By Laura Thomas
First of two articles
Seventy-five years ago, two-thirds of American women gave birth at home with no painkillers, often attended by a family doctor, as the tradition of relying on midwives and practical nurses was falling away.
The practice of modern obstetrics was on the rise and the trend toward the majority of births occurring in hospitals was just around the corner as the American Medical Association met in Kansas City in May 1936 and hotly debated the benefits of new childbirth analgesics and how far to go in relieving the pain of childbirth.
According to Time Magazine, Dr. Gertrude Nielsen of Norman, Okla., denounced such pain killing innovations as twilight sleep – a combination of morphine and scopolamine – and a synergistic anesthesia accomplished by injecting a mixture of morphine and Epsom salts into the muscles and introducing a mix of quinine, alcohol and ether in olive oil into the rectum.
“An analgesic that is perfectly safe for both mother and child has not been discovered,” she told the convention. She asserted that fear of childbirth contributed to pain and called for prenatal education to reduce fear: “That is the modern physician’s duty.”
Part of the tumult over the issue had been provoked by articles in the press describing these new drugs and their use. Dr. Buford Garvin of Kansas City observed: “American obstetrics seems to be becoming a competitive practice to please American women in accordance with what they read in lay magazines.”
Childbirth trends change dramatically in the 1960s and 1970s
We could fast-forward to the 1950s when hospital childbirths had become the norm, the pain of the experience was reduced by epidural anesthesia and women relinquished control over the process to the physician. When Dr. Sidney Sharzer joined Permanente in Southern California in 1956, he became an early proponent of change.
During prenatal consultations Sharzer encouraged women to consider breastfeeding, advice which ran counter to the then-popular American pediatric practice of giving “modern” formula. At the University of Toronto, where he received his degree, breastfeeding was still considered preferable: “It provided early immunity and was just the right formula in that there were no problems with digestion and it was the right temperature,” he said.
Formula was seen as a convenience, especially for many women who remained in the workforce after World War II, and it allowed fathers to take part in infant care. It was also heavily promoted by the cereal companies who manufactured it. Most of Sharzer’s patients were bombarded “with a lot of propaganda, or advertising, as we call it,” he said, and resisted his advice. “If you bottle-fed, you were liberated. And, in those days, you were not going to whip out your breast at a shopping center.”
“Liberated” women demand natural childbirth
Ironically, it was the “liberated” women of a later era who demanded a more natural approach to childbirth and support for breastfeeding. Those whispers from the 1930s questioning drug use were getting louder.
“The mid-1960s and early 1970s saw a wholesale consumer revolt against highly structured, hospital-centered prenatal care,” Sharon Levine, MD, Northern California Permanente Medical Group executive, testified before a U.S. Senate committee in 1995. “Rooming in became commonplace. Home deliveries returned. Nurse midwives, who had all but disappeared from the American health system, became increasingly commonplace.
“Maternal-infant bonding became recognized as an essential part of postnatal care. Breastfeeding of infants made a dramatic resurgence,” she said in her testimony against a law to dictate length of hospital stay for new mothers.
Some innovation had already occurred at Kaiser Permanente. In the mid-1950s at Permanente founding physician Sidney Garfield’s behest, the “rooming-in” program began at new facilities in San Francisco, Walnut Creek and Los Angeles. In these early “dream hospitals,” the nursery had been built adjacent to the maternity rooms with slide-through drawers for the babies to be passed in from the nursery through a soundproof wall.
The baby-in-the-drawer configuration allowed a mother to pull the baby into her room to nurse and hold her child as long as she desired. “It keeps mother and baby closer together. Nurses are able to help the new mothers learn better how to care for their infants,” said a Kaiser Permanente newsletter of the era. Most hospitals of the time kept newborns separate from their mothers, under the care of the nursing staff, except for feeding times.
Bringing dad into delivery room
Around 1961, when he took over as chief of service at Harbor City Hospital, Sharzer made a couple of bold moves. He decided to bring fathers directly into the birthing room, and he began to encourage women to use the “prepared childbirth” techniques. He was inspired by British doctor Grantly Dick-Read’s book, “Childbirth without Fear,” which advocated the use of breathing techniques to minimize pain and increase the joy of the experience.
Lamaze breathing techniques were introduced in the U.S. by Marjorie Karmel after she gave birth in France assisted by Dr. Fernand Lamaze, who developed his techniques based on Dick-Read’s. She started an organization in 1960 – now Lamaze International – that currently focuses less on birthing methods and more on achieving a natural childbirth without drugs or technological intervention.
Sharzer remembers his struggle to get these ideas accepted: “The consumers were pushing for it and it was the right thing…husbands should see what their wives are going through.” At the time, fathers were ushered into a waiting room or went home to await a phone call and while some were thrilled to be invited to watch the process, others were less so. The nurses would good-naturedly chide a reluctant father. “They’d say he was a lousy husband to desert his wife at a time like this. They would appeal to his better nature and then insult him,” Sharzer said.
Outside of Harbor City, it was an uphill fight. When Sharzer first suggested the notion to his colleagues at the five other Permanente Southern California facilities, he was voted down 5 to 1. There was a lot of hostility from both doctors and nurses who assumed the fathers would try to get in the way by second guessing the medical staff, he said. But even their resistance couldn’t stop the forces of history. Fathers were finally allowed in delivery rooms at all Southern California facilities by the end of the 1960s.
Sharzer moved on to West Los Angeles in the 1970s and became assistant medical director: “It gave me the opportunity to be innovative.” There, he was able to inspire younger and more progressive doctors to go along with the trend toward treating childbirth as a natural process.
Natural birth after C-section?
