By Ginny McPartland, Heritage writer
Second of a series
Forty years ago, before advanced nursing positions existed, a group of Kaiser Permanente nurses were cutting their teeth in new fields as specially trained nurse practitioners. In the beginning of this journey, these nurses worked in preventive medicine, well baby care and OB-GYN.
Dorola Haley began work with OB-GYN physician Albert Kahane when Kaiser Permanente first opened in Sacramento in 1965. Around 1970, Dr. Kahane received a Kaiser Foundation Research Institute grant to study the role of the nurse practitioner in OB-GYN practice. At the same time, Haley completed the requirements to become a nurse practitioner, and soon she and Dr. Kahane began to take turns seeing patients.
Dr. Kahane was the first in Sacramento County to propose the then-radical idea of fathers in the delivery room. Haley says there was a lot of resistance to this in the medical community, but he believed it to be beneficial for the family and was proven right.
“They wanted to run Al out of town on a rail,” Haley said. (OB-GYN physician Sidney Sharzer pioneered this in Kaiser Permanente in Southern California.)
Dr. Kahane felt that couples would find another way to be together during childbirth if hospitals didn’t modernize. He had been in the U.S. Air Force for four years in Alaska, where this was established practice.
More time to get to know patients
At a recent reunion, several of the early Sacramento NPs talked about how the extra time they spent with patients – a full, uninterrupted 30 minutes – was crucial to the member’s total health. Busy physicians could only rarely devote this much time to a single patient. The NPs’ stories are about striving to reach the ideals of preventive medicine, about getting to know the “whole” patient, and helping him or her to maintain good health.
“We knew our patients’ social history,” said Dianna Costa, an OB-GYN nurse practitioner still working part time for Kaiser Permanente today. “We knew whether the family had a dog, and if they did, who fed the dog. We knew what you (the patient) were eating, and if you exercised. In a 30-minute physical you learn it all. It (preventive care) was huge to us. It was life, not just a physical.”
“If you listen to a patient, really listen, you learn everything you need to know,” remarked Haley. “I’d ask them to tell me what’s going on. For prenatal patients, I’d talk to them about what’s going to happen in the next month.”
Nurse practitioner pioneers praise mentors
Carl Henriques, MD, medical director of the Sacramento Preventive Medicine program, now deceased, was ruthlessly strict in expecting his students to conduct physical examinations and medical histories perfectly. “You could say he was a tough task-master,” recalled Betty Taisch, one of the pioneer NPs.
Taisch recently attended a lecture by Abraham Verghese, MD, author of “Cutting for Stone,” a current best-selling novel. The Stanford University School of Medicine professor described the importance of caregiver-patient trust and rapport – and of touch. “You walk into a room and someone is sitting there with only a piece of paper covering them, and you ask them the most intimate questions,” noted Taisch.
“You have to quickly develop a bond of trust with this person. You have to understand the simple art of putting your hand on their shoulder. As I was listening to him (Dr. Verghese) describe his bedside manner, I was sitting there so proud because I recalled being taught exactly the same things by Dr. Henriques,” Taisch said.
Marge Geary, a nurse practitioner pioneer and health appraisal manager from 1978-1984, chimed in: “The way he taught us was systematic, so that we didn’t miss anything.” Dr. Henriques began all of his progress reports on student Marge Geary in 1972 with “This young lady . . .” Today she is both the assistant medical group administrator and director of nursing practice at Kaiser Permanente South Sacramento.
The early NPs have nothing but praise for Millie Kahane as well. They say she helped them reach for a higher level of professionalism through education and training. “She took a broad view of everything,” Geary recalled.
John Mott, MD, physician-in-chief at Sacramento Kaiser Permanente, summed up the experiment: “(In 1970) the medical climate for NPs was quite different than it is now. The status of the nurse practitioner was not clarified by the California Legislature until 1975.
“Had Dr. Henriques and Mildred Kahane, (BS, MA), slipped, the stature of NPs in California could have been delayed many years. Such are the dangers of living very close to the State Legislature, the Board of Nursing, the Board of Medical Examiners and the Attorney General. . . . (KP) Sacramento membership includes many articulate, highly educated, health-oriented groups . . . who might or might not approve of being examined by a nurse practitioner (rather than a physician).
“Credit should go where credit is due, and Dr. Henriques and Mildred Kahane did a tremendous job pioneering this field.”
