Dr Sidney Garfield and Betty Runyen

In the Fall of 1933, a young Dr Sidney Garfield and his friend and partner, Dr Gene Morris, had just taken a big chance. In the middle of the Depression, they opened a small hospital at a remote construction site in the Southern California desert.

Garfield and Morris had set out to meet the medical needs of 5000 Colorado River Aqueduct construction workers digging a man-made river across the desert and through mountains to connect the thirsty Los Angeles with the abundant water of the Colorado River more than two hundred miles away.

Dr Morris was already in practice in Indio, the nearest town of any size. As part of his contribution to the hospital start-up, he promised Dr Garfield that he would find and hire a suitable local nurse for their hospital. The name on the top of his list was 21-year-old Betty Runyen. Occasionally, she worked for him when his regular nurse needed time off for illness or vacation. He'd been impressed with both her professionalism and her charm. Betty had another advantage--she'd grown up in the area. Desert weather would be familiar to her.

Reached by phone in Los Angeles, where she was working at Methodist Hospital, Betty was excited by Dr Morris' offer of a full-time job at Contractors General Hospital. He said she would be working for his partner, Sidney Garfield, in what he described as the rough conditions of a desert construction camp--a challenge that appealed to Betty's adventurous spirit. Two days later, she reported for work at Contractors General Hospital. It was the day she met Dr Sidney Garfield.

Clearly, Garfield was glad to see her. In addition to being the only physician, he'd been trying to handle the nursing chores too. He needed help.

Playing the good host, Garfield eagerly showed Betty around the hospital he had personally financed, designed, and helped build. It consisted of 12 patient beds--ten beds in a ward and two beds in a semiprivate room--plus an exam room, a well-equipped OR, and a few rooms for the live-in physician and staff, including a married couple who were the hospital's orderly, ambulance driver, and housekeeping team. There was also a kitchen, a laundry, and a tiny bedroom for Betty. All of this was packed into a 2000-square-foot wood-frame building, set down among cactus and cholla bushes, on the edge of a construction camp about six miles west of the aptly named town of Desert Center. This little oasis of healing--the only hospital in the area--was to be Betty's home for the next five years.

Before long, Betty adjusted to the pace of life and work at Contractors General. Most mornings, she stayed in bed until she heard the orderly and his wife in the kitchen preparing breakfast. Then, she'd knock on Dr Garfield's door to wake him. Garfield slept in the combination office and apartment just inside the hospital's front door. This area was where the staff met for breakfast every morning. While Dr Garfield took his morning shower, the orderly set up breakfast on a folding card table.

There were no special dispensary hours for the aqueduct workers. They would just walk in the back door, go to the Treatment Room, and wait for someone. They didn't have to wait long because Betty or Dr Garfield would have heard the screen door slam and gone to help them. Broken arms, legs, and fingers were fairly common, as were back injuries. Another common malady was "Powder Headache": It was caused by getting a little too close to dynamite explosions, especially in the miles of hard-rock tunnels where they were blasting through mountain ranges to complete the aqueduct.

Although Betty often doubled as an ambulance driver, only once did she go out to pick up a patient by herself. It happened on an afternoon when Dr Garfield was in Indio, leaving Betty as the only medical person at the hospital. She was dreading that an emergency call might come in, and that is exactly what happened. A worker at a nearby construction camp had fainted from the heat.

When Betty reached the patient, she started an IV of normal saline for him, and the patient immediately began recovering. This procedure may seem routine today, but in 1933, nurses didn't start IVs; that was solely a function of the physician. However, it was typical of Dr Garfield that he had trained her to act in just this sort of emergency. Forty years later, when Nurse Practitioner training was introduced in Kaiser Permanente, Dr Garfield, along with the enthusiastic cooperation of a group of Permanente physicians, including the late Steven Taller, MD, helped the Medical Care Program demonstrate nationally that the Nurse Practitioner could be an important part of the health care delivery team.

In addition to satisfying her taste for adventure, the desert years with Dr Garfield gave Betty an opportunity to experience first hand some milestone events in health care history. She recalled that after nearly a year of struggling with underwriters to get full payment for treatment they were providing, Dr Garfield was running out of money. One day, she said, he did something very unusual: He invited her to join him for a glass of wine--in fact, for a couple of glasses. He had something unpleasant to say, but first he had to loosen up a little.

When he was ready, he told Betty that he was not going to be able to meet the next payroll. Then he blurted out, "I've got to cut your salary, and if you don't like it, you can quit." Coming straight out like that, it sounded almost like an ultimatum, but she understood that it really came from his discomfort.

Betty was shocked and surprised; but when Dr Garfield explained the problem, she and the housekeeping couple volunteered to work without pay until the hospital became more financially stable. During the next few months, with the help of Harold Hatch, an executive with an insurance company partially owned by Henry J Kaiser, the still-revolutionary concept of prepayment was introduced at Contractors General, covering up to 5000 workers. Within months, the hospital was on its way to becoming a financial success, and Betty and her co-workers received their back pay.

Dr Garfield and Betty Runyen thus were among the first to see how prepayment could change the whole economics of medical practice--a subject that Dr Garfield would promote for the rest of his life. Soon, with the proper incentive in place, Dr Garfield and Betty Runyen were out in the work camps, encouraging preventive care--safely shoring up tunnels, banging down nails, and reminding the men of the importance of wearing hard hats and keeping the workplace clear of dangerous, discarded objects. With Betty Runyen's help, the principles of what would become Permanente Medicine were being hammered into the historical record.

Editor's Note: Steve Gilford is an independent contractor who serves as Kaiser Permanente historian and archivist. He located and interviewed Betty Runyen (Baeker) eight years ago in Grass Valley, CA, where she was living in a retirement community near her son. At the time, she had not spoken to anyone from Kaiser Permanente (including Dr Garfield, who died in 1984) in more than 50 years. Delighted at being "found," Ms Runyen donated a large volume of photographs taken at Contractors General Hospital in the 1930s to Kaiser Permanente. Ms Runyen died in May of 1999. This article is an edited version of a three-part feature that Gilford produced as part of an ongoing historical series sponsored by The Permanente Medical Group.