This article is a companion piece to Multiply My Hands: Dr. Richard Smith and the Founding of MEDEX Northwest.  The focus of Multiply My Hands is primarily on Dr. Richard Smith’s early professional path leading to the successful launch of the MEDEX Northwest PA Program at the University of Washington in 1969. The aim of this article, The People Collector: Dr. Richard Smith and the MEDEX Group, is to bookend that story, in effect. We first take a more detailed look into Smith’s earliest years before then tracing Smith’s move from Seattle to Honolulu, where he and a team of like-minded professionals created the MEDEX Group and worked for the next 20 years to extend the MEDEX model on an international scale. Many are familiar with the story of Richard Smith as the founder of MEDEX Northwest, but fewer know the details of the many things Smith accomplished in the years that followed. This article is an attempt to remedy this fact and flesh out the story of Dr. Richard Smith. 

Table of Contents

1. Preface: The People Collector
2. Chapter One: The Early Years
3. Chapter Two: The College Years
4. Chapter Three: The Surgeon General’s Office
5. Chapter Four: Not a Settler
6. Chapter Five: MEDEX Micronesia – An International Vision Realized
7. Chapter Six: Assembling the Team
8. Chapter Seven: Thailand – Adapting from Micronesia Learnings
9. Chapter Eight: Guyana – A Long Term Success Story
10. Chapter Nine: Alma Ata Conference – “Health for All”
11. Chapter Ten: Lesotho – Fat Alice Is Ours
12. Chapter Eleven: Pakistan – Promising, and then a Hurried Exit
13. Chapter Twelve: The Primary Health Care Series
14. Chapter Thirteen: The Legacy of a People Collector

Preface: The People Collector

 

Dr. Richard Smith’s desk always held what was an essential tool of the trade in those days: a Rolodex. His was not the pocket-sized kind but rather the behemoth version, its 3×5 cards overflowing and perpetually updated with scrawled new names and numbers.

Mona Bomgaars, a long-time colleague of Smith’s, remembers it well.
“Dick was always on the phone, always networking. That Rolodex had the phone numbers of so many important people around the world. He would always be in his office talking to somebody, someplace in the world, someplace in the government, wherever it would be. It was that wonderful networking that really revolved around him, his professionalism, his personality, you know. Mister Charisma, even on the phone, even on the phone.”

Richard Smith’s charisma, whether on or off the phone, was a gift. From a young age, those he came into contact with recognized something extraordinary in him. People were naturally drawn to his warmth, and he reciprocated their affection.

As we explore his story, we’ll discover how Richard Smith formed lasting connections everywhere he went, leaving a lasting mark on those he encountered. In essence, he was a master relationship builder, a people collector. It was an endeavor that demanded charisma, certainly. But it also required genuine interest in others, the ability to captivate and be remembered, and a blend of intelligence, energy, and charm. 

Richard Smith possessed all these qualities in abundance. People collecting was a skill that would serve him well at almost every professional turn to come, from volunteering as a young student in Cuba, to graduating from Howard University medical school, to working with the newly formed Peace Corps, to leading the desegregation of the nation’s hospitals, to playing an instrumental role in the creation of the PA profession, to extending healthcare solutions to countries around the globe.

Small wonder that Smith’s stuffed Rolodex would always be close at hand.

Chapter One: The Early Years

Richard Alfred Smith entered the world on October 13, 1932, in Norwalk, Connecticut, the second child of Mabel and Julius B. Smith. Richard’s older brother was named Julius as well. Mabel worked as a house cleaner, his father Julius was a butler for a private family. ¹ Richard’s arrival coincided with the harsh realities of the Great Depression, marked by job scarcity, financial struggles, and widespread hardship.

Further complicating his early life, Richard was born with clubfoot. It was a treatable condition that his parents worked to correct by enrolling him in dance classes early on. Could this have sparked his lifelong passion for music?

This initial hurdle paled in comparison to the tragedy that struck just five months later. On February 28, 1933 ² Richard’s father, Julius, passed away from unknown causes, leaving Mabel a single mother with two young boys under the age of five. Raising two young children as a single black woman in the 1930s, especially with the limited income of a house cleaner, presented immense challenges for Mabel. Seeking stability in the face of limited choices, she remarried in 1934. Unfortunately, this union with an alcoholic proved detrimental, further worsening the family’s situation. As Richard later recalled, “We went from one difficult situation to another. There was a lot of work to be done, and my mother was just overwhelmed.”

A Better Life in West Virginia

Whether seeking to shield Richard from his alcoholic stepfather, provide him with a better upbringing, or for other reasons lost to time, Mabel made a pivotal decision. When Richard reached school age, she arranged for him to move to the small town of Institute, West Virginia, where he would live with his Aunt Cora, Uncle Robert and his cousins Gladys and Dorothy until completing elementary school. 

Richard’s later memories of life in this rural Black community in West Virginia wove a tapestry of both joy and fear. Aunt Cora ran a restaurant near the campus of what was then called West Virginia State College. This bustling environment became Richard’s playground. “I met young, energetic kids who were constantly stimulating me,” he recalled. At just eight or nine years old, he found himself surrounded by teenagers, the “action” of the town swirling around him. “I was involved with almost everybody on campus because my aunt had good food,” he recalled with a glimmer of nostalgia.

But however idyllic this could seem to him, life in West Virginia was also marred by the harsh realities of racial segregation. The town of Institute lacked a proper grocery store, forcing residents to travel ten miles to the all-white segregated town of Dunbar for their supplies. When Cora’s restaurant needed food and supplies, Richard often accompanied his teenage cousins on the journey by bus to Dunbar, where he witnessed the stark division enforced by signs proclaiming “whites only” and “colored only.” “As I think about it now,” Richard recalled, “how the hell did anybody get through this without either getting killed or killing somebody else? Me especially.” It was a harsh awakening to the injustices of the immediate world, and it left an imprint on his young mind for what lay before him.

Upon his completion of elementary school, Richard’s mother felt it was time for him to return home to Norwalk. He was older now and would be easier to care for. Sometime in the early 1940s, Richard bid farewell to his West Virginia life and embarked on his next chapter.

Back to Norwalk

As he settled back into life in Norwalk, a special place quickly captured Richard’s heart: the Christ Episcopal Church. “The town was just great,” he reminisced, “and the church had a certain magic to it. Lo and behold, I started going, and suddenly I was part of that magic.”

Richard immersed himself in the church community, singing in the choir and even serving as the organist for a time. It proved to be a very supportive environment for him. Richard’s wife Lorna puts it this way, “When Richard was a boy, I think people realized that he was different and special. And so people kind of helped him along.” As Smith himself would put it, “I met people who played major parts of my life in that church, and I received money periodically from people.”

A Serendipitous Encounter with a Literary Legend

Beyond the church’s support, Richard encountered another pivotal figure in his young life, a man who would become a father figure for him: Manfred Bennington Lee. A renowned author who wrote and published under the pseudonym “Ellery Queen,” Manfred Lee was more famous than Richard initially realized. Partnered with his cousin Frederic Dannay, Ellery Queen was one of the most popular names among American mystery writers of the 1940s, selling over 150 million copies globally. ⁴ His works inspired numerous movies, radio shows, and television adaptations.

Richard met Lee, Lee’s wife Catherine “Kaye” Brinker, a radio star in the 1940s, and their daughter Anya at a school event around 1944-1945, where the boys were acting as waiters. They immediately hit it off. Richard later reflected, “I had a crush on Anya from the moment I saw her. Her mother took a liking to me too and invited me to their house that weekend.”

Chapter Two: The College Years

College was an opportunity rarely afforded to someone from Richard’s background. However, the people in his life recognized his potential and propelled him towards education. He was accepted into Howard University in Washington DC and began classes in the fall of 1949. He wanted to study piano and play jazz professionally. While financial aid from his church helped, the cost of living in Washington D.C. demanded more. So Richard juggled multiple jobs to make ends meet as a student, working as a stock boy, flipping burgers, playing piano at a country club, and even hosting a radio show twice a week.

A Life-Changing Summer in Cuba

Recognizing Richard’s passion for service, a university counselor encouraged him to join a Methodist church work camp during the summer break of 1951. Richard embraced this opportunity and soon found himself gathered alongside twelve other volunteers, first at an orientation in Miami, Florida, and then split into two teams and headed off to the Cuban countryside. 

Situated in a rural health clinic near Mayari, a municipality and town in the Holguín Province of Cuba, Richard encountered a level of poverty he had never witnessed before. The clinic, visited by a doctor only once a week at best, relied on a young, barely-trained healthcare worker named Dora to handle the rest.

For eight weeks, Richard immersed himself in the clinic’s work. “What amazed me was that I saw these little children being taken care of by this woman who had practically no training, taking care of lots of kids and some adults with all kinds of maladies.” One memory remains particularly vivid: “One of the infants without a diaper crawling across the floor defecating liquid. And as he did a huge adult tapeworm emerged.” 

Without missing a beat, Dora reached down to tend to the infant as best she could before then turning to the many other sick people in the clinic waiting for care. 