By Steve Gilford, Senior Consulting Historian
Southern California physicians to replace plaque dedicated in 1992 to commemorate Sidney Garfield’s Contractors General Hospital
I’ve recently returned from Southern California where I assessed the damage vandals and thieves wreaked to the historical marker near the site of Dr. Sidney Garfield’s 1933-built Contractors General Hospital.
This location is significant because it’s where Kaiser Permanente’s pioneer physician first discovered how prepaid, preventive medicine could make health care more affordable.
The 110-pound bronze plaque, placed at the historical site 21 years ago, has been pried off its base and stolen, presumably for the value of the metal. This is another occurrence of the national trend of thieves dismantling historical markers to turn bronze to cash.
I traveled to the desert not only to evaluate the loss but also to arrange for a replacement plaque. My journey was successful: I found a safe location for a new plaque and an enthusiastic benefactor to pay the bill.
In 100-plus-degree heat that is usual for the area, I surveyed nearby Chiriaco Summit, an active way station for desert travelers, with Margit Chiriaco Rusche, the daughter of founders Joe and Ruth Chiriaco. We found an appropriate site for a new plaque in an island of green vegetation which many visitors pass.
Locating historic hospital site
For me, this mission was personal. Twenty-seven years ago, I uncovered the hospital site where, in 1933, Kaiser Permanente’s founding physician had started his prepaid health plan for workers on the Colorado River Aqueduct Project.
In 1986, Stanley Ragsdale, self-described “desert rat” and owner of Desert Center in Southern California, accompanied me on an expedition to find the long lost site of Garfield’s hospital, six miles west of the little town on Interstate 10.
As we approached the area, we could make out the foundation outlines, which were all that remained of the facility abandoned in the late 1930s. As someone with experience in archeological digs, I headed for the nearby garbage pit, in which I found medical artifacts that positively identified the site.
With this information and other research, I prepared an application and supporting materials for the site’s designation as a historical landmark. The California State Historical Commission unanimously authorized an official plaque recognizing the importance of the tiny hospital to American medicine.
In a 1986 ceremony, Sally Garfield Blackman, Dr. Garfield’s elder sister, unveiled the bronze plaque attached to a boulder near the spot where the once bustling hospital had stood.
Southern California physicians sponsor replacement plaque
Over the past two decades, the dusty town of Desert Center, with its two-block long main street, has fallen on hard times. The restaurant, gas station, general store, and ice cream stand are all gone. With no one around the abandoned town, the plaque was easy pickings for thieves, and several weeks ago they struck.
I mentioned the loss to Paul Bernstein, MD, San Diego area medical director for the Southern California Permanente Medical Group. Bernstein (Twitter: @sdthinkbig), personally interested in the history of Contractors General, is as chagrined as I am by the marker’s disappearance.
He approached the Southern California Permanente Medical Group, and they have agreed to replace the plaque as part of SCPMG’s 60th anniversary celebration in September. This year also marks the 80th anniversary of the hospital’s founding.
Chiriaco motorist stop fitting site for new historic marker
Joe and Ruth Chiriaco founded their first store the same year that Dr. Garfield opened Contractors General Hospital; they knew the hospital and Dr. Garfield well.
Ruth Chiriaco, a registered nurse, had worked in nearby Indio with Betty Runyen, Dr. Garfield’s first nurse. Having met the Chiriacos in my previous research, I was pretty sure the family would be amenable to putting the new plaque near their business that includes a store, restaurant and gas station.
This fall, Dr. Garfield’s favorite nephew and closest living relative, Dr. Robert Blackman, and Blackman’s two sons will participate in the dedication, as will nurse Betty Runyen’s three children. Betty’s daughter Susan, a nurse with Kaiser Permanente in Hawaii, has just finished a novel based on her mother’s life at Contractors General Hospital.
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
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, Heritage writer
In a highly technological world, paper medical charts no longer show up in Kaiser Permanente doctors’ hands when they interact with today’s tech-savvy patients. These collections of hand-written notes of our medical complaints, drug prescriptions, lab tests and more, are going the way of fax machines and typewriters.
They’ve been replaced by Kaiser Permanente’s award-winning electronic medical record system, Kaiser Permanente HealthConnect®, which brings patients much closer to their providers.1
But preserved paper patient records going back to World War II will continue to be a valuable asset for research, even as we trade in the old cumbersome model for the new.
Gary Friedman, MD, retired director of the Kaiser Permanente Division of Research in Oakland, Calif., says Kaiser Permanente’s medical records – whether the original hard copies or digital files– are valuable assets to allow groundbreaking research.