Sharzer questioned the long-held “once a cesarean, always a cesarean” policy after he observed countless women scheduled for cesarean arrive at the hospital late in labor and give safe births. “If it’s that dangerous, how come these women come in and two minutes after they hit the bed, the baby comes out naturally?” he said.
Doctors feared that the vertical incision made through the large uterine muscle would rupture during contractions and for years women who had had a cesarean were discouraged from having subsequent vaginal births. But an innovation – the transverse incision made across the lower belly – was introduced that reduced the likelihood of rupture and more doctors began to experiment with allowing women to try vaginal births, under close monitoring.
A five-year study of vaginal births after cesarean deliveries in multiple hospitals showed that reverting to a natural birth process could be successful for many women. “Kaiser Permanente conducted the definitive study concluding that vaginal birth after a prior cesarean section is possible and safe … vaginal births are generally safer and less expensive for the mother and infant,” Permanente’s Dr. Levine told senators.*
Sharzer recalls: “A doctor had to be present all the time and there was a lot of resistance” among the general obstetrical crowd, but at Kaiser Permanente, vaginal birth after cesarean, known as VBAC, was easier to implement because a doctor was always on duty in the maternity ward. “In our setup, it was very good and we were one of the early ones to do VBAC.”
Nurse practitioners deliver prenatal care
In those years, Sharzer also helped establish the first program in Southern California for training nurse practitioners at Cal State Los Angeles and when they graduated, he hired them to work under supervision assisting the doctors with prenatal care.
Retired since 1993, after delivering some 7,000 babies at Harbor City and West Los Angeles, Sharzer attributes the tremendous change in maternity care since 1960 to the Civil Rights Act of 1964: “It also changed the philosophy of equality…and that applied to women in our society. It had a lot to do with female power.”
That piece of legislation guaranteed equal rights to women as well as African-Americans. But women, especially those active in the civil rights and anti-war movements, found themselves relegated to supportive roles to male leadership and many split off and created the feminist movement, founding the National Organization for Women, among others. Health care and childbirth became a major arena in women’s struggle for equality and power over their lives.
Next time: How Kaiser Permanente responded to member demands for shorter postpartum hospital stays.
*Flamm BL, Newman LA, Thomas SJ, Fallon D, Yoshida MM. Vaginal birth after cesarean delivery: results of a 5-year multicenter collaborative study. Obstet Gynecol 1990: 76(5 pt 1):750-4.
By Ginny McPartland
Last in a series
The history of nursing at Kaiser Permanente actually begins in 1933 with Betty Runyen, Dr. Sidney Garfield’s sole nurse at the Desert Center Hospital near the construction site of the Los Angeles Aqueduct. Runyen, a young nursing graduate from Los Angeles, was just starting out and looking for adventure.
She was well aware of the early 20th century restrictions on her career options. Her mother had told her she could be a secretary, a teacher or a nurse. Nursing sounded the most intriguing. She became bored with her first job helping to birth babies, and sprung at the opportunity to help launch this pioneering hospital in the desert.
In 1933 nurses were not expected, or even allowed, to perform such a task as starting an IV (tube to introduce liquid intravenously). But Garfield, co-founder of Kaiser Permanente with Henry J. Kaiser, was forward thinking. He had taught Runyen how to start an IV, and the skill came in handy one day when she received an emergency call that one of the workers had succumbed to heat exhaustion. Dr. Garfield was not around, so she drove the ambulance to the job site and immediately inserted a saline IV. The patient quickly recovered.
KP history reflects national trends
Nursing history is also punctuated with challenges related to the nurse’s evolving role on the medical care team and with major changes in technology, including medical equipment and use of computers to record medical notes.
In the 1960s, 1970s, and 1980s care of patients shifted away from the hospital to outpatient settings. Advances in technology made it possible for surgery patients to spend less time in the hospital, and Medicare reimbursement policy revised in 1983 dictated shorter hospital stays. Despite a growing and aging population, the length of stay national average trended down from 8.5 days in 1968 to 6.4 in 1990 to 4.8 in 2005, according to the Centers for Disease Control (CDC).
These changes spawned the same day surgery program that allowed patients to have a procedure without staying overnight. The KP home care program was beefed up to provide surgery and hospitalization follow-up. Outpatient chronic condition management – for the benefit of the patient and the health plan – became ever more important to minimize the time patients had to spend in the hospital. Changes in maternity care also led to shorter hospital stays and an emphasis on family-centered perinatal practices.
New nursing specialties emerge
New categories of nursing have popped up throughout the decades. In the 1970s, the nurse practitioner role was developed to perform many of the tasks formerly done by the physicians. For example, the KP multiphasic or annual physical, initiated in the 1950s for the longshoremen’s union and expanded to the general membership, began to be administered by nurse practitioners working under supervision of physicians. Nurse practitioners were also tapped for well baby care and routine pediatrics visits as medical roles morphed during a critical shortage of medical manpower in America.
With KP’s emphasis on preventive care, its nurses have been called on to create outpatient education programs to help members manage their own health in partnership with their medical care team. Nurses have become specialized in outpatient management of chronic conditions such as heart disease and diabetes, and in providing home and hospice care. Specialized nursing roles have multiplied exponentially over the decades with today’s nurses trained in every aspect of medicine: surgery, intensive care, cardiac care, obstetrics, geriatrics, orthopedics, and the list goes on.
By Ginny McPartland
First in a series
Like other underappreciated groups who came home to a seemingly unchanged society, nurses were discouraged and hesitated to pursue their chosen profession due to low pay, low status and poor working conditions. Many nurses chose to be waitresses or factory workers where they could make more money and work more reasonable hours. The exodus from the nursing profession created a shortage of qualified nurses, which would intensify in later years.