“That’s when it hit me,” Smith reflects, “my first real revelation.” He wondered how much training had she had? Three months, maybe six? What if there were others like her? What if the answer to improved access to health care lay not simply in having more MDs, but in increasing the numbers of non-physician health care providers. What if the skilled caring hands of this young Cuban provider could be … multiplied? 

Cuba: A Catalyst for Change

Richard’s experience in Cuba was one of the most transformative moments in his life. The stark realities of poverty and inadequate healthcare he witnessed ignited a passion to serve those most in need. He recognized the limitations of his musical talents and decided to switch his major from music to biology when he returned to Howard in the fall. His goal was to pursue a medical career specifically focusing on helping underserved communities.  “I decided that I wanted to go to medical school and try to find a way to work with the poor that had no healthcare at all,” he proclaimed. ⁵ Smith experienced this not merely as a career choice, but as a vocational calling.

Howard: A Gateway to Opportunity and “People Collecting”

Richard Smith’s years at Howard University proved to be the first round in Richard’s journey of “people collecting.” He found himself immersed in a diverse and intellectually stimulating environment, competing with brilliant students from across the globe. Jamaicans, Nigerians, and Guyanese, all top performers in their respective countries, formed part of this vibrant student body. Richard embraced this opportunity, forging valuable connections that shaped his future endeavors. These relationships, particularly with Nigerian doctors, would later come into play during his Peace Corps service there. Similarly, his bond with a friend from Howard who became Guyana’s Health Minister would pave the way for MEDEX’s long-standing presence in that country.

Smith’s Vocational Calling

Fueled by his Cuban experiences – the stark poverty, the inadequate clinic, the untrained nurse, the child suffering from a tapeworm – Richard saw a path opening for him to “multiply his hands a thousandfold.” He decided he wanted to become a medical missionary with the Episcopal Church, his church.

In September 1952, at the age of 20, Richard attended the National Episcopal Church Convention in Boston. This event proved deeply impactful. Witnessing the predominantly white delegates pass a resolution declaring “Christ’s teaching is incompatible with every form of discrimination based on color or race” was a groundbreaking moment for him. This resolution showcased the Episcopal Church actively taking a stand against racial discrimination, a powerful message considering the Brown v. Board of Education decision wouldn’t occur for another 20 months. While American society grappled with racial inequalities, the church’s resolution served as a beacon of progress for young Richard.

However, the path to dismantling systemic racism was and continues to be, fraught with setbacks, a reality intimately familiar to countless Black Americans. At the convention, Richard sought guidance from church leaders who could help him realize his dream of becoming a medical missionary. He had a seemingly promising interaction with a leader who also chaired the admissions committee at Harvard Medical School. This leader provided Richard with a Harvard Medical School application and a plan for preparing for a career in medical missions in the church. This encouragement was fleeting, however. Just two years later, the same individual signed a rejection letter from Harvard Medical School, citing a disingenuous excuse that “it was not their year for a negro.” This experience laid bare to Smith the deeply ingrained and often contradictory nature of the fight for racial equality in America. 

Undeterred, Richard applied to other medical schools, including Howard and Meharry Medical Schools, both Historically Black Colleges and Universities, and was accepted to both. There was some doubt, however, about whether he would get into Medical School at all. Richard struggled with organic chemistry in his undergraduate studies and was worried that his poor grades would prevent him from getting into any medical school. “I pleaded with Dr. Ferguson (his organic chemistry professor) to get something other than a D, and he gave me a C,” Smith recalled. Smith told a compelling story in his medical school admissions paperwork, recalling his Cuba experience. “I wanted to multiply my hands a thousand-fold,” he said in his application. That story impressed the admissions committees enough to overcome his poor grade in Organic Chemistry.

The US Public Health Service Opens Doors

During medical school, Richard took a strong interest in parasitology. This is no surprise, perhaps, given his experience with the tapeworm in Cuba. As he neared the end of medical school, Smith applied to the Missionary Board of the Episcopal Church and told them he was almost finished with his medical school training. He repeated to them what he had told the medical school admissions committee: “I want to multiply my hands a thousand-fold.” However, there was a complication. Smith’s wife had an unexplained medical condition that delayed the Episcopal Church’s approval.

Smith’s wife at the time, Parbattee Sumariya Balkissoon Smith, was from Trinidad and had an unexplained case of eosinophilia. Eosinophilia occurs when the body produces too many eosinophils, a type of white blood cell involved in immune responses. Elevated levels can be caused by allergies, asthma, medication reactions, or parasitic infections. As a budding parasitologist, Smith diagnosed her with filariasis, a parasitic disease transmitted through mosquito bites. The condition is prevalent in subtropical regions, including Asia, Africa, the western Pacific, and the Caribbean—including Trinidad.

In an interview years later, Smith described this event as his “diagnostic coup.” It led to an invitation from Dr. Henry Beye, the director of the Middle America Research Unit in the Panama Canal Zone and a member of the US Public Health Service. Dr. Beye was the world’s leading authority on filariasis at the time. In 1956, Smith accepted the invitation and became the first medical student to be commissioned into the US Public Health Service.

One of Smith’s first projects for the USPHS was to find patients in Washington, DC who had filariasis. Smith completed his assignment by tracking down students from Trinidad and Tobago. He soon discovered that some students had a heavy worm burden and that the mosquito died if it picked up too many parasites from the host. When Smith presented data on this phenomenon to Dr. Beye, it changed the treatment method.

Mentorship from Dr. Hildrus Poindexter

“Hildrus Poindexter, one of the highest-ranking African Americans in the US Public Health Service at the time, took notice of Smith’s ‘diagnostic coup’ and reached out to him, becoming a mentor.”

Poindexter was a national figure in tropical medicine. He taught at the Howard University Medical School from 1931 until 1943, when at age 42, he entered the US Army as a major in the Medical Corps and served as an epidemiologist, malariologist, and tropical disease specialist on General Douglas MacArthur’s staff in the Pacific. Smith recalled, “General MacArthur said he wouldn’t go into the Philippines without Poindexter because he was sure that malaria would kill more troops than the enemy.” Poindexter earned four major battle stars and the rank of Lieutenant Colonel for “courage beyond the call of duty.” ⁷

Despite his distinguished career, impeccable qualifications, and prominence, Poindexter was denied a leadership position at the National Institutes of Health simply because he was Black. This stands as another stark reminder of the injustices that have long marred the fight for racial equality.

Frustration with the Episcopal Church

After completing his medical degree at Howard, Smith embarked on a diverse professional journey, honing his skills and collecting valuable experiences. He was still in touch with the Episcopal Church and he kept telling them he wanted to be a medical missionary to “multiply his hands,” but the church still wasn’t biting on Smith’s idea.

As a senior medical student, Smith was offered a prestigious position as head of the filariasis program at the National Institutes of Health. However, Poindexter discouraged him from taking the position. “Finish your education and get your degrees before anything else,” Poindexter advised. Guided by Poindexter’s insight, Smith chose not to pursue the NIH job and instead focused on completing his education, which would ultimately shape his future path.

Smith spent his medical school internship year at the U.S. Public Health Service Hospital in Seattle. His next stop was a pediatric rotation with the Navajo Nation in Fort Defiance, Arizona. It was there that he decided he wanted to get formal training in Public Health. He completed a residency in public health and preventive medicine with the Los Angeles City Health Department. Then in 1960, he pursued a Master’s degree in Public Health from Columbia University in New York, before returning to Seattle to work as an epidemiologist for the Washington State Department of Health. 

Through all these early career experiences, Dr. Smith was still aspiring to be a medical missionary. He intensified his efforts with the Episcopal Church, which finally led to an offer to care for patients at St. Luke’s Hospital in Manila, Philippines. Smith declined this offer, saying “I want to train people – I don’t want to be running a clinic.” ⁸ Frustrated with the slow progress by the church in embracing his ideas, Smith went to work and wrote an unsolicited proposal to the Episcopal Church which drew on his experiences in Cuba and outlined his plan to train “quasi-doctors” who would provide care to various populations within a country. 

To advance his proposal, Smith collaborated with Rev. John Burgess, ⁹ a deacon at the National Cathedral in Washington, D.C., whom he had met at Howard University where Burgess was the Episcopal chaplain. Burgess, planning to attend the 1962 World Council of Churches meeting in New Delhi, agreed to support Smith’s initiative, saying, “We’ve got to give this another try.” He arranged an overnight stopover to meet with the Archbishop of Canterbury to discuss Smith’s proposal. The Archbishop agreed to present it at the meeting, emphasizing Smith’s concept to “train the trainers and multiply his hands.” Despite its eventual rejection by the World Council of Churches, this setback wouldn’t deter Dr. Smith from his goal.

Rev. John Burgess

John Melville Burgess (1909–2003) was a trailblazing figure in the Episcopal Church and a champion of civil rights. Born in Grand Rapids, Michigan, he was the son of a minister and was deeply influenced by his family’s faith. Burgess earned degrees from the University of Michigan and the Episcopal Theological School, leading to his ordination as a priest in 1934.