In a 1998 article in The Permanente Journal, Friedman wrote: “Our collection of manual charts going back over 50 years is a national treasure and must be preserved despite the storage and retrieval costs entailed.”
In his 2006 oral history, Friedman said the highly touted study on the value of sigmoidoscopy in preventing colon cancer relied on paper records going back to the 1970s.2
He added: “(In) a recent study I did on the early symptoms of ovarian cancer (we found) by going into the charts (paper records) we could get much more of what the physicians recorded in text about the symptoms these women were having . . . Who knows what question might come up in the future (that could be answered) by looking at these charts that go back to the mid-1940s?”
Kaiser Permanente’s early foray into digital world
Kaiser Permanente’s journey into electronic record keeping started around 1960 and took advantage of emerging computer technology. A desire to prevent chronic disease through pre-symptom screening supplied the motivation to automate routine tests and to compile anonymous patient data for population-based research.
Barbara Breen, a medical assistant at Kaiser Permanente Oakland Medical Center in the early 1970s, had her hands on paper charts as well as on the pioneering electronic medical records of the day. She often stood by as lunch-time relief to ensure the computer ran fluidly as it processed punch cards that coded the results of patient visits for Kaiser Permanente’s complete physical (multiphasic) examination.
She was on the cutting edge of computer technology of the time and was in awe. “I got to see all these brand new machines and they assigned me to the spirometer (to test lung capacity),” Breen recalled recently. “The patients filled out a medical questionnaire (health assessment) and had 90 minutes to go around to all the cubicles where they had the tests.”
Data collected by Breen and others in the multiphasic unit were fed into early computers that took up the basement at 3779 Piedmont Ave., just off of MacArthur Boulevard near Kaiser Permanente’s flagship medical center in Oakland, Calif.
Tracking members’ health over decades
Over the years, these records, now considered invaluable and precious, have been the basis for many Kaiser Permanente longitudinal research projects. Collection of detailed patient data from 1964 to 1972 was made possible by the pioneering computer work of Morris Collen, MD, largely funded by the federal government.
Breen, who worked for Kaiser Permanente for 30 years mostly in the northern San Francisco Bay Area, recalls having the duty to retrieve charts for patients scheduled to come into the San Rafael facilities in the 1970s.
“I got a job down on Fourth Street, which was an old motel . . . General Medicine was downstairs and Internal Medicine was upstairs, and the garage next door is where all the charts were. And in those days, we didn’t have (access to) computers yet, so if you needed a chart ASAP you would order it by phone.
“The chart room didn’t always have an extra person to bring the chart over. So the medical assistant or other (staff person) went out, rain or shine, across the parking lot, into the remodeled garage and picked up your chart.”
Today, Kaiser Permanente medical centers are constructed without medical chart rooms, indicating a confidence that the electronic chart is here to stay. With KP HealthConnect® in place, patients get their routine test results much quicker, and they can discuss their care with their physicians via secure email and mobile devices.
For member convenience, patients who travel can have their medical data downloaded on to a memory stick to take wherever they go. For quality of care, physicians have access to patients’ medical information in any of Kaiser Permanente’s facilities nationwide, enabling better care and avoiding duplication of tests.
1 Kaiser Permanente has been awarded Stage 7 honors by the Health Information Management Systems Society Analytics for 36 of its hospitals. Stage 7 is the highest award in the category and recognizes environments in which paper charts are no longer used to deliver patient care. KP was also honored with the HIMSS Davis Award for excellence for 2011. The 2013 annual HIMSS conference is under way in New Orleans through Thursday, March 7.
2 Selby, JV, Friedman, GD, Quesenberry CP Jr, Weiss NS. A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. New England Journal of Medicine 1992.
Also see: “Screening for Better Health: Enter the Computer”
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
Fourth in a series
In 1956, my grandfather died suddenly of a heart attack. He was 56. I never got to know him. Grandpa Barr, a life-long inhabitant of rural Iowa who had weathered the Great Depression and sent a son to war, didn’t know what hit him. He had no idea he had heart disease, and even if he had been diagnosed, his small town doctor had little in his black bag to prevent his early demise.
In the 1950s, physicians and researchers had no more than an inkling of how they could treat cardiovascular disease. In fact, physicians weren’t sure of the causes of heart attacks, and researchers were struggling to put together the heart disease puzzle.
Fifteen years later my mother told me she would probably die of a heart attack in her 50s like her father. Almost true to her prediction, she developed heart disease in her 60s. In her 70s she told me she was living on “borrowed time.” Maybe she was, but with lots of drugs, plenty of visits to the medical center and the installation of a pacemaker, she made it to the age of 87.