Home-front nurses had been content to work without making demands during the war emergency. But after the war, they wanted more. Alameda County nurses had affiliated with the California State Nurses Association (now California Nurses Association or CNA) in 1941 and relied on the association to represent them to East Bay hospitals administrations. But in 1945 these nurses realized that the statewide association had not been effective in bringing them better pay and working conditions.
The association had developed employment guidelines for the benefit of nurses, but the association had no power to force hospitals to follow the voluntary rules. The East Bay Hospital Conference, made up of administrators from 12 hospitals, adopted a “Statement of Policy” regarding nursing issues in 1941, and dropped it after the war emergency was over.
Alameda County nurses form their own guild
Major Edith Aynes, a recruiter from the Army Nursing Corps, gave force to the East Bay nurses’ argument that their profession deserved a better status. Quoted in the San Francisco Chronicle in 1946, Aynes spoke about the military model of the registered nurse as someone who performed patient care, while other untrained staff performed peripheral menial tasks.
“Instead of taking temperatures, serving (food) trays, making beds and carrying bath water, the nurse is free to change dressings, give medications, care for sick patients and in general supervise the entire ward,” Aynes said.
Alameda County nurses took Aynes’ message to heart and decided to form their own nurses union in November of 1945. “The objective of the guild will be to establish standards relating to salaries, personnel practice and conditions of employment and to maintain an economic security program for registered nurses, members of the guild,” Kathleen Koepke, president of the guild, told the Oakland Tribune.
In March of 1946, the guild asked the U.S Conciliation Service to recognize the guild as bargaining agent for the nurses in negotiations with the East Bay hospitals. In April of 1946, guild members voted to affiliate with the Public Workers of America (PWA) and the CIO (Congress of Industrial Organizations), a federation of unions. This was at the same time the CIO and AFL (American Federation of Labor), then separate groups, were fighting in Sacramento over political endorsements for state offices.
Guild appeals to public for support
Soon after joining the CIO, the guild began a public relations campaign to win community support for their demands for better pay and working conditions. “You Needed the Nurse…Now the Nurse Needs You” was the title of the pamphlet the new Nurses’ Guild of Alameda County’s leaders developed and delivered to 8,000 trade unions, teachers, doctors, dentists and other professionals in Alameda County.
In the pamphlet, the nurses laid out their demands: “The immediate goal of the Nurses’ Guild is a collective bargaining contract that will guarantee the nurses a decent wage, reasonable amount of leisure, and fair working conditions …living symbols of our American Way of Life. Standing united, the nurses are determined that, no matter how long it takes, the hospitals must finally recognize the justice of the nurses’ case by signing the contract.
The guild leadership invoked the words of a prominent economist of the time, Varden Fuller, to bolster their case: “There will be no real end to the shortage of nurses in Alameda County until nurses can be guaranteed decent working conditions in hospitals,” Fuller was quoted in a guild press release. “It’s no wonder that so small a percentage of nurses coming out of the armed forces are returning to hospital work. A nurse can go to work in a warehouse or a cannery and earn as much or more money as in a hospital.” The nurses augmented that claim in the pamphlet, declaring that a woman paring and peeling in a cannery made $202.50 and a grocery clerk made $241 per month, while nurses were making $175.
KP’s chief physician Sidney Garfield makes history by signing first nurse contract
The Nurses’ Guild leaders urged the public to write to the hospitals and “let them know you’re in complete sympathy with the nurses’ just requests.” On the list of hospitals whose nurses had voted to be represented by the guild was the (Kaiser) Permanente Foundation Hospital at Broadway and MacArthur in Oakland, the first Permanente hospital, opened in 1942. Permanente administration distinguished itself by being the only hospital representatives that allowed a secret ballot for its nurses to select an organization to speak for them in labor negotiations. Sidney Garfield, MD, Permanente’s founding physician, was also the first to sign a collective bargaining contract with the newly energized nurses’ organization.
The nurses’ initial campaign for labor representation came to a close on August 1, 1946, with the announcement of Garfield’s signing. “Permanente’s historic contract gives working nurses a 40-hour work week for the first time in Alameda County hospitals,” the Guild press release stated. “Besides reducing the former 48-hour work week to 40 hours, the Permanente agreement raises the former basic wage of $175 to $185. The basic rate will go up to $190 on October 1 and $200 monthly on January 1, 1947.” Meanwhile, the California State Nurses Association was negotiating with other East Bay hospitals. Spokeswoman Edna Behrens told the Tribune their contracts called for a 44-hour work week beginning July 1 and a 40-hour week as of January 1, 1947. She said the shortened week would not mean a reduction in the minimum salary of $200 per month.
While nurses felt empowered after the war to pursue higher positions in the field of medical care, not everyone was anxious to embrace them in new roles. A case in point is neurosurgeon Howard Naffziger, who spoke in 1947 at a two-day conference of the Association of California Hospitals at Hotel Claremont in Oakland. “Highly specialized nurses should be called something else, because they have specialized themselves right out of the care of the sick.” He said nurses could learn all they needed to know in two years, or even one year of training. “The needs of the public for nurses exceed the ability of the public to pay,” the renowned neurosurgeon said.
Marguerite McLean, then superintendent of nurses at Highland Hospital and later director of the Permanente School of Nursing, countered his remarks: “Doctors …have had to spread themselves so thin that one wonders what would happen if nurses hadn’t been qualified to step in and take care of the situation,” McLean told the Oakland Tribune. She added that even the practical nurse with less training would need a living wage, which would have to be close to the $200 basic monthly pay of the trained nurse. “Nurses feel they are best qualified to know and understand nursing requirements.”