In 1969, he made history by becoming the first African American bishop to lead a diocese of the Episcopal Church in the United States, serving as Bishop of Massachusetts. Throughout his career, Burgess was a passionate advocate for racial equality and social justice, often intertwining his ministry with the fight for civil rights. He worked tirelessly to promote inclusivity and strengthen the church’s outreach to marginalized communities. His legacy as a spiritual leader and civil rights advocate endures in the Episcopal Church and beyond.

Peace Corps: A Pivotal Chapter Begins

As a commissioned officer in the U.S. Public Health Service, Smith’s next stop was Tuba City, Arizona, serving as Field Medical Officer at the Public Health Service Indian Hospital. While there, a flyer about the Peace Corps healthcare program caught his attention. 

The flyer detailed the U.S. Public Health Service’s new collaboration with the Peace Corps, calling for medical officers to ensure the health and safety of volunteers stationed in developing countries. It promised a challenging yet rewarding experience, working with communities around the world where access to healthcare was scarce.

Dr. Smith responded immediately and was soon invited to Washington D.C. to meet with the first director of the Peace Corps, Sargent Shriver. “I wanted to go to Columbia,” Smith recalls, expressing his initial preference to Shriver. Recognizing Smith’s potential, Shriver responded, “That’s great, but we need you in Nigeria.”

This marked the beginning of another pivotal chapter in Smith’s life, a “second revelation,” as he would call it. The Peace Corps became a life-changing experience, instilling in him a profound belief in the possibility of overcoming seemingly insurmountable challenges. “It was a 24-hour-a-day signal to me saying almost nothing is impossible,” Smith recalled.

Chocolate Mousse Hunting

On the way to his Peace Corps assignment in Nigeria in 1961, Dr. Richard Smith made a life-changing stop in Paris to visit his old friend, Michel Guernee, whom he had met as a high school foreign exchange student in Norwalk, Connecticut. It was during this visit that Smith experienced his first mousse au chocolat. This indulgence became more than just a culinary treat for Smith. It evolved into a stress-relieving hobby that followed him through the rest of his life. Whether working in Asia, Africa, South America, or Europe, Smith’s playful pursuit of the ultimate chocolate mousse became an integral part of his identity among health professionals. It became the way Smith balanced his dedication to improving healthcare worldwide.

Nigeria: A New Frontier

Dr. Smith’s Peace Corps assignment took him to Nigeria, where he was responsible for the health and safety of the Peace Corps volunteers there. His work took him from village to village, which were sometimes 300 miles apart. Volunteers living in areas with unfamiliar diseases and harsh conditions came to rely on his medical guidance. This experience strengthened Dr. Smith’s resolve to improve healthcare in underserved populations and laid the foundation for future work, where building local connections would become key to his approach. Reflecting on his time in Nigeria, Dr. Smith saw it as a crucially formative period in his medical career, where book knowledge met the realities of tropical diseases, and his growth as a physician was matched by his development as a human being. Immersed in a new culture and facing new medical challenges, he learned that serving in areas with limited resources is not only a test of medicine but also of ideas and adaptability. 

Beyond Volunteers: Empowering Local Communities

But Dr. Smith’s dedication didn’t stop with the Peace Corps volunteers. He recognized the immense need for healthcare access in rural Nigerian communities and volunteered his medical expertise at mission hospitals. There, he embarked on a novel initiative: training local individuals known as “dressers”—health workers responsible for treating wounds, administering first aid, and changing dressings—to provide basic medical care. These dressers were crucial in areas with limited healthcare facilities, and Dr. Smith’s training empowered them to meet the broader needs of their communities.

“I volunteered my time to train these folks in the bush—not in urban centers, but in rural mission hospitals,” Smith recalled. “I selected two individuals in each setting who seemed particularly bright and had a good grasp of English,” he explained. “I trained them to identify and treat common ailments like malaria, fever, and chest infections.” He gradually expanded their training to include diarrhea, dysentery, worms, and malnutrition—addressing the vast majority of healthcare needs in rural Nigeria.

The results were immediate and significant. The “dressers” quickly became the primary healthcare providers in their communities, handling nearly 90% of local health needs.

Dr. Smith’s success validated his belief in “multiplying his hands,” showing that empowering minimally trained individuals to deliver care wasn’t just feasible—it was revolutionary. This realization built on his experience with Dora in Cuba, where he first saw the impact one person could have with basic training. In Nigeria, Smith saw the same potential. Each success showed that his approach could be adapted to different settings and scaled to meet the healthcare needs of underserved communities worldwide.

Chapter Three: The Surgeon General’s Office

Returning from Nigeria in 1963, Smith’s dedication and expertise were quickly recognized. He was appointed the Africa Regional Medical Officer for the Peace Corps, overseeing all doctors on the continent. His innovative approach to training Nigerian “dressers” resonated with superiors, and within a year, he became Deputy Director of the entire Peace Corps Medical Program Division. Working alongside Dr. James Banta, Smith’s vision of “multiplying his hands a thousandfold” was gaining traction in U.S. government circles.

In 1965, Smith received a pivotal opportunity. U.S. Surgeon General William Stewart invited him to join his staff as an Executive Trainee. This role exposed Smith to the intricacies of social change, equipping him with crucial knowledge beyond his medical expertise.

Smith recalls, “I needed to develop an understanding of the forces at play when you’re dealing with social change. The political, technical, regulatory, and financial factors, all these things that I had to learn about, they were totally new to me as a physician. Most importantly, I would have to learn how to turn detractors into supporters. And I had to learn about systems and how you would develop a systems approach to doing this. [But] the first thing that I had to learn about was the receptive framework for this crazy idea that I called MEDEX. The Surgeon General had heard me talking about this for a couple of years. And so, it was on the tip of his tongue like it was on the tip of my tongue: “MEDEX.” ¹¹

As we’ll see, there followed three specific experiences along Dr. Smith’s professional path that  proved instrumental in propelling the MEDEX concept forward.

The Receptive Framework

Dr. Richard Smith’s Receptive Framework was essential for introducing new health professionals in less developed countries. It focused on engaging key stakeholders, including physicians, government officials, and community leaders, to gain broad support for healthcare reforms. This involved addressing cultural, legal, and logistical challenges to ensure acceptance.

In these settings, public perception played a crucial role. Smith understood the importance of presenting new health workers in ways that resonated locally, such as using the term “Wechakorn” in Thailand to fit the cultural context. Additionally, the framework emphasized the need for sustainable support, including legal recognition and ongoing education, as seen in Guyana’s Medex Act, which formalized the role of these workers in rural areas. This approach ensured successful integration of new health professionals into local healthcare systems.

Experience One: Desegregating Hospitals

In July 1965, President Lyndon B. Johnson signed the Medicare Act. This new and far reaching law mandated among other significant changes the desegregation of hospitals receiving federal funding. With the implementation deadline looming just a year away, the Surgeon General faced a daunting task: ensuring compliance from hundreds of segregated hospitals across the nation. Dr. Smith, recognized again for his leadership and ability to navigate complex situations, was tapped by the Surgeon General to spearhead this critical initiative.

“We had less than a year to desegregate thousands of hospitals,” Smith recalls, emphasizing the urgency and scale of the challenge. “It was the fastest thing I’ve ever seen.” Despite the tight timeline, significant progress was made. “Here was an idea that took into consideration those for and those against, and how to change attitudes to move a social effort forward,” he summarized. 

This experience proved to be a valuable lesson in social change for Smith. He saw firsthand that addressing diverse viewpoints and encouraging attitude shifts were essential for progress. Most particularly, this experience held valuable lessons applicable to his burgeoning MEDEX concept, requiring similar strategies to overcome potential resistance and gain broad support.

The 1965 Medicare Act

The requirement for hospital desegregation as a condition for Medicare participation led to rapid and widespread changes. Many hospitals that had previously been segregated began to integrate their facilities, services, and staff to comply with federal law and to ensure their financial viability. This period marked a significant step forward in improving access to healthcare for African Americans and other minority groups.

Experience Two: Floating the MEDEX idea in Southeast Asia

In late 1966, Dr. Smith’s boss, Surgeon General William Stewart, was asked to accompany Eugene Black, former World Bank president and Special Adviser to President Johnson on Southeast Asian Social and Economic Development, on a trip to establish the Asian Development Bank. Amidst the escalating Vietnam War, President Johnson was seeking humanitarian and economic solutions, specifically aiming to demonstrate goodwill through improved healthcare access.

Black’s delegation, including Stewart, visited 10 Asian countries and  returned with a resounding message: “We need doctors.” Stewart then approached Dr. Smith with a proposal: “You know this crazy idea you have about physician extenders (Medex)? I think we can make it happen.”

The concept of “physician extenders” was gaining traction at the time, emphasizing the potential of trained personnel to bridge the gap in underserved areas. This concept resonated deeply with Smith, aligning with his experiences in Cuba and Nigeria and further shaping his evolving vision.

During their trip, Stewart had presented Smith’s ideas to local officials, who were receptive and curious: “He reported that they thought it was a good idea,” Smith recalls, “but wanted to know why we weren’t doing it in the US.” This question caught Dr. Smith’s attention. Up to that point, he had mostly envisioned the use of community health workers and physician extenders as a solution in international settings. But now he began to wonder, why in fact weren’t we doing it in the US?