The difference between my mother’s fate and her dad’s is an amazing body of research and advances in technology that makes it routine in 2012 for doctors to be able to extend the lives of heart disease victims by decades.
A kernel of evidence emerges in the 18th Century
The earliest recognition of what might cause heart attacks was documented in 1772 when Edward Jenner, an English physician, noted hardening of the coronary arteries in the autopsy of a heart attack patient under his care.
“. . .after having examined the most remote parts of the heart, without finding any means for which I could account for his sudden death, or the symptoms preceding it, I was making a transverse section of the heart pretty near its base when my knife struck against something hard and gritty, as to notch it. I well remember looking up at the ceiling, which was old and crumbling, conceiving that some plaster had fallen down. But on further scrutiny the real cause appeared: The coronary arteries had become bony canals,” Jenner wrote to his colleague, Caleb Hillier Parry.
In 1938, O.F. Hedley, MD, a Philadelphia public health official, discussed Jenner’s letter in an article in the American Journal of Public Health (AJPH). “The opinion Jenner expressed concerning the progressive nature of the underlying changes was prognostically prophetic, for medical science still waits methods for preventing coronary artery disease or satisfactorily postponing its more serious consequences.”
Long journey to understanding heart disease
Many decades have gone by since Jenner first implicated atherosclerosis (hardening of the arteries) as a culprit in heart disease. In the intervening years, researchers have inched forward in their quest to bring down the heart disease death toll.
In a 1927 AJPH article, William Munley, a New York physician, reported that between 1910 and 1925, New York City’s deaths from heart disease had increased by 50 percent – from 175 per 100,000 population to 266 per 100,000. He estimated that 2 million Americans were afflicted with heart disease at that time. The statistics had shifted so that atherosclerotic heart disease accounted for 40 percent of the deaths while rheumatic heart conditions made up 25 percent. (Syphilitic heart disease made up 10 percent with the rest in the category of unknown cause.) Rheumatic heart disease, thought to be the main cause of heart attacks and failure until the 1920s, had been largely conquered through public health efforts to eradicate rheumatic fever, which often left a damaged heart.
Munley wrote: “We have no established facts concerning the prevention of the degenerative types of heart disease. It is true that much has been written of the physical stress and nervous strain of the present-day (1927) mode of living as a factor in the production of high blood pressure and hardening of the arteries. . . While no preventive methods are at present known for this type of disease, people can be taught the right way to live. Though we cannot cure this disease, we can hope to relieve some of the suffering produced by it and thus hope to prolong life.”
So that was medical researchers’ mission for the next six decades: find ways to treat coronary atherosclerosis and high blood pressure to prevent early death. Technical advances in the 1920s and 1930s gave birth to the first blood pressure monitor and the electrocardiogram (EKG), both useful diagnostic tools. Researchers also forged ahead to discover ways to prevent heart disease, and other chronic conditions, through exercise and dietary and lifestyle changes.
Federal government gets into the act
In 1948, the federal government, recognizing heart disease as a growing threat to public health, sponsored the Framingham Heart Study, a compilation of the health data of thousands of ordinary people in Framingham, Massachusetts. Data collected initially from 6,000 residents was used to make the connection between the study group’s health, diet, medical history and lifestyle and the eventual development of heart disease. The now-legendary project has followed three generations and spawned over 1,200 research articles, shedding light on many aspects of heart disease.
In the early 1960s, the Framingham researchers published results that showed cigarette smoking, high cholesterol levels, high blood pressure and abnormalities in EKG results indicated increased risk for heart disease. In 1967, they found that physical activity reduced the risk of heart problems while obesity increased the probability.
In 1970, they published studies that identified high blood pressure and atrial fibrillation (uncontrolled fast heart rate) as risk factors for stroke. In 1976, they found menopause increased the risk of heart disease; in 1988, they learned that high levels of the “good” cholesterol HDL (from fats such as avocados, olive oil, fish oil and nuts) reduced the risk of heart disease.
KP researchers undertake key studies
Meanwhile, other organizations, including Kaiser Permanente, were conducting studies of their own. In 1959, KP joined with the Public Health Institute and UC Berkeley for the Child Health and Development Studies (CHDS), a collection of data from 15,000 East Bay pregnant health plan members from 1959 to 1967. CHDS scientists continue to use the data collected 50 years ago to study biologic, behavioral, genetic and environmental factors in early family life and how they affect the health of the subjects as adults.
