February 26, 2012

Global enterprises gave rise to export of Kaiser Permanente health care

KFI nurse visits with Nigerian patients at Port Harcourt.

Established initially as an industrial health plan, Kaiser Permanente had grown and morphed into a community health plan with over one million members in six states by the mid-1960s. Meanwhile, Henry Kaiser’s ventures had spread across the globe and the basic concepts of industrial and preventive health care traveled with him.

A package disaster hospital as it arrived in Lagos, Nigeria, to be transported by river steamer to Port Harcourt where Kaiser Foundation Inernational restored a war damaged hospital in 1970.
A package disaster hospital (PDH) as it arrived in Lagos, Nigeria, to be transported by river steamer to Port Harcourt where KFI restored a war damaged hospital. Public Health Reports photo, 1970.

This meant the idea of prepaid health care provided by doctors in group practice was getting a lot of exposure in places where it might be needed most.

The World Health Organization was busy helping African and other developing countries set down their “national health plans,” and industrial nations were taking a serious look at investments in these countries. Already with health care programs in Jamaica, Ghana, Argentina and Brazil, Kaiser Permanente seemed in a prime position to take the lead in other emerging nations.

“At first, we held the belief that since we managed a large, comprehensive and widely-accepted health care system in the United States, that we were in a favored position to cope with the health problems associated with industrial enterprises all over the world,” KP Health Plan President Clifford Keene told a group at Harvard University in 1969.

“This theory turned out to be true in a limited sense,” he continued. “We learned quickly that the medical care circumstances in rural India and in Jamaica are essentially different from those in California.”

Keene explained that developing nations, especially those with a national health plan, urgently needed primary health care workers, clean water, sanitation and disease control before they could even think about clinics and hospitals. Adjusting to local circumstances, Kaiser industrial health care leaders filled in the gaps where needs were most urgent — and bided their time.

Kaiser Permanente establishes independent international agency

Two young Nigerian childrean sit in front of wood and canvas cots from a package disaster hospital in 1970.
Wood and canvas cots from a package disaster hospital (behind these Nigerian children) were put to good use. Public Health Reports photo, 1970.

By 1964, Kaiser Permanente was getting requests from the U.S. and foreign governments to help plan and launch health care services in needy countries. Feeling the strain and drain on the Permanente Medical Care Program whose staff was responding to the calls, Keene and the board of directors established Kaiser Foundation International (KFI).

This not-for-profit entity, with an $55,000 initial grant from the Kaiser Foundation, was a separate self-sustaining agency established to fulfill government contracts to provide help setting up health care in foreign or domestic rural areas.

In its life between 1964 and 1975, KFI was involved in projects in more than 30 countries, including the U.S. where the agency helped set up programs in rural areas of California, West Virginia and Utah. Its workers took on projects in 13 countries on the African continent, as well as in India, Pakistan, Bahrain, Italy, Indonesia, Venezuela, Argentina, Brazil, Peru, Jamaica, the Bahamas, Canada, Okinawa, Taiwan and the Island of Curacao.

Nigerian civil war leaves damaged hospital in its wake

Kaiser Foundatoin International physician Carl Friedricks, right, explains his work in Nigeria to Kaiser Permanente Hospital Administrator Peter Rout and Violet Rout, MD.
KFI physician Carl Friedricks, right, explains his work in Nigeria to KP Hospital Administrator Peter Rout and Violet Rout, MD.

KFI was called upon in 1969 to bring back to life a Nigerian hospital that had been debilitated in the civil war that started in 1967. James Hughes, MD, Kaiser Industries vice president of Health Services at the time, explained:

“This project was completely unrelated to any commercial activities by Kaiser Companies in Nigeria. It was undertaken strictly in response to an urgent request by the government (U.S. Agency for International Development) for technical assistance in a matter of general medical care. Presumably, the request was based upon our prior experience in the organization and delivery of health care on other West African (Ghana, Ivory Coast, Togo, and Senegal) projects.”

The 250-bed hospital at Port Harcourt in the area of Biafra previously had been the referral center for the entire Rivers State of Nigeria with a population of one million. “The Port Harcourt situation looked particularly grim,” reported Keene.