Experience Three: Attending the World Health Organization Assembly

The third critical factor in the development of the MEDEX concept came in 1967 when Dr. Smith was appointed to the United States delegation at the United Nations World Health Organization Assembly in Geneva.This international gathering presented a unique opportunity, not just to gauge the global scope of the healthcare workforce crisis, but also to lay the groundwork for his innovative solution.

Dr. Smith met repeatedly with delegates from all over the world who expressed their needs to this young, inquisitive, Black doctor from the U.S. to increase the primary healthcare workforce in their countries. It was a universal challenge: a critical shortage of primary healthcare providers.

His conviction in the international applicability of MEDEX was solidified. This global perspective not only validated his vision but also fueled his determination to bridge the gap between conception and widespread implementation.

Smith began forming a mental map of the many factions and forces that would influence the viability of his new approach to healthcare delivery. He began to build the receptive framework and a context for the change he wanted to see. Not only was he meeting with dozens of leaders from around the world, he was cementing relationships with powerful people in the US government. People who heard his ideas. People who would be instrumental in helping him implement his ideas.

“The characters on that US delegation were an incredible bunch of people,” Smith recalled. “We had breakfast at 7:00 every morning, sometimes lunch, sometimes dinner. There were receptions every evening, and we drank coffee all day long with each other and with other delegates.”

Geneva became a springboard for MEDEX. It gave Dr. Smith a global perspective, connected him to key allies, and created an environment for collaboration. These elements helped transform MEDEX from a promising concept into a real-world solution to a pressing global need.

Smith’s knack for gathering people proved invaluable at the assembly, where he connected with key figures in healthcare, policy, and government who would help bring his idea to fruition:

• Melvin Laird, who later became Secretary of Defense, was head of the House Appropriations Committee in 1967.
• Congressman Neil Smith from Iowa, head of Health Appropriations.
• William Stewart, the U.S. Surgeon General.
• Gerald Dorman, a trustee and future president of the American Medical Association, who became a behind-the-scenes supporter of MEDEX.
• Malcolm Merrill, president of the American Public Health Association.
• Jim Cain, President Lyndon Johnson’s personal physician.

“This was the network that MEDEX developed early on to bring about this change.” Smith recalled. “And I stumbled into it. At least I had the Peace Corps experience to say, “Yeah, watch this. Look at this. Take care of this. Look what’s happening.” At least I had that kind of background to move forward on it.

Dr. William Stewart

• As the 10th U.S. Surgeon General, Dr. William Stewart played a key role in advancing the concept of “physician extenders,” supporting Dr. Richard Smith’s innovative ideas to address healthcare shortages, particularly in underserved areas.
• In 1965, Dr. Stewart appointed Dr. Richard Smith as the Director of the Office of Planning for International Health, where Smith became the youngest U.S. delegate to the World Health Assembly in Geneva.
• Stewart’s collaboration with Smith during their tenure led to the creation of the MEDEX program, which expanded healthcare access in both international and domestic settings, building on Smith’s insights from the Soviet Feldsher system.

Secretary Melvin Laird

• Secretary of Defense during the Vietnam War, Melvin Laird advocated for better healthcare services for soldiers and veterans, leading to significant reforms in military medicine.
• As head of the House Appropriations Committee, Laird ensured funding for critical global health initiatives, playing a behind-the-scenes role in U.S. participation in international healthcare efforts.
• Served with Dr. Richard Smith at the 1967 World Health Assembly, contributing to discussions on global health policy and U.S. involvement in international healthcare.

Congressman Neal Smith

• Served with Dr. Richard Smith on the 1967 US delegation to the WHO World Health Assembly in Geneva.
• Iowa Congressman who played a pivotal role in advancing agricultural and rural health initiatives.
• Known for his environmental conservation efforts and championing of healthcare access in rural America.
• His legislative contributions significantly impacted public health, particularly in healthcare funding for underserved populations.

Dr. Gerald Dorman

• Served with Dr. Richard Smith at the 1967 World Health Assembly, where they contributed to shaping U.S. involvement in global health policy and initiatives.
• President of the American Medical Association (AMA) from 1969 to 1970, Dr. Gerald Dorman worked closely with Dr. Richard Smith to advocate for the MEDEX program, urging the medical community to adopt physician extenders as a solution to healthcare shortages.
• Dorman’s leadership and forward-thinking approach helped pave the way for the recognition of mid-level health practitioners, marking a shift in the medical profession’s approach to healthcare delivery.

Dr. James C. Cain

• Personal physician to President Lyndon Johnson, Dr. Cain played a crucial role in providing medical care during a pivotal time in American history.
• Served with Dr. Richard Smith on the 1967 U.S. delegation to the WHO World Health Assembly in Geneva, where they collaborated on international health initiatives.

 

Chapter Four: Not a Settler 

Dr. Richard Smith dedicated four years (1969-1972) to a transformative mission: tackling the worsening healthcare crisis in the United States, particularly the lack of practitioners in rural areas. His solution? MEDEX Northwest, a groundbreaking program that introduced a new medical profession.

But MEDEX wasn’t just about training individuals. Recognizing the potential of medically trained veterans, Smith tapped into this underutilized resource. He understood that successful change required a “systems metaphor,” a dynamic approach that went beyond simply equipping individuals with skills. It involved creating a supportive infrastructure, a receptive framework, for seamless integration into the healthcare system.

This commitment to a holistic approach resonated across diverse communities, first in Washington state, then across the United States. MEDEX programs flourished in affluent, poor, and middle-class settings, rural and urban alike. With successful programs established across various time zones, Smith knew he had achieved his goal: proving MEDEX could work anywhere in the United States.

From Pioneer to Innovator: Smith Takes MEDEX Global

With at least nine successful MEDEX programs established across the US, Dr. Smith had achieved his proof of concept. However, his pioneering spirit yearned for new challenges. “I’m not a settler,” he declared, acknowledging his preference for innovation over established management. This sentiment resonated with the entire MEDEX Northwest leadership team at the time. As Deputy Director Ray Vath aptly described the group, “We love the challenge of creating, but not one of us likes to manage.” This distinction between pioneers and settlers, as Vath phrased it, perfectly captured Smith’s mindset. He recognized his strengths lay in systems development, not in managing established processes.

This understanding of his own inclinations led Smith to a crucial decision: it was time to leave Seattle and take MEDEX to the world stage. His pioneering spirit and passion for innovation propelled him towards new frontiers, leaving the established success of MEDEX Northwest in the capable hands of his team.

For a fuller telling of this period of Dr. Richard Smith’s professional career, click and read Multiply My Hands: Dr. Richard Smith and the Founding of MEDEX Northwest.

Chapter Five: MEDEX Micronesia – An International Vision Realized

In late 1971, Dr. Richard Smith received an invitation that would set the stage for MEDEX’s global expansion. Tony Kunimura, a state legislator from Kauai at the time, invited him to launch a MEDEX program in Hawaii. This opportunity resonated with a long-held ambition Smith had been nurturing since his time at the World Health Assembly in 1967, certainly, but also in many ways since his proposal to Episcopal Church years earlier: to establish MEDEX as a global solution to healthcare workforce shortages. 

Fueled by the successful implementation of MEDEX programs at the University of Washington and across nine other universities, Smith saw this as the perfect opportunity to take his vision internationally. His decision was further bolstered by familiar faces at the University of Hawaii:

Rear Admiral Jerrold Michael

• Youngest Assistant Surgeon General in U.S. Public Health Service history, Jerrold Michael rose quickly through the ranks, becoming a Rear Admiral at just 37, and playing a key role in shaping national health policy.
• Collaborated closely with Dr. Richard Smith in the Surgeon General’s office, and later at the University of Hawaii, where they continued to push the boundaries of public health education and practice.
• As Dean of the School of Public Health at the University of Hawaii, he revolutionized public health education in the Pacific, building a network of schools and training the next generation of global health leaders.

Dr. James Banta

• Medical Director of the Peace Corps from 1963 to 1965, Dr. Banta worked closely with Dr. Richard Smith, who served as Deputy Medical Director, ensuring the health of Peace Corps volunteers in remote areas around the world.
• Briefly served at the University of Hawaii in the early 1970s, continuing his collaboration with Dr. Smith during a pivotal period in public health development in the Pacific.
• As Dean of the School of Public Health and Tropical Medicine at Tulane University, Dr. Banta was a key figure in advancing global health education, mentoring future public health leaders across his long career.

With arrangements made to transfer his assignment with the Public Health Service, and his MEDEX Northwest team in Seattle on solid footing, Smith relocated to Hawaii. Once settled in Hawaii, however, Smith realized almost immediately that launching a MEDEX program in Hawaii would face significant resistance from the established medical community. Smith recalled in 2008, “And within three months, I realized that was political suicide. There was no way we could ever start a MEDEX program in Hawaii. The doctors were too threatened financially. They didn’t understand the finances though.” ¹¹

This setback, though challenging, did not deter him. Instead, it propelled him to shift his focus to Micronesia.

