And at least once the story has been cited in a novel about the desert doctor’s operations, where a fictional Dr. Sidney Garfield speaks to a fictional nurse:
“I picked up another nail. ‘Look at all these dirty nails. Just lying around, waiting for someone to step on them and end up with a puncture wound, tetanus, or worse.’ ”[iii]
In his own words
When we examine the historical record and let the doctor speak for himself, as in this circa 1934 quote in which he describes a disquiet of conscience from collecting fees from illness and injury, we see his true role.
“We had been anxious to have sick men or injured men come into the hospital because that meant income and that we would continue to exist. . . It was embarrassing to me to want people to get hurt. So we started to do safety engineering. . . We would get a bunch of nail punctures from a job and we would go out there and get them to clean up the nails. Or we would get a lot of head injuries . . . and we would get them to shore up the tunnels better.”[iv]
Garfield’s commitment to worker safety was genuine, but it was his nurse, Betty Runyen, RN, who actually went to the work sites to speak to the importance of taking salt tablets and drinking water to avoid sunstroke, and of donning gloves to prevent the spread of impetigo from pick axes and shovels. The competent nurse was also the visage of an angel in those hostile environs with her blonde curls and pretty smile.
Water district’s safety efforts
It should also be noted that Garfield and Runyen had help as well. The Metropolitan Water District of Southern California, the builder of the aqueduct, and Workmen’s Compensation insurance companies all placed their own safety engineers in the field to remedy dangerous job situations.
The 1937 Colorado River Aqueduct project manual describes their role thusly: “It is the duty of the safety engineer and members of his organization to visit all work on the aqueduct at frequent intervals to see that the work is being carried on in accordance with established safety rules, to offer advice and instructions to those in charge of construction operations, and to assist in the elimination of dangerous operations and equipment.
“In addition, each division engineer is charged with the responsibility of reducing accidents to the minimum. Special safety meetings are held at various points along the aqueduct at frequent intervals and a regular plan of safety education is maintained.”[v]
All of these efforts apparently had an impact – accident frequencies were reduced to a point well below the average rate experienced in that class of construction during that period.
In the desert years (1933-1938), Garfield did not wield a hammer or gather stray nails at the job site. But it is still fair to say that he overturned the conventional wisdom that a physician must derive his income from illness and injury. In the desert he realized the incentive to keep people well and on the job. Thereafter, preventive care became paramount, first in his imagination, then in reality when he partnered a few years later with Henry J. Kaiser at Grand Coulee Dam project in Washington State.
Kaiser Permanente Core Values,” conducted by Martin Meeker in 2007, Regional Oral History Office, The Bancroft Library, University of California, Berkeley, 2007.[ii] Can Physicians Manage the Quality and Costs of Health Care? The Story of The Permanente Medical Group, by John G Smillie, MD; book review by Morris F. Collen, MD, The Permanente Journal, Summer 2001
by Tom Debley, the Permanente Press, 2009, p. 21
By Ginny McPartland
Millie Cutting was the wife of Kaiser Permanente’s pioneering chief surgeon Cecil Cutting, but her influence on the fledgling medical program during World War II contradicts any cliché prescribing the role of a doctor’s spouse. She was a vibrant, energetic force in her own right, a good woman behind a good man, but much, much more.
The Cuttings met in Northern California at Stanford University in the early 1930s. He was training to become a physician; she was a registered nurse with a degree from Stanford. They met on the tennis courts and married in 1935.
During her husband’s nonpaid internship, Millie Cutting worked two jobs – for a pediatrician during the day and an ophthalmologist in the evenings – to pay the bills. He was making $300 a month as a resident when Sidney Garfield, MD, contacted him about joining the medical care program for Henry Kaiser’s workers on the Grand Coulee Dam in Washington State.
Millie was at first reluctant to leave San Francisco to relocate in the desert. But when Cecil convinced her that he would have more opportunity as a surgeon with Garfield than in San Francisco, she was game. “Oh, she was willing to go along; she had a lot of spirit and enthusiasm,” Cecil Cutting said in his oral history.
“I think with a little reluctance, perhaps of the unknown,” he told interviewer Malca Chall of UC Berkeley’s Regional Oral History Office in 1985. “We didn’t have any money. She had worked during my residency as a nurse, to keep us in food.” Sidney Garfield was able to match the $300 Cutting was earning at Stanford to get him to Coulee.
A rough start at Grand Coulee
Unfortunately for Millie, things at Coulee didn’t start out too well. John Smillie, MD, writes: “Cecil and Millie Cutting resided in the company hotel. They were flat broke. The young couple had exhausted their resources getting to Washington. Neither of them thought of asking for an advance.”1
“My wife couldn’t take the heat very well,” Cutting told Smillie. “She would lay on the bed with a wet sheet over her; and we didn’t have enough money to eat, really. She would go to the cafeteria and see how far she could stretch a few pennies to eat. Of course, I ate well at the hospital and had air conditioning and everything.