In 2010, these researchers published a study that established a connection between preeclampsia (high blood pressure and protein in the urine) in pregnancy and heart disease later in life. Of the women who participated in the early study, 481 developed preeclampsia and 266 of them died of cardiovascular disease many years later. This link gives physicians and patients knowledge of an increased risk that can be ameliorated with preventive measures. CHDS researchers are taking the longitudinal study to a new level today by following up with the adult children whose mothers participated in the initial study.
In 1971, researchers in the California Department of Public Health and the University of California at Berkeley published an 18-year follow-up study of 3,263 Oakland and San Francisco longshoremen who participated in the Kaiser Permanente multiphasic (comprehensive health check-up) examinations in 1951. The study revealed that 350 of the participants – all male – had died of heart disease and 93 of stroke by 1970.
Researchers separated out the high- and low-risk populations and identified four categories associated with cardiac death: already having heart disease and/or high blood pressure, smoking one or more packs of cigarettes a day and being overweight. The study also found that the heart attack rate was less for men who had physically demanding jobs.
Total Health Project focuses on prevention
By 1981 the understanding of what causes heart disease had progressed far enough to spur KP founding physician Sidney Garfield to launch a study essentially to test patients’ willingness to change their lifestyle to prevent chronic disease. He invited new KP members to complete a health self-assessment and to have a comprehensive physical at the experimental Total Health Center in Oakland. The participants were encouraged to avail themselves of expanded groundbreaking health education services to learn more about how to preserve their good health.
The Total Health Project gave rise to enhanced health education services throughout the KP health system so physicians could refer their patients to programs that could help them prevent disease and to manage chronic disease when it struck.
In 1985 the Division of Research (DOR, Oakland, CA) collaborated on a study of young adult men and women, black and white, from Oakland, Chicago, Minneapolis and Birmingham, Alabama. The Coronary Artery Risk Development in Young Adults (CARDIA) followed 5,000 Americans who were 18 to 30 years of age in 1985-86 to middle age 20 years later.
The 20-year follow-up study showed that the participants gained an average of 30 to 35 pounds. Testing of the participants, now 38 to 50 years of age, showed that 18 percent had calcification of the coronary arteries (atherosclerosis, a precursor to cardiac disease).
Evidence of early disease was most common in those whose high fat diet and lifestyle increased their risk. The CARDIA researchers also found that individuals who continued to be physically active into middle age, particularly women, gained less weight over the years compared to those who were sedentary.In 1998, a KP Division of Research team worked with UC San Francisco to study the usage and effectiveness of beta-blocker drugs prescribed for patients after an acute myocardial infarction (heart attack). The research team focused on 396 patients who took beta-blockers and compared their experience with the rest of the 1,050 study group. They concluded the use of beta-blockers, even in a lower dose than initially recommended, resulted in 38 percent fewer heart attack deaths.
Physicians associated with Kaiser Permanente’s Center for Health Research (Hawaii and Oregon) collaborated in studies in 1995, 1997 and 1999 to assess the success of the Dietary Approaches to Stop Hypertension (DASH) trial involving Americans with high blood pressure. Ethnically diverse study subjects followed one of three diets in the research carried out in four clinical centers across the country.
In the 1999 study, hypertensive participants who followed the DASH fruit and vegetable diet or the expanded combination diet, which also included whole grains, low-fat dairy, fish, poultry and nuts, experienced significant reductions in 24-hour blood pressure. The others who continued to eat a regular American diet of red meat, sweets and sugary soda saw no reduction in blood pressure.
KP’s aggressive approach to heart disease two-pronged
In the past decade, Kaiser Permanente has made great strides in attacking heart disease. On the research front, studies have been done to validate drug therapies (i.e. beta blockers, aspirin, etc.) that stave off heart attacks and keep heart disease patients alive. This research includes a major study between 1999 and 2008 that showed a marked decrease in the number of KP patients who died following a heart attack.
In 2010, KP’s Division of Research published “Population Trends in the Incidence and Outcomes of Acute Myocardial Infarction,” in which they reported a 24 percent decrease in heart attacks among KP patients during the study period. They also reported a 62 percent decrease in serious heart attacks that do permanent damage in the same time frame. This decline in heart attacks contributed to the KP Northern California region’s status as an island where heart disease is no longer the number one cause of death, as it is in the rest of the country.