(Next time: In 1966, Kaiser Permanente nurses stage first work action in California history.)
For more on Kaiser Permanente nursing click here.
By Laura Thomas
In the early days of Permanente medicine, co-founder Dr. Sidney Garfield had to be nimble at getting the resources needed to take care of newly signed-up plan members. Working quickly to add new groups just after the war, often Garfield had to scramble to hire doctors and set up care facilities. Sometimes that meant occupying whatever building was available immediately – however seemingly unsuitable.
From the late 1940s into the 1950s, thousands of union workers in the Bay Area joined the Permanente plan and were able to get care at the new Kaiser Foundation Hospital on MacArthur Boulevard in Oakland. But the Bay Area was growing beyond the towns on the bay shore in the wake of the war’s great westward migration, and the medical plan had to grow with it.
Thus, when Henry Kaiser and Garfield took on members too far away to make an easy drive to central Oakland, the physicians moved into any building deemed workable. The health plan took over many wartime health facilities and small hospitals, but at different times, Permanente doctors and nurses saw patients in examining rooms fashioned out of the bedrooms of a motel and a once-stylish, turn-of-the-century hotel, the offices and storerooms of a San Francisco office building, the tight quarters above a modest dress shop and a ranch house on an historic estate.
First postwar facilities at Vallejo military-style hospital
Kaiser’s first opportunity to extend the health plan beyond the shipyards came right as the war ended. Residents of the apartments and dormitories built for the workers that flooded Vallejo to work at Mare Island and the Benicia Arsenal had laid the groundwork in 1944 by lobbying for a government-sponsored hospital.
They succeeded in getting the Vallejo Community Hospital, which was built – military cantonment style – between a slough and a hillside on the north edge of town. Now that the war was ending, the barracks-like facility was slated for closure and the tenants re-grouped. They appealed to Permanente to come to Vallejo to care for up to 25,000 people living in eight housing projects.
In September 1945, the doctors moved into an infirmary downtown near the corner of Fourth and Maryland streets. The facility, which had been used by the U.S. Public Health Service during the war, was renamed the Permanente Medical Center. With only 60 beds, the makeshift hospital was temporary.
By 1947, Permanente re-opened the nearly new Vallejo Community Hospital and – with the ample space it provided in several single story buildings spread over 30 acres – was also able to bring to Northern California the Kabat-Kaiser Institute, now called the Kaiser Foundation Rehabilitation Center. The original institute was established in Washington, D.C., at Henry Kaiser’s behest to help victims of neuromuscular disease, including his son, Henry J. Kaiser, Jr., who had multiple sclerosis (MS).
Later when a new Vallejo hospital was built in 1972, the campus continued to house the outpatient departments. In 2010 the newest Vallejo medical center was completed with 248 beds, a state-of-the-art rehabilitation wing with two gymnasia, and halls filled with natural sun light and the works of North Bay artists.
Next stop San Francisco
The first doctors recruited by Garfield had no grandiose expectations. Most were committed to the ideal of health care for the masses, accepted the salary offered and the challenge of making do. It was all about “good humor and team spirit,” as long-time allergy supervisor Renee Owyang recalled in 1982 as she reflected on her early years in the first San Francisco clinic.
In 1946, while the Alameda-Contra Costa County Medical Society was preparing an attack on Permanente medicine and its prepaid, group practice health model, shipyard workers at Hunters Point joined the health plan. To avoid attracting controversy in San Francisco, Garfield’s doctors took over a small clinic that had served the workers during the war on the third floor of an old lower Market Street office building and put the name of Dr. Cecil Cutting on the door.
In 1948, the Permanente Foundation acquired a 35-bed hospital in the Bayshore District of San Francisco near Hunter’s Point Naval Shipyard. The old structure at 331 Pennsylvania St. had been previously owned by an ambulance company. Garfield had the picturesque building refurbished and re-named it Permanente Harbor Hospital.
For years before the Market Street clinic merged with the new hospital on Geary Boulevard, the San Francisco staff saw patients and even began an allergy department in a loft area that was served only by stairs and a freight elevator. “We often served as elevator operators for our allergy patients who were unable to climb the stairs,” Owyang said. She remembers putting out several buckets on rainy days to catch drops falling in the waiting area from the roof and enjoying the various tunes created by the rhythmic plops: “often we were tempted to rotate the buckets to get a new tune.”
Rambling ranch house turned into Walnut Creek clinic
In 1952, Henry Kaiser, who lived in Lafayette, was eyeing the small, but bustling town of Walnut Creek as the place to locate a new hospital and found a 5-acre site along Newell Avenue. The owner was Edward Counter, soon to be mayor of the town, who lived there in an old, rambling Arts&Crafts style house he and his wife had turned into a cultural center. “It was kind of a collecting place for all the little (old) ladies of Walnut Creek, you know, and they had a tea room,” remembered the hospital’s administrator, Jack Chapman, in 1982.
Chapman also noted in an oral history that the price had been fixed at $75,000, but the ever impatient Kaiser was seen at the property. “He couldn’t wait, you know, he stomped around here one night and somebody saw him and automatically it went up 25,000 bucks.”
The house that had once been surrounded by orchards was turned into a clinic, with an older home at the back becoming the housekeeping department and a swimming pool turned into a morgue, Chapman recalled. When the clinic opened, he was joined by a gardener, to take care of the grounds, a nurse, receptionist and three doctors. By the end of 1953, a new clinic and hospital had been built on the property and 35,000 people trooped through it during an open house that lasted two weeks.
And not a minute too soon, for in the same month (September), Local 1440 of the steelworkers union up the road in Pittsburg voted to join Kaiser – after a bitter campaign by local doctors designed to dissuade them — and suddenly 10,000 more people became Permanente members. “They demanded then that we open a clinic,” Chapman said.