“She finally learned to come over and sit in the waiting room on the very hottest days. Since then, Dr. Garfield laughed at us and said, ‘Why didn’t you ask me for money?’ We didn’t know enough to do that!”
“At the end of the first discomforting month, Cutting received his first paycheck for $350,” Smillie writes. “He and Millie moved into a remodeled schoolhouse, the largest home in the community, and it soon became the social center for the physicians and the Kaiser executives.”
Millie gets her groove back
During the rest of their time at Coulee, Millie not only got her energy back but she exhibited her strength as a staff nurse and as a community volunteer. Probably her most significant contribution was the development of a well-baby clinic in a community church. As a volunteer, she organized the clinic and went door to door soliciting funds for its operation. She had no qualms about knocking on the portals of the town’s brothels.
“The madams were very friendly,” Cecil Cutting told Smillie. “The community church provided the space, and the houses of ill repute the money – a very compatible community.”
Garfield’s right hand ‘man’ at wartime shipyards
The Grand Coulee Dam was completed in 1940, and the medical staff and their families scattered. The Cuttings settled briefly in Seattle where Dr. Cutting set up a surgery practice. But it wasn’t very long before World War II broke out and Dr. Garfield was called upon again to assembe the medical troops.
Cecil Cutting was the first physician to arrive in Richmond, California, where Henry Kaiser set up four wartime shipyards. Millie Cutting volunteered to work side by side with Sidney Garfield to get the medical care program up and running and to take charge of any job that needed to be done.
She recruited, interviewed and hired nurses, receptionists, clerks, and even an occasional doctor, to staff the health care program that was set up in a hurry in 1942. She smoothed the way for newcomers and helped them find homes in the impossible wartime housing market.
Thoroughly adaptable Millie drove a supply truck between the Oakland and Richmond hospitals and the first aid stations and served as the purchasing agent for a time. As she had done at Grand Coulee, Millie set up a well-baby clinic for shipyard workers’ families, and she opened her home in Oakland as a social center for the medical care staff.
Perturbing postwar perceptions
After the war, Millie and Bobbie Collen, wife of Morris Collen, MD, started a Permanente wives group in 1949. The association created a support system against an often hostile medical establishment that shunned prepaid group practice of medicine as “socialist.” The physicians were not allowed in the local medical society, and the women felt socially ostracized.
“They organized themselves as the Permanente Wives Association, which had a nickname, ‘Garfield’s Girls,’ ” Smillie wrote. “They had dances, parties, picnics and social outings several times a year that were really a lot of fun. The auxiliary. . .became famous for its rummage sales.”
The Cuttings became good friends with Sidney Garfield, and in fact, he spent periods of time living with them in their Orinda home in the 1940s and 1950s. Cecil Cutting credits Garfield with the couple’s decision in 1948 to adopt their two children, Sydney and Christopher. “He talked us into it,” Cutting said.
Garfield often went to them for advice about business matters, as well. “I think he talked over a lot of things with Dr. Cutting and Millie,” said Smillie in his oral history. “He had a great deal of confidence in their judgment. If they told him he was wrong, he was able to accept it.”
The Cuttings were the friends Garfield chose to share the happy moment of burning the mortgage papers once the renovated Fabiola Hospital (the first Kaiser Foundation Hospital in Oakland) note was paid off. The private celebration took place in the Cuttings’ home with just Garfield and Millie and Cecil present.
Dr. Cutting worked his way up to become the executive director of The Permanente Medical Group in 1957 and retired in 1976 after 35 years as a major figure in the organization. Millie Cutting continued to volunteer at the Oakland Kaiser Foundation Hospital all of her life. She had to quit in 1985 when she became too ill to leave her house. She died that year at the age of 73. Cecil Cutting received a flood of condolence notes from all the people whose lives Millie had touched.
One woman wrote: “When life seemed just too much, Millie’s unforgettable laughter would ring in my mind’s ear, and the will to tackle life again would be there like a gift from her. She didn’t just give. She was a gift.”
1 John Smillie, MD, Can Physicians Manage the Quality and Costs of Health Care? The Story of The Permanente Medical Group, McGraw-Hill Companies, New York, 1991
This blog was originally posted on August 7, 2009
By Ginny McPartland
Isidore “Ig” Falk was a 20th Century hero, but most Americans have never heard of him. Falk was a major figure in the 1930s to 1980s discussion of how health care should be organized in America. He was the head of research for the Senate Committee for the Costs of Medical Care (CCMC), whose voluminous report was published in 1932.