While in Honolulu, preparing for his new appointment at the University of Hawaii, Richard Smith had a chance meeting that would shape the future of healthcare in Micronesia and the future of MEDEX itself. “There was so much luck involved,” Smith recalled with awe. ¹²

Ngas Kansou was the health officer of Truk Atoll and was at the University of Hawaii getting his Master’s in Public Health. Smith and Kansou met and hit it off right away.  Smith invited Kansou to Seattle to see the Medex program there before he left for Hawaii permanently. Smith recalls, “I took him around the State of Washington and showed him what our Medex were doing and he was turned on. So when I arrived [in Hawaii], Ngas and I had already begun the groundwork for Medex in Micronesia.”

Hawaii: A Strategic Launchpad for Global Outreach

Hawaii’s proximity to the third world, coupled with the connections Smith had forged at the World Health Assembly, made it an ideal base for his international endeavors. He envisioned attracting international health officials to Hawaii, leveraging the allure of the location to secure support for MEDEX’s global implementation.

Hawaii’s unique location offered several advantages for Dr. Smith’s international ambitions. Situated 2,000 miles from the mainland US, it provided easier travel logistics for health ministers from around the world. Additionally, Hawaii’s multicultural population offered a more international atmosphere, potentially resonating better with foreign visitors.

The most crucial benefit of moving the operation to Hawaii was that it held political clout in Washington, D.C. Senator Daniel Inouye, chairman of the Senate Foreign Appropriations Committee, secured significant funding – $31 million over 21 years – for MEDEX’s international expansion.

Senator Daniel Inouye

• Senator Daniel Inouye developed a close relationship with Dr. Richard Smith, and as chairman of the Senate Foreign Appropriations Committee, he secured $31 million in funding over 21 years to support MEDEX’s international expansion, leveraging Hawaii’s unique geographic and cultural advantages for global health collaboration.
• As a strong advocate for veterans’ rights, Inouye, a decorated WWII hero himself, pushed for policies that improved healthcare services for veterans across the U.S., ensuring better access and care for those who served.
• Known for his work on civil rights and healthcare equity, Inouye was instrumental in advancing legislation that expanded healthcare access to underserved communities, particularly in rural and indigenous areas.

The islands of Micronesia, colonized by various powers over time, eventually became a US-administered UN Trust Territory. This region, facing similar healthcare challenges to those addressed by the MEDEX program in Washington state, became the initial target for the program’s international implementation.

The University of Hawaii and Micronesia: A Longstanding Connection 

The University of Hawaii School of Medicine’s relationship with the Micronesian islands stretches back to 1966, rooted in the Regional Medical Programs (RMPs) initiative. Established as part of President Lyndon B. Johnson’s Great Society programs, RMPs aimed to combat major health concerns like heart disease, cancer, and stroke. The US was divided into 56 regions, each receiving funding to encourage collaboration between medical schools, research institutions, and hospitals.

The RMP for Hawaii, Guam, American Samoa, and the Trust Territory of the Pacific Islands (TTPI) received its initial planning grant in 1966, with the University of Hawaii’s Research Corporation serving as the applicant. After extensive planning, the program received its first operational grant in 1968.

In 1969, Dr. Masato Hasegawa, director of the RMP Hawaii, appointed Dr. Satoru Izutsu from the University of Hawaii to oversee RMP activities in the Pacific Basin, including the TTPI. The first RMP-funded projects in Micronesia commenced in 1971, with a pilot cervical cancer detection program in Palau and a feasibility study for a standardized health assistant training program across Micronesia.

Dr. Satoru Izutsu

• Played a key role in developing healthcare programs across the Pacific Islands, focusing on community-based primary care that improved access to medical services in remote areas.
• As a leader in medical education, he helped establish training programs for healthcare professionals in underserved regions, particularly across the Pacific.
• A close advisor and encourager to Dr. Richard Smith, Dr. Izutsu provided crucial support for Smith’s global health initiatives, especially in advancing healthcare in the Pacific region.

Building Momentum in Micronesia: Smith’s Strategic Moves

Dr. Smith wasted no time in establishing a foothold in the Trust Territories. Shortly after joining the University of Hawaii, he and Dr. Izutzu were appointed to the Health Council in August 1972. This council, comprising health leaders from all districts, aimed to develop a training program for healthcare personnel.

Identifying a critical gap, Dr. Smith noted, “There was no support for the health workers on the atolls.” He found a crucial ally in Juan Sablan, a Senior Administrative Officer in Truk, who “got us what we needed when we needed it,” Smith recalled. Dr. Smith’s ability to identify and engage individuals who shared his vision and possessed the power to make it a reality proved invaluable. Just five years later, Sablan’s rise to Deputy High Commissioner further solidified their partnership.

To lead the new training program, Dr. Smith recruited Dr. William Peck, who had recently retired as the head of health programs for the Trust Territory of the Pacific Islands (TTPI). He also brought on James Van, a recent graduate from the Medex Northwest program in Seattle. “Dr. Smith didn’t give me much time after graduation to give him an answer,” Van recalls. Van and his wife Christine were excited for the opportunity. But Van’s father, who had his own history in Micronesia as a B29 pilot in World War II, didn’t share the enthusiasm. “We bombed the hell out of that place,” his father said.

The third member of the implementation team in Micronesia was Dr. Ronald Wilson. Wilson was a Peace Corps physician who just finished his assignment in Thailand and was looking to continue working in international health.

Dr. William Peck

• Recruited by Dr. Richard Smith to lead the new healthcare training program in Micronesia, Dr. Peck brought his extensive experience as the former head of the Trust Territories of the Pacific Islands (TTPI) health programs.
• Played a pivotal role in adapting the MEDEX model for Micronesia’s unique needs, ensuring healthcare workers were equipped to serve in remote and geographically dispersed communities.
• His leadership and commitment to healthcare education laid the foundation for sustainable healthcare systems in the Pacific.

James Van

• Recruited by Dr. Richard Smith after graduating from the Medex Northwest program (Class 3), James Van played a crucial role in the launch of the MEDEX program in Micronesia.
• Van’s adaptability and expertise helped shape the program, providing essential training to healthcare workers across the remote islands of Micronesia.
• As a key member of the MEDEX implementation team, Van helped lay the groundwork for sustainable healthcare in one of the world’s most geographically challenging regions

Dr. Ronald Wilson

• Peace Corps physician in Thailand, Dr. Ronald Wilson brought his expertise to the Lampang Project, where he served as Associate Field Director and Chief-of-Party for the University of Hawaii’s School of Public Health.
• Played a critical role in the MEDEX program in Micronesia, ensuring its successful launch and sustainability while working alongside James Van and Dr. Richard Smith to train healthcare workers for remote islands.
• Honored with The Most Honourable Order of the Crown of Thailand, Dr. Wilson was recognized for his untiring service to the Ministry of Public Health, contributing significantly to the healthcare infrastructure in Thailand.

Adapting the MEDEX Model for Micronesia’s Unique Needs

Recognizing the distinct needs of Micronesia when compared to the US mainland, Dr. Smith and his team undertook a crucial step before deploying the MEDEX program. They gathered in Hawaii for a month of intensive curriculum refinement, drawing on valuable insights from both the original MEDEX Northwest program and its successful recent adaptations in rural Alaska.

Micronesia’s vast archipelagos, scattered across the Pacific Ocean, presented a unique challenge. Unlike the relatively close-knit communities served by MEDEX graduates in the US, Micronesian healthcare providers often faced significant geographical separation. Remote island locations and limited transportation infrastructure meant that supervising physicians wouldn’t always be physically present to provide immediate guidance.

To address this challenge, the curriculum for Micronesia’s MEDEX program was meticulously tailored. While retaining the core foundation of competency in essential medical, surgical, pediatric, nutritional, and obstetric care, the program placed particular emphasis on the most prevalent medical and surgical issues encountered in the Micronesian context. This ensured that graduates possessed the necessary knowledge and skills to effectively address the specific healthcare needs of the region’s diverse communities.

Furthermore, the curriculum acknowledged the reality of limited in-person supervision. It incorporated robust training in radio communication, equipping MEDEX graduates to confidently consult with supervising physicians remotely and, when necessary, initiate essential treatments independently. This crucial adaptation ensured that even in remote locations, MEDEX graduates could provide timely and effective healthcare services while maintaining vital connections with their supervisory support network.

By carefully considering the unique geographical and healthcare realities of Micronesia, Dr. Smith and his team successfully adapted the MEDEX program, paving the way for a sustainable solution to address the region’s pressing healthcare workforce shortage. This strategic adaptation not only addressed the immediate needs of Micronesia but also established a valuable framework for future iterations of the MEDEX program in other geographically dispersed and resource-limited settings.

Hitting the Ground Running in Truk

Upon arrival in Truk, James Van and Dr. Ron Wilson encountered a program already in its initial stages. Housing and a designated classroom, conveniently located in the air-conditioned nursery of Truk Hospital (essential for their aging copy machine!), were already prepared.