KP’s second approach is prevention with a capital “P.” In the literature it’s sometimes called “primordial prevention.” This is defined as the individual’s commitment to improve his or her lifestyle to maintain a healthy weight, exercise and avoid heart disease. Kaiser Permanente’s “Thrive” campaign, launched in 2004, was initiated to highlight the health education and prevention programs that help KP members to keep their risk of chronic disease low.
Farmers’ Markets sponsored in every KP region, Community Benefit programs to reach out to underserved populations living in healthy food “deserts,” online Healthy Lifestyle programs, “Everybody Walks,” “Safe Routes to School,” and other exercise campaigns, as well as participating in community health promotion events, all contribute to KP’s Community Health Initiative.
Kaiser Permanente is one of the sponsors of the Home Box Office (HBO) documentary on obesity in America that premiers on May 14 and 15. For more information about KP’s part in fighting this epidemic: http://bit.ly/IJHVhm
Next time: Diabetes mystified researchers and doctors for 3,000 years.
By Ginny McPartland
Nurses have a friend in the music business, I discovered recently. Country Joe McDonald, who many will remember as the creator of one of the most famous anti-Vietnam war anthems, has become enamored with nursing angel Florence Nightingale and her dedicated, compassionate and intelligent successors.
McDonald, who inspired 300,000 Woodstock Festival revelers in 1969 with his “I Feel Like I’m Fixin’ to Die Rag,” today sings the praises of nurses who carry on the tradition begun by Nightingale in 19th century Europe.
He has developed a comprehensive Florence Nightingale Web site and a 50-minute live show that incorporates the story of Nightingale and of the many who have followed in her footsteps, especially in times of war. In the road show, McDonald performs four original songs of tribute to nurses.
Nightingale marshaled female forces to care for war victims
An upper-class Englishwoman, Nightingale (1820-1910) embarked on an aggressive nursing mission in her early 30s. In 1854, she essentially forced the English army to allow her and 37 other women to take care of wounded soldiers on the Turkey battlefront in the Crimean war. At first the army rejected the women’s help but relented and welcomed the nurses when the casualties became overwhelming.
The first action Nightingale took was to clean up the hospitals and the patients to prevent unnecessary deaths from infections. After the war, she implemented sanitary measures in English hospitals and applied her mathematical skills to collecting data and showing how by insisting on sterile environments nurses could save lives.
Nurses stand by soldiers in war
McDonald, who co-founded the 1960s rock band Country Joe and the Fish, became interested in Nightingale when he went to a 1981 seminar about the problems of Vietnam veterans in Berkeley, California. His eyes were opened to the contribution of nurses throughout history, and he realized that nurses who cared for the war-injured had not been adequately recognized.
“One speaker was a Vietnam War nurse named Lynda Van Devanter who was the first Vietnam War nurse to ‘come out’ and speak for women in the military. As a member of the audience I was stunned at the realization that I was also guilty of ignoring women in the military in my writings,” relates McDonald, who joined the U.S. Navy in 1959 but did not see action.
After the seminar, he looked up nursing in the encyclopedia and found a biography of Florence Nightingale, considered the founder of modern nursing. Next he went to the now-defunct Holmes Bookstore in Oakland, California, and bought an autographed copy of Sir Edward Cook’s Nightingale biography. McDonald devoured all he could find about Nightingale’s life and work – and was hooked.
“I visited Florence Nightingale’s home at Embley (England) along with her gravesite at East Wellow, her summer home Lea Hurst (in Derbyshire, England), the Selimiye Barracks Hospital in Turkey (scene of the care of the Crimean War victims), and Kaiserswerth in Germany (where she graduated from nursing school). I began work on a major film treatment of her life. I am still working on that film treatment and am still a student of her life,” he writes on his Web site.
Singing praises to the lady nurse
One of McDonald’s tribute songs, “Lady of the Lamp,” recalls Nightingale’s nightly walk among the mass of war injured during the Crimean War. Carrying a lamp, she covered a four-mile route as she checked on patients lying on cots 18 inches apart. Legend has it that the soldiers kissed her shadow as she passed.
McDonald has also penned and performed three other songs, “The Girl Next Door (Combat Nurse),” “Clara Barton,” and “Thank the Nurse.” “The Girl Next Door” is the closest to McDonald’s Vietnam War protest message, with the lyrics pondering the “why” of war. The song begins:
She grew up in America, just the girl next door
Never thought to question what we were fighting for
They sent her off to war and showed her death and pain
And the girl next door will never be the same.