Falk, educated at Yale with a PhD in Public Health, was largely responsible for writing the committee’s recommendations that called for prepaid group practice and integrated health care in America. The committee said that fee-for-service health care should continue to exist, but that in some fashion, quality health care should be made accessible to everyone, rich, poor, and in-between. The committee majority figured that prevention of illness, like public education, was good for the country, as well as for the common man.
Garfield—A grass roots approach
As Ig Falk pursued these ideals on a national scale, another of my heroes—Sidney R. Garfield—was busy putting these ideas into practice on a grass roots level. Born in humble circumstances, Garfield attended medical school at his parents’ insistence and was out to make a living in California during the Great Depression.
For all the right reasons, Falk spent a good chunk of his life advocating for the principles embodied in the committee recommendations. Alas, due to political circumstances, i.e., charges that he was pushing socialized medicine, and a lack of public understanding and support, Falk didn’t succeed in achieving prepaid, coordinated medical care for all Americans. (He’s still a hero in my book.)
Sidney Garfield took care of industrial workers in the California desert on a fee-for-service basis. He soon realized he couldn’t make it if he waited for the patients to come to him. So he made a deal with the workers’ insurance company to pay him in advance for the workers health care. Voila! Prepaid health care that was affordable and sustainable.
Garfield’s troubles begin
With the help of industrialist Henry J. Kaiser, Garfield enhanced and refined his methods of health care delivery and brought them to the World War II home front, and in 1945 introduced his brand of care to the public. That’s when his troubles really began.
Like Falk, Garfield had to fight. He had to fight to keep himself out of jail and in the business of taking care of people. Not only did they call him a socialist or communist, his opponents said he was violating medical ethics, and he was brought up on charges for running a group practice. Anyone who tried to join Garfield’s medical group was scorned by their peers and warned against ruining their careers by being associated with this renegade doctor.
Fortunately, Garfield did not fail. Amid all the obstacles, Garfield kept it together and with the support of organized labor and physicians in academic medicine, today his legacy lives on in Kaiser Permanente. He’s the fellow who pushed his colleagues to get into computers in the early 1960s. He’s the one who pushed the idea that if you screened patients for signs of early chronic illness, you could slow down or stop the advance of disease.
A great model of health care
Garfield is my hero because he persisted in his mission to keep his modest plan alive. He won myriad battles and left us Kaiser Permanente as one of the U.S. models of health care that works. I’m personally glad because I’m one of the lucky ones who have good, no great, health care.
One period of my life when I wasn’t a member of Kaiser Permanente, I sought a mammogram, a vital preventive screening for women. I picked a radiologist out of a network book and I had the exam. Up to a year later, I was still receiving past due notices that my insurance had not paid the claim.
In contrast, in the past two months, I’ve received several letters and phone calls from Kaiser Permanente reminding me that it’s time for a mammogram. When I went in for the exam at a convenient evening hour, my copayment was waived. Somehow I get the feeling that someone is watching over me. Wow!
Health care reform still a discussion
As I’m sure you know, the people in Washington today are wrangling over health care reform again (read, still). Right now the quest for change seems to be stymied by political special interests. Reminiscent of Falk’s time and renewed conversations in the 1940s and the 1990s, transformative change remains elusive. Perhaps a 1997 discussion of Falk’s challenges by Alan Derickson, PhD, in the American Journal of Public Health can help us reach a solution to benefit all Americans:
“If a chorus of demands from many sources were to drown out overheated ideological claims, public discussion might shift to a fuller consideration of human need and the capability of an affluent society to meet it.”
To learn more about Sidney R. Garfield, MD, you can read: Dr. Sidney R. Garfield: the Visionary Who Turned Sick Care into Health Care. The newly released book illuminates for the first time the details of Garfield’s professional and personal struggles and triumphs.
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.
By Laura Thomas
Throughout its history, Kaiser Permanente has relied on the “can-do spirit” of its dedicated workers and on the support of organized labor to keep the prepaid health plan strong.
Coming out of World War II, the medical plan had proven its viability in caring for a large shipyard workforce, but with the end of shipbuilding contracts, Henry Kaiser and Permanente founder and medical director Dr. Sidney Garfield had a big problem. Where were the large numbers of new members going to come from?
Kaiser, a friend of labor, attracted workers’ unions whose leaders understood the power of prepaid health care and wanted it for the welfare of their workers. Bay Area workers – from Oakland city employees, who were the first to sign up, to union typographers, street car drivers and carpenters – embraced the Permanente Health Plan with its emphasis on preventive medicine.
In 1950, Harry Bridges brought the 6,000-member International Longshoremen and Warehousemen Union (ILWU) into Kaiser Permanente, bringing the total West Coast membership, including Los Angeles, to almost 160,000. In 1951, the Retail Clerks union added 30,000 to the membership rolls in Los Angeles.