A motel on Los Medanos Street behind Pittsburg Post-Dispatch building was purchased and used for nine years until a larger clinic was built in Antioch. “So we bought this funny little building that was about to be a motel,” said Dr. Wallace Cook in 1982 “and turned each motel room into an office. It had a courtyard so you peeled off and went to surgery or medicine or wherever, depending on which motel room your doctor was in.”
Southern California coastal group finds space above a dress shop and in posh hotel
In 1950 Ira “Buck” Wallin MD hurriedly set up shop in a medical office in downtown San Pedro when longshoremen union members joined the health plan. The interim clinic was pulled together in two weeks with Harry Bridges, leader of the International Longshoremen and Warehousemen’s union, breathing down Garfield’s neck.
There were 3,000 new members to handle and, within seven months, 30,000 retails clerks were added to the Southern California membership rolls, many living in the San Pedro-Long Beach communities. Busting at the seams, the plan found space for several more doctors and the administrative offices above a dress shop on South Pacific Avenue.
By 1954, a new clinic was opened in a large Victorian house on Atlantic Avenue in Long Beach, which had room for five internists, including a pediatrician, and had an X-ray department, but no laboratory. It became popular immediately and another site was opened in the turn-of-the-century Kennebec Hotel, which had been a center of action in Long Beach’s heyday as a beach resort.
Remodeled in 1950, the guest rooms were equipped with toilets and showers and accommodated surgery, internal medicine OB/Gyn, pediatrics and physical therapy.
“It was hot in the summer and cold in the winter but had a good view of The Pike,” said staffer Hannah Wilson. The Pike, the mile-long boardwalk and amusement park that was still roaring in the 1950s featured such attractions as a large indoor swimming pool, carousel, rollercoaster and 10-cent rides for children on Wednesdays.
In 1992, the Long Beach clinic relocated a fourth time to its present site on the Pacific Coast Highway, just before the traffic circle. On most days, members and staff have a clear view of the city’s high rise buildings and the Walter Pyramid at California State University, Long Beach.
The clinic is modern and efficient, but no doubt it has little of the charm of those earlier facilities, none of the pink bordello walls, warm ocean breezes or shrieks of delighted children, that the staff and doctors remember from the old Kennebec.
By Steve Gilford
Senior KP History Consultant
A recent phone call brought me the sad news that Jeanne Wallin, wife of the late Ira “Buck” Wallin, MD, a Southern California Permanente Medical Group pioneer, had passed away this month at the age of 89.
I first met Jeanne a bit more than ten years ago when my interest in recording first hand accounts of the origins of Kaiser Permanente led me to her and Buck Wallin, one of the first Permanente doctors on the ground in Southern California.
In 1950, after just a few weeks at the Permanente hospital at the Kaiser Steel plant in Fontana, Calif., Permanente founder and executive director Sidney Garfield enlisted Wallin to open medical offices to care for longshoremen at Los Angeles harbor in San Pedro. This was the first expansion of the program into Southern California outside of the steel plant and the beginning of the Southern California Region.
After Buck’s death in 2002, I remained in occasional contact with Jeanne. A cheerful, articulate woman with an easy manner, she enjoyed reminiscing about “the old days.” Unlike others I had talked to about Dr. Garfield, Jeanne Wallin knew him neither as family nor as physician. He’d been a friend with whom she, her then-husband, Joe Lydon, and a group of other couples, would often share weekend afternoons and evening parties.
Permanente founder had movie star quality
Jeanne, a native of Oakland, Calif., had married Wallin in 1987 after the death of Lydon, a marketing consultant. It had been Lydon who, in 1972, had introduced her to Dr. Garfield. Before Jeanne met Sidney Garfield, Lydon told her, “You’ll like this man, he’s such a gentleman; everyone likes him.” Soon Jeanne and Joe had become close friends with Sidney, his wife Helen, Health Plan Regional Manager Karl Steil and Karl’s wife, May.
“Almost every weekend, Sid and Helen came down (to Alameda) so we spent a lot of time together.” What they all had in common was a fondness for boats and so much of their social time together was aboard either the Steil’s boat or their own, berthed near each other at Alameda’s Ballena Bay Yacht Club.
According to Jeanne, Dr. Garfield had a movie star quality. “He reminded a lot of people of Spencer Tracy . . . The women adored him.” Even so, she recalled, “He was very, very quiet around me.” However, after they’d become better acquainted, he began to open up a little.
“One day, we were cruising somewhere. He and I were sitting out in the cockpit and he told me all about designing the Oakland hospital. . . . and how originally he wanted to be an architect. He had a very quiet way about him. He was utterly charming. I could see why women liked him so much.”
Garfield pushed good health, not health plan
Dr. Garfield didn’t mind that she and her husband were not members of the Permanente Health Plan. In the 1970s when Jeanne mentioned to him that she and Joe were planning a trip to Europe, he insisted that they have a medical checkup before they leave. “You cannot go until you have a ‘multiphasic,’” he said.
The multiphasic program was basically a battery of screening tests that was offered to Kaiser Permanente members. The advantage was that in a short period of time, with minimal inconvenience, a patient could get a complete health examination. Sidney told them that if they went through the multiphasic examination before they left, they could leave the country knowing that they were in good health.
Garfield arranged simultaneous appointments for the couple at the Oakland Kaiser Permanente hospital. “Of course, my husband went one way and I went the other . . . Sid personally took me through the whole multiphasic. We’d have little stops: open a door and go in and there’d be cake and cookies and a cup of coffee. It was the most wonderful way to get all these physicals done and over with.”