You can see the similar sentiments in McDonald’s spirited and passionate “I Feel Like I’m Fixin’ to Die Rag:”
Well come on all of you big strong men, Uncle Sam needs your help again,
he got himself in a terrible jam, way down yonder in Vietnam,
put down your books and pick up a gun, we’re gunna have a whole lotta fun.
and its 1,2,3 what are we fightin for?
don’t ask me i don’t give a dam, the next stop is Vietnam,
and its 5,6,7 open up the pearly gates. Well there aint no time to wonder why…WHOPEE we’re all gunna die.
now come on wall street don’t be slow, why man this’s war a-go-go,
there’s plenty good money to be made, supplyin’ the army with the tools of the trade,
just hope and pray that when they drop the bomb, they drop it on the Vietcong.
Affinity for nursing runs in the McDonald family
The last song “Thank the Nurse” pays tribute to the everyday nurse who does the hard work of standing by the sick night and day. The lyrics are timeless but apropos for today. Joe McDonald should know about a nurse’s daily work: His wife Kathy McDonald is a labor and delivery nurse at Kaiser Permanente (KP) Oakland, California, and his brother Billy is a nurse practitioner at KP in nearby Richmond.
Thank the Nurse that’s nursing you.
The one that nursed you through.
Thank the Nurse that’s nursing you,
For saving your life….for saving your life..
For SAVING YOUR LIFE!
“Country Joe’s Tribute to Florence Nightingale and Nursing,” debuted at the Berkeley Fellowship of Unitarian Universalists in 2009. Joe continues to take the show on the road and will perform March 2 at Emporia State University in Emporia, Kansas. Audio clips of his songs and the lyrics are available online.
McDonald’s Web site has an educational bent, and teachers can find encyclopedic quality facts about Florence Nightingale and her legacy. Visitors to the site can even access a YouTube video that has an 1890 audio of Nightingale speaking. She recorded a segment for an English cancer prevention campaign in which she said: When I am no longer even a memory – just a name, I hope my voice may perpetuate the great work of my life.”
By Tom Debley
Director of Heritage Resources
The world was changing dramatically 65 years ago this week. The war in Europe was over, and Japan would surrender within a few weeks. In Richmond, Calif., the last Victory ship built in the Kaiser Shipyards was readied for launch on July 28. Above the ship, the S.S. Burbank, the word ‘Aloha’ in giant letters was suspended between two cranes.
An orchestra played Hawaiian music, guests wore leis made from fragrant pikake blossoms, and Henry J. Kaiser’s wife, Bess, cracked the traditional flower-wreathed bottle of champagne across the bow.
“In launching the last of the Victory ships, we are not registering a finality,” said Kaiser, “but beginning the second phase in the achievements of our industrial family.”
Looking on were Kaiser’s two adult sons, Edgar and Henry Jr.
It was said 10,000 people were on hand, including shipbuilders who had worked on the very first Victory ship. They sang “Aloha” to Mr. and Mrs. Kaiser and, as the S.S. Burbank slid down the way into San Francisco Bay, flowers tossed from the deck showered the crowd.
The symbolism of the “Aloha” theme has only grown over time. The Hawaiian word is used to say both goodbye and hello. America was saying farewell to World War II, and greeting the post-war world. Henry Kaiser was leaving shipbuilding and embarking on new ventures—including opening the Permanente Health Plan, later renamed Kaiser, to the public. And he was advocating for national reforms that would make health insurance available to all Americans.
Indeed, days before the launch of the S.S. Burbank, Kaiser announced he had drafted a legislative proposal that he presented to several U.S. Senators to create a national program of voluntary prepaid medical care.
“…The greatest service that can be done for the American people,” said the preamble to Kaiser’s 1945 proposal, “is to provide a nationwide prepaid health plan that will guard these people against the tragedy of unpredictable and disastrous hospital and medical bills, and that will, in consequence, emphasize preventive instead of curative medicine, thereby improving the state of the nation’s health.”
These events also were coupled with opening the Permanente Health Plan and Hospitals to the public under the leadership of physician co-founder Sidney R. Garfield. Thus, this week became the springboard for the 65 years—to date—of continually defining the future of health care with the growth and leadership of Kaiser Permanente . (See: Opening a Prepaid Health Plan to the Public 65 Years Ago this Month.)
This would be Kaiser’s ultimate legacy.
As the preeminent California historian, Kevin Starr, has noted, “After all the things he did—the great dams he had built, the great waterways, the unprecedented work in the shipyards—Kaiser knew that this was the thing that would last.”