Opposition tries to squelch KP
Despite this success, Kaiser and Garfield often faced rear guard actions from private practice doctors who felt threatened by group practice medicine. In 1953 when KP opened a new hospital in Walnut Creek and sought the health plan contract with workers in the U.S. Steel plant in Pittsburg, California, all hell broke loose in that small town along the Carquinez Strait.
Before Kaiser Permanente came along, the steelworkers union had both a national hospitalization plan and a local supplementary health plan with local private practice doctors. The workers were not satisfied with the current health plan and were complaining that providers charged too much and were lackadaisical about responding to emergencies and requests for house calls.
For their part, the Pittsburg area doctors argued that inflation required rates to rise and disputed the idea that service to members was lax.
Kaiser Permanente already provided care to steelworkers at the South San Francisco Bethlehem Steel plant and was prepared to expand services to the Pittsburg area. The beginning of KP’s negotiations with the Steelworkers Local 1440 in Pittsburg raised the hackles of the 41 private practice doctors already established in the area.
These doctors, all members of the East Contra Costa branch of the Alameda-Contra Costa Medical Association, quickly devised a new and better plan to offer the union, including 24-hour emergency service and a cap on fees.
Offer steelworkers couldn’t refuse
Joseph Garbarino, in his 1960 study of the Pittsburg conflict for the University of California, reported that the union bargainers welcomed Kaiser Permanente because of its offer to provide comprehensive care for a specific price for a specified period of time. This arrangement was attractive to the local union whose leadership had never before been able to negotiate such a favorable deal with their private practice providers.
The Pittsburg area doctors were furious and immediately mounted a campaign to discredit the Kaiser Permanente agreement. The doctors appealed to the steelworkers to reject the decision of their insurance committee and place the KP plan and the private doctors’ revised offer side by side for a vote of the full membership.
Fred Pellegrin, a Kaiser Permanente physician in the new Walnut Creek facility, remembers a rally where the local doctors “begged us not to go to Pittsburg … People stood up, yelling at us, called us Communists. It was a real shouting match.”
Using full-page newspaper ads, handbills and direct mail, the fee-for-service doctors bombarded the community with arguments supporting their plan and implied that the national Steelworker union officials were investigating the local’s decision.
The union answered the doctors’ charges in its newsletter and then agreed to a Sept. 3 (1953) election. Both sides agreed to a break in hostilities for the month of August. The agreement called for the doctors to stop their campaign and for the union leaders to remain neutral on the election.
The truce ended just days before the election when the union distributed voting packets with both health plan proposals, and included a leaflet encouraging members to favor the Kaiser Permanente plan. Enraged private practice doctors took to the battlements again, issuing a more detailed plan explanation and blasting the union in a full-page newspaper ad.
The doctors hired a truck with a loud speaker that cruised through workers’ neighborhoods broadcasting their opposition to Kaiser Permanente. They enlisted supporters, including Pittsburg doctors’ wives, to distribute literature in the steel company parking lot. Plan B was to drop leaflets from the air if solicitors were barred from the plant. According to news reports, tensions rose and the sheriff’s department was called, but no clashes occurred.
Victory of KP health plan
The Pittsburg medical establishment’s effort failed as steelworkers voted 2,182 to 440 to retain the Kaiser Permanente plan. For KP, this was a victory, but more struggles related to organized labor were yet to come.
Financial troubles in the 1980s and 1990s resulted in labor issues that threatened to stunt the health plan’s progress. Happily, those years of turmoil spawned Kaiser Permanente’s landmark Labor Management Partnership (LMP), which forged a cooperative relationship between KP’s 26 unions and the health plan leadership. The partnership fosters a respectful collaboration to improve health care for members and to create a positive work environment.
Kaiser Permanente unions had a big role in bringing about that partnership. In the midst of hostile bargaining in 1995, union leaders realized the labor disputes could damage the future of the health plan. Kathy Schmidt, a member of the bargaining team from Oregon, recalled, “We realized: here is the most unionized system in the country. Why don’t we try to help them? We learned more about trying to have a Partnership.”
Then-Kaiser Permanente CEO David Lawrence reached back across the abyss and agreed. “What I remember thinking about at that meeting was: We’ve got nothing to lose by being forthcoming about what I believed needed to happen …about the kind of collaboration that I think is required to deliver modern medical care in all of its complexity,” he told Harvard University researchers in 2002.
Today, scholars at both Harvard’s School of Government and Stanford University’s School of Business are following the progress of the LMP and consider it a prime example of labor and management cooperation. Its continued success will contribute to the realization of KP’s goal of being the model for health care delivery in the United States.
Read more about the Labor Management Partnership.