February 26, 2013

Sidney Garfield, MD: Hands-on work site safety practitioner — or not?

This illustration appeared in the Grand Coulee Dam newsletter The Columbian, May, 1940. This newsletter was distributed to workers at the Columbia Basin and Grand Coulee Dam sites from 1938-1941.

The image of Kaiser Permanente founding physician Sidney R. Garfield as a hammer-wielding workplace safety diehard has been passed down through the decades from his early days as a desert doctor. But is the legend true? Did Garfield really charge out into the dust and dirt himself and pound down rusty nails, shore up tunnels to prevent rock showers, and insist workers wear hard hats?

This story of Dr. Garfield’s passionate preventive practice on the Colorado River Aqueduct project has endured for eight decades, since about 1933. The oft-told tale conveys the young doctor’s commitment to worker safety and preventive care once he instituted the unconventional prepaid model of health care that saved his little hospital from extinction.

Garfield was certainly committed, but his allegedly active role in the cleanup of aqueduct work sites is a stretch of the imagination. And he was not alone in promoting workplace safety.

Fact or fiction?

The story has sometimes been presented as fact:

“There was a funny little story that Dr. Garfield, on the first day in which prepayment began in the desert, got up early in the morning with his hammer, and went around the worksite pounding down nails. . . The notion is that if you can keep the patients healthy, then it’s a good thing not only for the patient, but it’s a good thing, financially, for the program.” [i]

Sometimes it’s told as legend:

“There (in the Mojave Desert) he also discovered the importance of preventive medicine, and he strove to remove potential health hazards for the workers — although it is only legend that Garfield would go to the construction sites and pound down any protruding nails himself.” [ii]

And at least once the story has been cited in a novel about the desert doctor’s operations, where a fictional Dr. Sidney Garfield speaks to a fictional nurse:

“I picked up another nail. ‘Look at all these dirty nails. Just lying around, waiting for someone to step on them and end up with a puncture wound, tetanus, or worse.’” [iii]

In his own words

When we examine the historical record and let the doctor speak for himself , as in this circa 1934 quote in which he describes a disquiet of conscience from collecting fees from illness and injury, we see his true role.

Betty Runyen presents a safety award hard hat to a Colorado Aqueduct project construction supervisor, 1934.

“We had been anxious to have sick men or injured men come into the hospital because that meant income and that we would continue to exist. . . It was embarrassing to me to want people to get hurt. So we started to do safety engineering. . . We would get a bunch of nail punctures from a job and we would go out there and get them to clean up the nails. Or we would get a lot of head injuries . . . and we would get them to shore up the tunnels better.” [iv]

Garfield’s commitment to worker safety was genuine, but it was his nurse, Betty Runyen, RN, who actually went to the work sites to speak to the importance of taking salt tablets and drinking water to avoid sunstroke, and of donning gloves to prevent the spread of impetigo from pick axes and shovels. The competent nurse was also the visage of an angel in those hostile environs with her blonde curls and pretty smile.

Water district’s safety efforts

It should also be noted that Garfield and Runyen had help as well. The Metropolitan Water District of Southern California, the builder of the aqueduct, and Workmen’s Compensation insurance companies all placed their own safety engineers in the field to remedy dangerous job situations.

Tunnel rescue squad serving the Colorado River Aqueduct Project workers, circa 1933. Photo from Colorado River Aqueduct project manual, Metropolitan Water District of Southern California, 1937.

The 1937 Colorado River Aqueduct project manual describes their role thusly: “It is the duty of the safety engineer and members of his organization to visit all work on the aqueduct at frequent intervals to see that the work is being carried on in accordance with established safety rules, to offer advice and instructions to those in charge of construction operations, and to assist in the elimination of dangerous operations and equipment.

“In addition, each division engineer is charged with the responsibility of reducing accidents to the minimum. Special safety meetings are held at various points along the aqueduct at frequent intervals and a regular plan of safety education is maintained.” [v]

All of these efforts apparently had an impact — accident frequencies were reduced to a point well below the average rate experienced in that class of construction during that period.

In the desert years (1933–1938), Garfield did not wield a hammer or gather stray nails at the job site. But it is still fair to say that he overturned the conventional wisdom that a physician must derive his income from illness and injury. In the desert he realized the incentive to keep people well and on the job. Thereafter, preventive care became paramount, first in his imagination, then in reality when he partnered a few years later with Henry J. Kaiser at Grand Coulee Dam project in Washington State.


[i] Bruce Sams interview, “Kaiser Permanente Medical Care Oral History Project II, Year 2 Theme: Kaiser Permanente Core Values,” conducted by Martin Meeker in 2007, Regional Oral History Office, The Bancroft Library, University of California, Berkeley, 2007.

[ii] Can Physicians Manage the Quality and Costs of Health Care? The Story of The Permanente Medical Group, by John G Smillie, MD; book review by Morris F. Collen, MD, The Permanente Journal, Summer 2001

[iii] Courage to Heal — A Novel by Paul Bernstein, MD, 2008

[iv] The Story of Sidney R. Garfield — The Visionary Who Turned Sick Care into Health Care, by Tom Debley, the Permanente Press, 2009, p. 21

[v] Colorado River Aqueduct project manual, Metropolitan Water District of Southern California, 1937.