Another key element, the students, had also been selected. Unlike the US-based program, there was no formal selection conference. Instead, medical officers on the ground identified and recruited individuals with prior medical experience who met the program’s criteria. This approach ensured representation from each of the six administrative districts (Marianas, Marshalls, Palau, Ponape, Truk, Yap) spanning four time zones. The first class comprised a diverse group, including practical nurses trained in Saipan and village health assistants already providing care in their communities.

This pre-established groundwork, while offering a head start, also meant adapting to existing decisions. Van and Wilson’s role involved effectively delivering the curriculum and guiding the students through the program, leveraging their expertise to equip them with the necessary skills to address Micronesia’s unique healthcare challenges.

The Challenge of Healthcare in Micronesia: A Vast Region with Scattered Populations 

The vastness of the Trust Territories of the Pacific Islands (TTPI) presents a formidable obstacle to delivering effective healthcare. Stretching across an expanse comparable to the continental US, the TTPI encompasses over 2,000 islands, but only around 100 are inhabited. The area, while vast in terms of ocean territory (covering 3 million square miles), boasts a landmass of just 700 square miles, emphasizing the scattered nature of its population. This geographical dispersion, with an estimated 5% of the Pacific Ocean’s water contained within the TTPI, creates immense logistical challenges for establishing and maintaining consistent healthcare services.

With a population of around 90,000 in 1970, nearly 40,000 resided in concentrated areas, leaving the remaining 50,000 inhabitants dispersed across the remote outer islands. Delivering medical care to these isolated communities proved incredibly challenging. Maintaining facilities and supplies was difficult due to remoteness, and doctors were primarily stationed in district centers with better infrastructure and resources. Furthermore, many health assistants on these outer islands hadn’t received any formal training updates in over two decades, since the “Navy times.” ¹³ 

This complex reality demonstrates the critical need for an innovative solution like the MEDEX program, designed to address the unique healthcare workforce shortage and geographical challenges faced by Micronesia.

 

Micronesia’s Healthcare Landscape in 1972: A Need for Change

In 1972, Micronesia’s healthcare system faced significant challenges due to limited resources and a geographically dispersed population. The existing workforce primarily consisted of:

• Micronesian Medical Officers: Trained in Fiji under a six-year British model, these individuals formed the core of the medical leadership.
• Practical Nurses: Providing a combination of nursing care, village care, and maternity services.
• Health Assistants: Serving in remote villages, offering basic healthcare services.

James Van aptly summarized the need for the MEDEX program: “It aimed to elevate the skills of existing healthcare personnel, particularly Health Assistants and Practical Nurses, enabling them to provide a higher level of care for isolated communities, reducing reliance on evacuation or lengthy boat journeys for essential medical attention.”

The MEDEX Program Takes Root

On November 18, 1972, the inaugural class of Micronesian MEDEX trainees commenced their studies at the dedicated MEDEX/Micronesia Training Center in Truk. The program followed a structured format:

• 6 months of intensive training: Equipping students with the necessary knowledge and skills in various medical areas.
• 6 months of clinical rotations: Providing practical experience in real-world healthcare settings.

This combined approach ensured graduates were well-prepared to address the unique needs of Micronesia’s diverse communities.

The first MEDEX class graduated on December 11, 1973, in a ceremony marking a significant milestone. The High Commissioner of the Trust Territories delivered the keynote address, alongside Dr. Jerry Michael and Dr. Richard Smith. With the first class successfully launched, the second cohort was already well into their studies, paving the way for a more robust and accessible healthcare system in Micronesia.

Moving On from Micronesia: New Opportunities Arise

In 1974, James Van and Ron Wilson, having successfully launched the MEDEX program in Micronesia and ensured its sustainability for the next two years, faced a critical decision. Dr. Richard Smith offered them the opportunity to continue their international healthcare work by joining a new program about to start in Thailand.

For Van, the decision was complex. He and his wife, Christine, had recently welcomed their daughter in Micronesia and yearned to introduce her to their families back home. Additionally, Van felt a strong pull to return to the US and resume practicing medicine. His former preceptor from Medex Northwest, Dr. Robert Bethel, eagerly awaited his return to collaborate. Ultimately, Van opted to return to the US and rejoin Dr. Bethel.

Ron Wilson, on the other hand, had found love in Micronesia, marrying Termotis “Teri” Wilson during their time there. They briefly resided in Hawaii after their wedding. However, Wilson’s prior experience in Thailand through the Peace Corps, combined with the allure of the new project, proved irresistible. In 1974, he and Teri embarked on a new chapter, relocating to Thailand to begin work on the Lampang Project.

While their paths diverged, both Van and Wilson’s contributions to the MEDEX program in Micronesia laid a strong foundation for improving healthcare access in the region. Their dedication and expertise paved the way for future generations of healthcare providers to serve the diverse communities of Micronesia.

Continuing the Legacy: Building on Success

Following James Van’s departure, John Padgett, a Medex Northwest graduate and Vietnam War veteran, joined the Micronesia program. Arriving after the first two graduating classes, Padgett took on the role of instructing Classes 3 and 4.

With the initial MEDEX Micronesia training program concluding in 1975, Padgett and Dr. Peck received new titles: Padgett as Field Coordinator and Peck as Director of the newly established Health Professional Training Staff within the TTPI. This office, funded by the United States Department of Health, Education, and Welfare, aimed to provide ongoing education and skill development for existing health assistants in remote island dispensaries. Essentially, it built upon the foundation laid by the MEDEX program, further refining and standardizing the skills of these vital healthcare providers.

Padgett’s dedication extended beyond the initial program. He remained in Micronesia for a time, collaborating with Dr. Peck before embarking on a new challenge in 1976 – providing healthcare support for workers constructing the Alaska Pipeline.

{INSERT: Story on Padgett’s time working on the Alaska Pipeline?}

John Padgett

• A Medex Northwest graduate of Class 4 and Vietnam War veteran, John Padgett joined the Micronesia MEDEX program and played a key role in instructing Classes 3 and 4.
• After the initial program concluded in 1975, Padgett became Field Coordinator, working alongside Dr. William Peck to continue training health assistants in remote island dispensaries across Micronesia.
• His dedication to healthcare extended beyond Micronesia, as he later took on a new challenge providing healthcare support for workers on the Alaska Pipeline and spent many years working in PA Education.

The Micronesia MEDEX program successfully trained 54 individuals over its four-year run, concluding in 1975.  However, the University of Hawaii’s Health Manpower Development Staff continued its commitment to the region well into the late 1970s, offering ongoing support to MEDEX graduates and local healthcare leaders.

As the program gained traction, Dr. Smith’s vision garnered international attention. A 1973 landmark article in prestigious journal, The Lancet, served as his announcement to the medical world, introducing the MEDEX program as a novel solution to the global healthcare workforce crisis. Smith emphasized the program’s adaptability to diverse settings, highlighting its successful implementation in both the US and Micronesia, paving the way for its potential application across the globe.

Chapter Six: Assembling the Team

With the successful implementation of the MEDEX concept in the United States and Micronesia, Dr. Richard Smith had the full attention of the United States Agency for International Development (USAID). The agency’s various mission outposts around the world were requesting assistance to deliver healthcare. In April 1974, the Office of International Health (OIH) approached the University of Hawaii on behalf of USAID with a special proposal. The task was to “develop a Health Manpower Development Staff to serve as a resource and response unit capable of planning and developing mid-level (MEDEX type) health manpower who can provide basic health services as designated by USAID.” ¹⁵

For many years, USAID and other health organizations working with developing nations had struggled to implement effective healthcare delivery systems. Most low-income countries couldn’t afford to build full-scale medical schools like those in Western countries, and USAID saw MEDEX as a promising solution. The program was practical, proven to work, and relatively low in cost.

The formation of the Health Manpower Development Staff (HMDS) allowed Dr. Smith to assemble a team of experts whose job was to develop a way to train and deploy mid-level health workers for various countries around the world. The initial focus was on 20 countries in Central Africa, with Liberia, Ghana, Tanzania, and Botswana being top priorities. Asia followed closely behind, with Nepal, Pakistan, Afghanistan, and Thailand identified as regions of significant need.

Although Dr. Smith was fully capable of reviewing and adapting the training modules to fit local needs himself, he knew his time was better spent “selling” the MEDEX concept to health ministers and other decision-makers. Implementing MEDEX was a task better left to others. It was time for Dr. Smith to pull out his Rolodex again.

Building the Health Manpower Development Staff

Dr. Smith carefully selected a team of professionals whose backgrounds suited the international expansion of the MEDEX program. As we’ll see in the chapters ahead, each person brought their own unique expertise, having worked in diverse healthcare settings across the globe. The individuals highlighted here were key contributors to MEDEX’s international efforts, though they represent only a portion of the many talented experts Smith brought together over the years. Their collective expertise and collaboration was instrumental in shaping the work of the Health Manpower Development Staff (HMDS).

Finding a Deputy

Smith’s first task was to find a deputy who could balance his vision and idealism with strong managerial and administrative skills. He needed someone who could help shape and run the global expansion of MEDEX while providing practical solutions. For this role, Smith chose someone he had met many years earlier in Africa: Dr. Rodney Powell.