Garfield as architect and planner collaborated with Wallin
She remembered another one of the Garfield innovations she’d seen that afternoon: colored lines painted on the medical center floors to help patients find their way easily from one test station to the next. “Well, I thought it was fantastic, following the lines. He told me how he’d invented all this stuff.
“Then he showed me through the whole hospital and how he designed the rooms to be between the central corridors and the outside ones off of the center corridors. It was so charming of him to share this with me, and you could tell the great pride he had in it. Great pride. I felt very honored,” she related.
In the mid-1950s, Dr. Garfield collaborated with Medical Director Wallin on the design of the 56-bed Harbor Hospital in Harbor City. When membership grew, Wallin and Garfield worked together to plan that hospital’s expansions. In the early 1960s, the two men again collaborated to plan and launch the new Bellflower service area, including the layout of the hospital, the budgeting and selection of the 60-physician staff.
In 1966, when the health plan took over the financially troubled San Diego Community Health Association, Wallin became the founding medical director there. Dr. Wallin served on the board of the Southern Permanente Medical Group until 1973. He stayed on in San Diego as a member of the staff there for several more years until he moved to the Bay Area.
When Jeanne met and married Dr. Wallin, she took great pride that Buck had played an important part in what had become the largest private medical care program in the world. Following her death, her family paid her a high tribute, “Jeanne embraced life in both difficult and joyous times.”
By Ginny McPartland
Affordable health care was an elusive commodity in 1930s America. Medical practice was becoming more sophisticated, and qualified doctors were in great demand. Consequently, private professional care was out of reach for many Americans. Employer-sponsored health plans started to spring up in the late 1930s and early 1940s, but even those progressive prepaid plans were slow to add workers’ families to the coverage.
Permanente medicine, developed by industrialist Henry J. Kaiser and enterprising physician Sidney Garfield, was launched to take care of workers in Kaiser’s West Coast shipyards. The two had done this before: Garfield had set up a prepaid plan for workers on the Los Angeles Aqueduct project in 1933, and he and Kaiser had teamed up to care for workers at the Grand Coulee Dam in Washington state in the late 1930s.
The Kaiser-Garfield prepaid, group practice plan for shipard workers was progressive and exemplary by all accounts. Unlimited medical care for the individual workers was provided for 50 cents per week. But Garfield and his doctors had their hands full, so initially only the worker – not the family members – was covered by the health plan.
Stuart Lester of “Medical Economics,” writes in the February 1944 issue: “The principal threat to the permanence of the Permanente Foundation – which provides virtually unlimited medical care for 130,000 Kaiser shipyard workers in two states* is the workers’ complaint that it makes no provision for their families.”
The article continues: “The family problem is especially acute in the shipyard town of Richmond, Calif., where the ratio of physicians to population is something like 1 to 4,000 and where the only hospital facilities of any consequence are those provided by Kaiser’s Richmond Field Hospital.”
In Richmond, Portland (Oregon) and Vancouver (Wash.), nonsubscriber family members were treated for a fee. Office visits were $2.25. For maternity, $200 covered prenatal care, delivery, hospitalization, C-section if required, postnatal care, and care for the newborn. Employees at the Kaiser Fontana steel plant in Southern California were the exception. In 1944, Fontana workers could purchase complete coverage for a family of four for $1.80 a week.
Physicians debate how to cover families
“Medical Economics” writer Lester refers to three possible solutions proposed at the time: an expansion of the Permanente plan to include family members; an expansion into the Richmond area by the California Physicians’ Services (CPS) prepaid plan as operating in other war industry communities; or the development of a prepaid arrangement for families through a private physician network.
The California Medical Association (CMA) launched the CPS in 1939 to offer prepaid care to low-income families in California. Initially, the physicians association’s plan offered a “full coverage contract” that included all outpatient physician services. In 1942, CPS excluded the first two doctor visits from coverage to make the plan financially viable, according to the April 1943 issue of the CMA’s “California and Western Medicine.” In 1943, CPS, the precursor to Blue Shield, had 39,000 commercial members, 5,100 government rural health program subscribers and a total of 32,000 war housing resident members in Vallejo, Marin, Los Angeles and San Diego.
“Dr. Sidney R. Garfield, Kaiser’s medical director, sees two obstacles to an extension of his program to include families: One is opposition by the local medical societies. The other is lack of facilities – particularly in the hospital at Richmond,” Lester wrote in “Medical Economics.” The article noted that expansions of the Richmond Field Hospital and the Permanente Foundation Hospital in Oakland were under way.
The second proposal – having CPS provide family coverage for Richmond area workers – had been tried previously and failed. In 1942, CPS had offered a family plan in nearby El Cerrito and was not able to attract enough members. The coverage for non-Kaiser workers was enticing: a $5 flat fee no matter how many family members. It wasn’t practical for Kaiser employees, however. To take advantage of the CPS plan, a worker would have to buy his or her own coverage for $2.16 a month and then pay $5 for the rest of the family.
According to the “Medical Economics” article, solving of the family care issue by fee-for-service doctors was doomed from the beginning. A shortage of private doctors and inadequacy of medical facilities made any such plan unfeasible. Also, California private practice physicians were admittedly just tolerating the Permanente model of prepaid, group practice with salaried physicians. One private doctor told the magazine: “The Kaiser-Garfield groups are doing a job right now that is aiding the war effort, and are doing it well. But we don’t like their system.”