“The war was still in progress 50 miles north of the city and the Biafran troops were making periodic sorties toward the airfield on the outskirts of Port Harcourt. KFI existed to handle tough overseas assignments, but we have never acted in a war zone,” Keene continued.

“When the physician (Carl Friedericks MD) arrived, he told us his first impulse was to turn around and come home. Medical care was critically needed by the remaining civilian population and by refugees streaming out of the jungle zone,” Keene reported.

Kaiser Permanente team resuscitates Port Harcourt hospital

The initial team of five acquired a package disaster hospital (PDH)* from the U.S. Public Health Service. Electrical generators, emergency water equipment, and medical supplies and equipment were “scrounged from unbelievable sources,” Keene said. “A Nigerian staff was recruited and trained, on a counterpart system (that matched) native physicians, technologists and nurse volunteers to (our 20) personnel from the United States.”

In the first months at Port Harcourt, the hospital had a daily census of 80 to 100. Dr. Friedricks saw patients with familiar diseases such as diabetes, hypertension and pneumonia. But he also noted many patients with tuberculosis, parasitism, malnutrition and severe anemias.

“Tropical ulcers are common and yield to prolonged medical treatment and skin grafting. Malaria is the most common cause of fever . . . One young lad suffering from a heavy hookworm infestation came in with a hemoglobin of 2.0 grams, or about 13% of normal levels; blood transfusion and medication brought him up to 42% of normal hemoglobin to permit his discharge for home medication.”

Intravenous kits from the disaster hospital were used to save starving children, left. A technician, at right, displayed an X-ray developed by using a Polaroid process that didn't require water. Circa 1970.
Intravenous kits from the disaster hospital were used to save starving children, left. A technician, at right, displayed an X-ray developed by using a Polaroid process that didn't require water, which was in very short supply at Port Harcourt. Public Health Reports photo, 1970.

They also dealt with issues such as having no dishes to feed the inpatients, getting fuel for the repaired coal stove and outfitting the makeshift operating room and exam rooms with light fixtures. Transportation was not a problem: the U.S. government supplied them with four Land Rovers and a Rambler station wagon. Nigerian Airways had regular flights between Port Harcourt and Lagos, the largest urban area in Nigeria.

San Francisco Kaiser Permanente nurse goes to Nigeria

Kaiser Foundation International report, circa 1972.
Kaiser Foundation International report, circa 1972.

Frances Fuller, formerly assistant director of KP’s San Francisco Medical Center, arrived in Nigeria in September of 1969 as the KFI chief nurse. She went to work setting up nursing classes for 40 Nigerian students as well as developing a hospital procedure manual and a central supply and distribution system.

Fuller reported remodeling of a lecture theater for use as a temporary surgery. “When the room is ready, we will take the instruments and other supplies from the PDH (package disaster hospital) and start doing more surgery.” In the midst of her reporting on the status of the medical facilities, she interjected: “Grounds are being well kept. We even have flowers in the courtyard.”

In 1971, the KFI team departed Port Harcourt leaving a locally staffed, well-functioning and well-equipped community hospital.

Financial troubles doom international agency

Unfortunately, all of KFI’s ventures didn’t end happily. In Peru, a project to set up a hospital system for blue-collar workers was ended abruptly when the government was overthrown and all funds for health care projects withdrawn.

In 1968, politics killed another KFI project, this time in Libya. At the request of the U.S. state department, KFI sent a physician to discuss improved medical staffing of hospitals and clinics in Libya. When Libyan government officials learned that Kaiser assembled its Jeeps in Israel, they dropped the project, due to the Arab League boycott of companies doing business with Israel.

An ill-fated project to bring prepaid group practice to Saudia Arabia in 1974 ultimately brought down KFI, Permanente medicine’s first but not last international arm. Scott Fleming, KP senior vice president, said the project presented major cultural and legal problems that were costly to solve. In general, the KFI financial picture didn’t look promising at that time so the directors decided to discontinue its operation altogether in 1975.