Both men had served as Peace Corps doctors—Smith in Nigeria and Powell in Ethiopia—and they first crossed paths at a conference for Peace Corps physicians in 1962. Smith had been asked by Sargent Shriver to organize the conference. It was here that the seeds of their long partnership were sown.

“I met Dick, and we immediately became good friends,” Powell recalled. Their bond was founded on a mutual frustration with the healthcare situation in Africa and a shared desire to implement long-term solutions at a systems level. Both men were dissatisfied with the isolated and disjointed efforts being made at the time.

“There was a lot of money being thrown at specific issues—malaria, childhood immunizations, pneumonia—but none of it was part of a sustainable system,” Powell explained. “It wasn’t organized; it lacked management.” They realized that trained healthcare professionals, whether educated abroad or locally, were reluctant to serve in rural areas, where they were most needed.

After that initial meeting, their paths diverged. Smith remained in Nigeria, eventually moving to Washington, D.C., where he became the Africa Regional Medical Officer for the Peace Corps. Powell returned to Ethiopia but maintained contact with Smith. Years later, Smith would call on Powell to help turn his international vision for MEDEX into a reality.

Powell’s Life Before MEDEX

Rodney Powell’s path to MEDEX was shaped by his deep commitment to healthcare and social justice. As a medical student at Meharry Medical College in Nashville, Powell became involved in the Civil Rights Movement. After moving to Nashville in 1957, he trained in nonviolent resistance under the guidance of Rev. James Lawson, alongside activists like John Lewis, Diane Nash, and his future wife, Gloria Johnson. Together, they organized sit-ins that played a pivotal role in desegregating Nashville’s lunch counters.

In 1961, Powell helped organize the Freedom Rides but chose not to participate after receiving advice from Dr. Martin Luther King Jr. to prioritize his medical education, as the Black community needed more doctors.

The Civil Rights struggle in Nashville reached a peak when the home of civil rights attorney Alexander Looby was bombed in retaliation for the movement. A mass protest followed, leading to a confrontation with the mayor. When asked by Diane Nash whether he believed segregation was right, the mayor responded, “No, I do not.” This marked a turning point in Nashville’s desegregation efforts.

Powell’s involvement in the Civil Rights Movement is chronicled in great detail in David Halberstam’s book The Children, which tells the story of the young leaders of the movement, including Powell and his wife, Gloria.

After completing medical school, Powell took an internship in pediatrics at the University of Minnesota. Thinking back on that period, Powell said, “I had spent so much time in the civil rights movement that I really felt lucky to get the internship at University of Minnesota Hospital’s pediatric program. I knew it was time to fully commit to my medical education. It was a wonderful year.”

After his internship, Powell joined the U.S. Public Health Service, working at the National Institute of Neurological Disease and Blindness. He had originally intended to pursue a career in pediatric neurology, but his path shifted when he was recruited by Sargent Shriver for the Peace Corps. Powell recalled how Shriver was “raiding the NIH campus looking for physicians” to serve in the Peace Corps. He was offered the position of overseeing healthcare for Peace Corps volunteers in Ethiopia. Powell discussed the opportunity with his wife, Gloria, who was also pursuing a medical career. “They need Peace Corps physicians to oversee Peace Corps volunteers’ healthcare in Ethiopia. Would you like to go?” Powell asked her. “Because she’s as crazy as I am, she said, ‘Yes, let’s do that,’” Powell laughed. So they packed up with their four-month-old daughter and moved to Ethiopia.

While Powell was stationed in Ethiopia during his first Peace Corps stint, a significant moment in his relationship with Smith arose. In 1963, Powell refused to attend a U.S. Embassy Fourth of July picnic, feeling conflicted over celebrating American independence following the assassination of Medgar Evers on June 12, 1963. The boycott quickly gained attention, and the Associated Press and BBC picked up the story. News of the picnic boycott made it all the way back to Washington, D.C. Dr. Richard Smith, who was Africa Regional Medical Officer for the Peace Corps at the time, was ordered by Sargent Shriver to “get the hell over to Ethiopia and fire that guy.” 

When Smith arrived, Powell greeted him warmly, not knowing the reason for his visit. “Dick, it’s so good to see you! What brings you here?” Powell asked. Smith replied, “I’m here to fire you.”

Powell, unfazed, explained his reasons for the boycott. “If they think I boycotted the ambassador’s picnic, that’s erroneous,” Powell said. “But if they want a boycott, fire me and send me home, and I can demonstrate what a boycott using non-violent resistance will really look like.”

Following their conversation, Smith decided that firing Powell wasn’t the right decision. He returned to Washington, D.C. and convinced Sargent Shriver to drop the idea. The experience reinforced the mutual respect between Smith and Powell and deepened their bond.

Upon returning to the U.S., Powell completed his training, serving as chief resident in pediatrics at UCLA. He later earned his Masters in Public Health from the UCLA School of Public Health. His next step brought him to the Watts Neighborhood Health Center, where he became director in the years following the 1965 Watts riots. This Office of Economic Opportunity (OEO) sponsored center was part of the University of Southern California Medical School’s efforts to provide healthcare in the community.

Powell took on the challenge of addressing the tension between the university and the community it served.  “The community felt they had no say in what was happening, even though there was a $5 million grant to provide healthcare every year,” Powell explained.  His goal was to empower the community by building the advisory board’s confidence so they could become the direct grantee of the federal funds. After years of advocacy, the grant was transferred from USC to the community, easing the tension between the two institutions.

Unfortunately, the vision for a comprehensive, community-driven healthcare system was short-lived. The newly established Charles Drew School of Medicine became involved and decided to restructure the center into an outpatient-focused model—the very thing Powell had been striving to change.

Frustrated by this shift, Powell began looking for new opportunities. He returned to the University of Minnesota, where he joined the faculty with plans to pursue a major OEO grant. His aim was to revamp primary healthcare by developing a systems-based approach that integrated the medical school’s resources, community efforts, and the health center. Focused on disease prevention, health promotion, and sustainability, Powell worked tirelessly. However, after two years, it became clear that the institution wasn’t fully committed to the changes he envisioned. “I really felt by the end of two years that the University of Minnesota was more interested in having one of their residents come home and being able to show their commitment to civil rights. I felt, to a large extent, that that wasn’t enough because they weren’t making any of the commitments needed.” Disillusioned, he decided to go overseas again.

Return to the Peace Corps

From 1971 to 1973, Powell returned to the Peace Corps as Director of Regional Public Health for Africa. His initial post was in Uganda, where the political situation rapidly deteriorated under Idi Amin’s brutal regime. “Idi Amin was running amok,” Powell recalled. With Amin expelling 40,000 Asians from the country and violence escalating, Powell quickly realized the danger to his family. “He was running around town shooting his gun,” Powell remembered. Fearing for their safety, Powell persuaded USAID to transfer his family to Dar es Salaam, Tanzania.

This experience in Uganda gave Powell a first-hand understanding of the potential dangers of working internationally. By the time he joined MEDEX, he was well-prepared to navigate the challenges of operating in volatile regions—skills that would prove invaluable as MEDEX expanded into similarly unpredictable areas around the globe.

Powell’s Personal Journey: Embracing His Identity

While Powell had long fought against racial prejudice, another internal battle had weighed heavily on him since childhood. Growing up in the 1940s and 50s, Powell harbored a secret: “By the age of ten, I already knew I was different from other boys,” he recalled. Although he couldn’t yet name it, he knew he was gay and feared rejection from his family, friends, and community if his secret was discovered.

“There was no language that I knew to describe my sense of alienation,” Powell said. For years, he struggled with this hidden part of his identity. “I instinctively knew this secret must be faced alone and suffered in silence,” he added. While fighting publicly for racial equality, Powell was privately battling the fear of being ostracized due to his sexual orientation.

It wasn’t until 1965—after his civil rights protests, marriage to Gloria, and the birth of two children—that Powell found the courage to acknowledge his sexuality. “I found that courage in a three-letter word: gay.”

However, it would take another decade before Powell could fully embrace this part of his identity. It wasn’t until his forties that he finally accepted himself, after years of hiding. He later reflected, “The fear and numbing anxiety from my ‘secret’ was far more terrifying than the racism I experienced as a Black child in 1950s Philadelphia.”

By the time he embraced his identity as a gay man, Powell had spent decades navigating life in silence. His journey from the margins of society to acceptance of his race and sexuality shaped his activism, pushing him to advocate for both racial equality and LGBTQ+ rights later in life.¹⁶

Smith’s Long Pursuit of Powell

Smith and Powell had kept in contact over the years, and as soon as the Health Manpower Development Staff (HMDS) was formed in early 1974, Smith knew he wanted Powell to join him. However, it took nearly three years for Smith to finally bring him on board.

Powell remembered the process: “We had stayed in contact, and he asked me to consult on the program in Micronesia, which was the very first country where Dick was trying to apply his concept of bringing the experience from MEDEX Northwest in Washington into the international, developing world setting. So, I did that. I came out and met with the staff, discussing issues as a consultant. Then Dick began offering me a position.”