Kaiser extends coverage to shipyard families
In the spring of 1945, the Permanente medical plan, now with expanded facilities to accommodate more members, was extended to the families of all Kaiser shipyard workers. “Medical Economics” reported the details of the Permanente family care plan: for $117 a year ($2.25 per week) for a family of four, coverage was extensive. It included 111 days of hospitalization, complete diagnostic services, necessary drugs, physician services at home or medical office, major and minor surgery, and ambulance service within a 30-mile radius. Members paid an extra charge of $60 for comprehensive maternity care, $15 for a tonsillectomy and $2 for a house call.
“Medical Economics” concluded the article with this statement: “Insurance men pointed out that the total annual cost for a family of four, $117 a year, is an amount which has generally proved to be too high for any wide participation on a voluntary basis.”
Workers who left the shipyards could maintain coverage for a “slightly higher” premium as long as they continued to live in the service area. This retention provision foreshadowed Kaiser and Garfield’s plans to keep the Permanente medical care plan alive after the war industries shut down.
*Kaiser shipyards health plan actually took care of workers in three states, California, Washington and Oregon, and enrolled up to 190,000 members at the peak of the war.
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.
By Ginny McPartland
When I first heard Kaiser Permanente was offering its employees a $50-to-charity incentive to take the THA, I wasn’t that impressed. I didn’t think the donation would convince people to participate in KP’s initiative to build a healthier workforce. I also didn’t think $50 would go that far. I have to admit I was WRONG!
By mid-December, more than 22,000 (14.5%) KP employees nationwide had taken the THA and by that small action collectively raised an impressive $1.1 million. Now that will go a long way. How far? For starters, each $50 could buy 700 pounds of fruits and vegetables or 77 dozen eggs for the hungry. Or it could provide 10 pediatric flu shots for needy kids. Multiply those items by 22,000 donors and you get the picture.
The money raised by the 2010 THA incentive program will go to community healthy eating initiatives and to support health care for disadvantaged people and families, especially the homeless, the disabled and those living with HIV/AIDS. The KP region whose employees raise the most money will receive an extra $50,000 for charities in their communities. The winner will be announced in January; the money will be awarded in March.*
I think it says something about the KP culture that so many employees were motivated to raise money for others less fortunate than themselves. If they hadn’t felt compelled to take the assessment for their own sake, they were motivated to help others. Of course, Kaiser Permanente has given millions to good causes over the years through its Community Benefit programs.†
Total health assessment by any other name
Given our history as a preventive care organization, it shouldn’t come as a big surprise that Kaiser Permanente has been a champion of the total health assessment for over 60 years. In 1950, such an assessment was called the “multiphasic examination,” and it was initiated when labor leader Harry Bridges of the International Longshore and Warehouse Union (ILWU) demanded it for all members of the union.
These records, still accessible today, have supported long-term health research related to heart disease and other chronic diseases. One such study, “Characteristics of Longshoremen Related to Fatal Coronary Heart Disease and Stroke” by Paffenbarger et al., was published in the “American Journal of Public Health,” in 1971.
In the late 1960s, Permanente founding physician Sidney Garfield launched a program called “The Total Health Care Project” to expand the multiphasic programs in Oakland and San Francisco. Garfield and Robert Feldman, MD, hired and trained KP’s first nurse practitioners to run the program that included the use of computerized lab machines that yielded results while the patient was still at the clinic. Their goal was to collect baseline health data that could be used to identify health risks and to prevent disease.
Today’s iteration of the multiphasic exam is a system of chronic disease screening programs designed to detect symptoms early and identify risk factors. The total health assessment questionnaire challenges participants to scrutinize their lifestyles and work with their doctors to figure ways to head off diseases such as diabetes, heart disease and cancer.
For me, the THA results are a reminder of what I need to do to stay healthy. I’m also hoping I can improve my sleep by following through with the online insomnia program. But most of all, I feel glad that my co-workers saw fit to get involved for themselves and to raise money to improve the health of others less fortunate.
*Benefit-eligible Kaiser Permanente employees and physicians may earn the $50 charitable donation by taking the THA by Dec. 31. Go to the Healthy Workforce site to participate.
†Click here for more information about Kaiser Permanente’s Community Benefit Program.
By Tom Debley
Director of Heritage Resources
It’s time for me to say farewell after 15 years with Kaiser Permanente. The last seven years have been as founding director of Heritage Resources, our history program. But at the end of the day on Dec. 17, I will head off to new adventures in retirement.
Do not fear, my able colleagues Bryan Culp and Ginny McPartland will carry on the history work in Heritage Resources!
So what does one say to many friends, colleagues and Kaiser Permanente history buffs other than good-bye?
For me, I quote the literary great, Robert Penn Warren: “History cannot give us a program for the future, but it can give us a fuller understanding of ourselves, and of our common humanity, so that we can better face the future.”
Recently, I was reminded of the importance of this – and a key reason why we maintain a historic archive at Kaiser Permanente. It came as an inquiry on our History of Total Health Blog from John Herron, a history professor at the University of Missouri, who had read a blog about Rachel Carson and Kaiser Permanente’s environmental history by our intern, Jac Brown.
Carson’s last public lecture prior to her death was delivered at an October 1963 Kaiser Permanente symposium attended by 1,500 doctors, scientists, medical students and journalists at the Fairmont Hotel in San Francisco.
This was a year after publication of Carson’s then very controversial book “Silent Spring,” critiqued in 1962 in Time Magazine, which concluded: “Many scientists sympathize with Miss Carson’s love of wildlife, and even with her mystical attachment to the balance of nature. But they fear that her emotional and inaccurate outburst in Silent Spring may do harm by alarming the non-technical public, while doing no good for the things that she loves.”
Today, of course, Carson’s “Silent Spring” is a classic of the 20th century and she is considered the catalyst for the modern environmental movement.