Or, as Kaiser, himself, said on several occasions in the last years of his life in Hawaii, “Of all the things I’ve done, I expect only to be remembered for…filling the people’s greatest need—good health.”
National health care legislation failed in 1945 and many times thereafter, but Kaiser, Dr. Garfield and their successors have persisted in advocating for heath care for all ever since and saw President Obama sign the Affordable Care Act last March 23. That came exactly 65 years and 20 days after the official date of Henry J. Kaiser’s original “Proposal for a Nationwide Prepaid Medical Plan Based on Experience of the Permanente Foundation Hospitals,” which had been prepared in consultation with Dr. Garfield.
Today, Kaiser and Garfield are honored for their contributions on the Home Front of World War II at the Rose the Riveter/World War II Home Front National Historical Park for making prepaid medical care “a legacy of the WWII Home Front.”
(Special thanks to Veronica Rodriguez, Museum Curator at the Rosie the Riveter/World War II Home Front National Historical Park, for locating and sharing use of the program images for the launch of the S.S. Burbank Victory, July 28, 1945.)
By Ginny McPartland
Preston Maring, MD, the Oakland Kaiser Permanente physician who has nurtured our farmers’ markets nationwide, is being honored by the National Park Service (NPS) with the 2009 World War II Home Front award.
The award will be presented to Maring during Richmond’s annual Home Front Festival 2:25 p.m., Saturday, Oct. 3, in the Craneway Pavilion on the Richmond waterfront. Admission to the festival is free. The theme of this year’s all day event is “We Grow When We Come Together,” highlighting victory and community gardens.
Dr. Maring is receiving the award for his role in “keeping the legacy of World War II victory gardens alive by establishing farmers’ markets at Kaiser Permanente and by promoting the role of fresh produce in preventive medicine,” said Carla Koop of the NPS.
Last year’s recipient of the Home Front award was Faith Petric, renowned folk singer and Home Front New Jersey shipyard worker who has championed union, civil rights and anti-nuclear movements since the 1930s.
Dr. Maring started the Friday Fresh farmers’ market at the Oakland Medical Center in 2003. Since then, he has helped to grow 35 more local produce markets at Kaiser Permanente facilities across America. Kaiser Permanente has also supported other farmers’ markets in communities near our medical centers and clinics.
Dr. Maring, an OB-GYN physician with 38 years experience, authored the introduction to EatingWell in Season, the Farmers’ Market Cookbook, published in 2009 by EatingWell magazine. He has been acclaimed nationally, interviewed by many writers and appeared on “Good Morning America Health” in April.
Here are some examples of his yummy, accessible recipes: Moroccan Tomato Soup, the Quarterpounder Revisited, healthy Mash Potatoes, Radicchio with Chicken, Pine Nuts, Raisins, and Orange/Balsamic Vinaigrette salad, and Strawberry, Yogurt and Granola Parfait. For more recipes, go to: recipe.kaiser-permanente.org
Preventing Disease through Healthy Eating
Kaiser Permanente first took on the role of encouraging healthy eating as preventive medicine in the Kaiser Shipyards during the war. Dr. Sidney R. Garfield, founder of the medical care program, and his fellow physicians urged shipyards workers to grow their own fresh fruits and vegetables in the face of shortages.
The shipyard newsletters often carried articles instructing workers to eat a balanced diet, including vitamin-rich produce, to stave off illness and build the stamina to work at a pace and intensity to meet seemingly impossible goals and deadlines.
Kaiser Permanente is a sponsor of the Home Front Festival and will have an exhibit in the Craneway Pavilion at the Oct. 3 event. The display will chronicle the birth of Kaiser Permanente’s preventive care program in the West Coast Shipyards.
Garfield Biographer to Speak at Festival
Also, Heritage Resources Director Tom Debley will speak during the festival on the Red Oak Victory ship docked at historic Shipyard No. 3, which is part of the Rosie the Riveter/WWII Home Front National Historical Park. Debley will discuss the life and achievements of Sidney R. Garfield, MD, who launched the nation’s largest Home Front medical care program at the Kaiser Shipyards.
Debley is the author of Dr. Sidney R. Garfield: The Visionary Who Turned Sick Care into Health Care, published this year. His talk will begin at noon. Free shuttles will be available to take festival participants from the pavilion at the end of Harbour Way South to the Red Oak Victory, located west of the Craneway in the historic Shipyard No. 3 (Port of Richmond).
For more information about the Home Front festival: homefrontfestival.com