Quite naturally, Professor Herron wanted to know why the then vice president, and later president, of Kaiser Foundation Health Plan and Hospitals, Dr. Clifford Keene, invited such a controversial figure to lead off a public service symposium, the theme of which was “Man Against Himself.” We sent him materials for writings he and other scholars are preparing for the 50th anniversary of the publication of “Silent Spring.”
And that’s one of two reasons why we have a history program. One is to share stories of our history with our physicians, staff and communities. The other is to be here for scholars, museums and others who seek historical insights.
I started our Heritage Resources program in 2003. Professor Herron’s recent question reminded me of the day in 2003 that I first read a one-paragraph item about Rachel Carson’s lecture in a list of “highlights of the year 1963” in an old annual report.
Immediately, I flagged this event as something around which to begin collecting documents for archival purposes. Why? This was a high-water mark that helps illustrate why Kaiser Permanente is a recognized leader in sustainability, because sustainability is important to building healthy communities.
Today, we have Ms. Carson’s lecture text, copies of the correspondence between her and KP planning for her presentation, and other documentation.
As a result, we have collected and archived a wide array of historical materials. A mere handful of these documents illustrate how we stand on the shoulders of other leaders like Rachel Carson:
- Founding physician Sidney Garfield was looking for sustainable practices and was recycling in the Great Depression and during and after World War II;
- It was a Kaiser Industries executive who was among those who founded The League to Save Lake Tahoe in 1957, and coined the phrase seen on bumper stickers and elsewhere to this day: “Keep Tahoe Blue”;
- Kaiser Steel was pioneering pollution control equipment in the 1950s and 60s – before the modern environmental movement and before the first Earth Day in 1970;
- In the early 1970s, employees at the Kaiser Permanente Medical Center in Santa Clara, California, formed an Ecology Committee with an objective of teaching employees “ecological common sense”;
- In the 1980s, employees in Vallejo, California, were honored for reducing energy consumption by half in five years;
- Today, the efforts continue with Kaiser Permanente adding solar power generation to 15 of our facilities by next summer. These groundbreaking projects will eliminate purchase and disposal of 40 tons of harmful chemicals and dramatically reduce KP’s use of fossil fuels.
Our commitment to sustainability is but one example of Kaiser Permanente’s mission to improve the health of its members and of the communities in which they live.
History reminds us, as Robert Penn Warren said, of who we have been, why we are who we are, and where we are headed if we remain true to our values and mission – as individuals and as institutions.
By Tom Debley
Director of Heritage Resources
Since this is National Breastfeeding Awareness Month, you may have read that Kaiser Permanente believes that one of the most important ways a mother can promote the health of her baby is to choose to breastfeed exclusively.
That’s a position that is based on more than a half-century of tradition that began in the 1950s with Kaiser Permanente as one of the leaders in reversing early 20th century trends that led American women to more commonly bottle-fed their babies.
The story also is one of the most popular in Kaiser Permanente lore: The Baby in the Drawer.
The story begins one evening in the early 1950s when several doctors and their families were socializing at the home of Dr. John G. Smillie, an early Permanente Medical Group pediatrician. Smillie told founding Kaiser Permanente physician Sidney R. Garfield he had read an interesting article about the now famous Yale University School of Medicine research experiments with rooming-in for mothers and babies.
Well, this was a prime example of the kind of innovation Garfield fostered, always scanning the environment for new ideas or research findings and quickly applying them to the care of his growing Kaiser Permanente patient population. Garfield was in the process of designing three brand new hospitals for San Francisco, Los Angeles and Walnut Creek. He locked on to the rooming-in idea, adding the Baby in the Drawer.
Garfield arranged each mother’s maternity room in a circle around an adjacent nursery. A bassinet for the infant was set in an ordinary metal file drawer built into the wall separating the mother’s room and the nursery.
“When the mother wanted to take care of the baby,” Garfield explained, “she’d pull the drawer out and there was the baby. (If) she wanted to put it back in the nursery, she could put it back in. That was a great hit.”
This allowed a newborn to be adjacent to its mother while also being under the direct supervision of the medical staff. A simple light signal would tell the nurse whether a baby was in the nursery or in its mother’s room.
Because Garfield believed strongly in research and innovation, the Baby in the Drawer proved to be one of the best illustrations of his further belief that these principles could keep care cost-effective, bring better patient outcomes and make Kaiser Permanente a better place to work. The reasons: the Baby in the Drawer reduced an estimated seven out of 10 steps for the maternity nurses, large numbers of mothers chose to breastfeed as a result of the system, and it improved bonding between baby and mother.
That it was, as Dr. Garfield put it, “a great hit” has been borne out by history.
When Ora Huth, an oral historian in the Regional Oral History Office at the University of California at Berkeley, interviewed Dr. Smillie in 1985 as part of a series with Kaiser Permanente pioneers, he told her the Baby in the Drawer story. Huth interrupted him to announce she had used the Baby in the Drawer system in San Francisco.
“I thought it was such a great idea,” Huth says in the published oral history.
“Now you know where the idea came from,” the late Dr. Smillie responded.
In 2004, when the Oakland Museum of California did a special exhibition on the life of Henry J. Kaiser, co-founder of Kaiser Permanente with Dr. Garfield, it included a life-size replica of the Baby in the Drawer hospital room.
Today, whenever I give a talk about this concept I’m almost always guaranteed that someone in the audience will come up to me afterward to announce, “I was a Baby in the Drawer.” It’s equally likely that the person was breastfed as an infant because Dr. Garfield was helping to turn the tide away from bottle feeding after World War II.
I’m sure Dr. Garfield would be smiling if he could see the Kaiser Permanente News Center website item: Kaiser Permanente’s Care Delivery and Research Support Breastfeeding to Promote Healthy Families.