During this period, Powell was also navigating a deeply personal journey. He had come to understand that, while he had married his best friend in medical school, Gloria Johnson, and they had three children together, he was living a life of duality. “I told my wife that I’m coming to grips with who I am, and that I’m not rejecting her, but I can’t live this dual life any longer.”

Although it was a difficult time for both of them, Powell knew that he had to embrace who he truly was. In 1975, they separated, and Powell eventually filed for divorce. At the same time, Powell’s professional career was continuing. He had returned to Los Angeles, where he worked as the director for a program then known as Crippled Children Services with the California State Health Department. Smith’s invitation to join him at MEDEX came at a time when Powell was struggling with the balance between his professional life and his personal responsibilities. “I hated the thought of leaving my kids, but I knew I needed to put some separation between us.”

Smith’s persistence paid off in January 1977, when Powell officially joined MEDEX as Deputy Director of the Health Manpower Development Staff, marking a pivotal chapter in his career. “By the time I came on board, MEDEX [in Hawaii] had been around for about five years,” Powell reflected. “The principles that Dick was developing had been tried in Micronesia, Thailand, Guyana, and Pakistan. One of my first tasks was to help pool together all of those experiences into a cohesive system and document what we had learned.”

As Powell began settling into his role at MEDEX, an important moment occurred that deepened his relationship with Smith. “I had only been in Hawaii for about a month,” Powell recalled, “and Dick took me apartment hunting.” While they were looking at places, Smith made a casual comment about the proximity of a club with beautiful Hawaiian girls. Seizing the moment, Powell revealed a part of himself he had long kept private. “I said, ‘Dick, don’t you know where there’s a club with beautiful Hawaiian guys?’”

Smith’s response was characteristically accepting and straightforward. “Dick just said, ‘What?’ and then we both laughed.” Powell reflected on the significance of the moment: “And that was it. There was no more discussion about it. Dick didn’t make a big deal out of it.”

This brief exchange solidified a bond of trust, mutual respect, and friendship between the two men. Smith’s openness and respect allowed Powell, who had spent decades grappling with his identity as a gay man, to feel fully at ease.

From that point on, Powell fully embraced his role, and as he settled in, the global reach of MEDEX continued to grow. The deep connections between team members and their shared commitment to building sustainable healthcare systems ensured that MEDEX would flourish in some of the most challenging environments in the world.

Powell quickly became involved in the development of the MEDEX Primary Health Care Series, a project designed to synthesize lessons learned from various global healthcare initiatives into practical, adaptable training modules for health workers around the world. “Dick was focused on creating a collaborative framework,” Powell said. “He talked about how we needed to institutionalize what had worked at MEDEX Northwest in Washington, emphasizing a broad base of support from local health professionals and developing competency-based training tailored to each country’s needs.”

Together, Powell and Smith worked to ensure that the MEDEX program remained focused on what mattered most: providing healthcare workers with the specific skills required to serve their communities, particularly in rural and underserved areas. “This was not a theory-based program,” Powell explained. “We trained people for what they needed to know, focusing on the knowledge and skills required to do a specific job, and avoiding superfluous procedures they would never perform or conditions they were unlikely to encounter.”

For Powell, this work at MEDEX was a continuation of his lifelong commitment to creating systems that served the most vulnerable populations. His personal experiences and professional dedication had prepared him well for the challenges ahead.

The Chocolate Mousse Tradition

During their travels, Smith introduced Powell to one of his more lighthearted rituals: the pursuit of the perfect chocolate mousse. Powell humorously recalled their shared experiences:

“Dick Smith and the pursuit of chocolate mousse—wow! I’ve eaten chocolate mousse with Dick, and I sometimes wondered what was in that mousse that Dick was getting that I wasn’t getting,” Powell remembered. “Dick’s correlation between his international health experiences and the chocolate mousse is an incredible, wonderful, funny, and provocative experience.”

Powell described how wherever they traveled, whether to Geneva or elsewhere, they would seek out chocolate mousse: “We didn’t have many opportunities to travel together, as it was usually either Dick or myself who had to go into programs at that level. But whenever we were together, we would seek out chocolate mousse. I remember once, we were given chocolate mousse, Dick tasted it and I could see the rapture in his eyes. I tasted it and said, ‘Tastes like chocolate, Dick.’ He looked at me and asked, ‘Well, what kind of chocolate?’ I replied, ‘Sweet chocolate,’ and Dick just said, ‘You’re hopeless.’”

This shared pursuit became a comforting constant amidst their demanding work, providing moments of lightness and humor during their global endeavors.

Conclusion

The creation of the Health Manpower Development Staff was a pivotal moment in the effort to expand global healthcare access. This achievement was not just a professional triumph for Dr. Smith, but a confirmation in his ability to unite a group of visionaries, each bringing unique expertise to the shared mission of expanding healthcare access worldwide.

Dr. Smith’s team was a mosaic of talent and experience. Rodney Powell’s journey to MEDEX was driven by a deeply personal commitment to social justice that aligned perfectly with Smith’s vision. His expertise in community health and his strong administrative and managerial skills became instrumental in shaping MEDEX’s approach to healthcare delivery in underserved areas. Powell’s leadership in navigating complex systems made him invaluable to the program’s success

Tom Coles’ work in developing curriculum for the Village Health Worker Program in South Vietnam became foundational to much of the MEDEX training model. His global experiences contributed to adaptable, community-based healthcare solutions that could be applied in a variety of settings.

Dr. Mona Bomgaars, with her rich experience in Nepal, brought invaluable insights into community health systems and maternal/child health, ensuring that MEDEX’s strategies were both effective and culturally sensitive.

Joyce Lyons, with her background in education and nursing, designed training programs that were culturally appropriate and globally applicable. Her experience in Thailand, Pakistan, and Guyana played a key role in enhancing MEDEX’s reach.

Michael O’Byrne’s expertise in pediatric care and rural public health added another layer of depth to MEDEX’s training programs, enabling the team to create practical, community-level healthcare solutions across different regions.

Together, these individuals helped Smith transform MEDEX into a globally recognized program, each contributing their specialized knowledge to the program’s success. Their shared commitment to improving global health created a strong sense of camaraderie. Moments of levity, like Dr. Smith’s quest for the perfect chocolate mousse, were a reminder to enjoy life’s small pleasures, even amidst the complex challenges of their work. 

Each of these individuals brought a distinct story, shaped by their experiences, expertise, and commitment to global health. Their journey’s led them to MEDEX, where their shared vision helped the program flourish in some of the world’s most challenging environments.

The model developed by Smith and his team became a blueprint for similar initiatives worldwide, influencing global health education and practice for decades to come. As healthcare evolves in the face of new challenges, the principles and practices established by Dr. Smith and his team continue to shape global health—now and into the future.

Chapter Seven: Thailand – Adapting from Micronesia Learnings

It’s likely that Dr. Malcolm Merrill’s contact card had a well-worn place inside Dr. Smith’s Rolodex. Smith and Dr. Merrill first crossed paths in 1967, when both men served on the delegation to the World Health Assembly in Geneva, making this yet another chapter in the international story of MEDEX that has roots in that delegation. 

Dr. Malcolm Merrill

• Visionary leader in public health, known for his work with the American Public Health Association (APHA), where he influenced national and global healthcare policies.
• Played a pivotal role in shaping public health systems and advocating for healthcare reform, particularly during his tenure at the California Department of Public Health.
• A trusted advisor on international health programs, Merrill’s collaboration with global leaders helped transform healthcare approaches in developing regions.
• Served with Dr. Richard Smith on the 1967 US delegation to the WHO World Health Assembly in Geneva.

Background on DEIDS

In November of 1965, two years before meeting Dr. Smith, Malcolm Merrill joined the United States Agency for International Development (USAID) as Deputy Assistant Administrator for Health, Population, and Nutrition. His deputy was a man named Lee Howard. USAID was well connected with health organizations around the world, especially the World Health Organization (WHO). It didn’t take long before Merrill recognized the urgent need within developing countries to improve rural healthcare. In response to these needs and with Merrill’s direction, Lee Howard developed an approach he called the DEIDS project (Development and Evaluation of Integrated Delivery Systems).

DEIDS was designed to solicit innovations by less developed countries to provide new ways of delivering healthcare to their people. Project proposals could include, but were not limited to, Maternal and Child Health, Family Planning, and Nutrition. The projects were intended to cover large populations in predominantly rural areas. They were to utilize in-country resources for the service component, although external assistance organized by DEIDS was available for planning, evaluation, training, and limited amounts of essential equipment. The expectation from USAID was that successful health delivery systems could be subsequently replicated in the country or the region once proven by a pilot project.

DEIDS had three phases:

1. Phase I: Gathering information on local health services, disease patterns, community involvement, and the potential for integration and innovation.
2. Phase II: Detailed planning, involving both local and DEIDS experts, if Phase I showed potential.
3. Phase III: Launching pilot operations, which could last up to eight years.

Shortly after the 1967 World Health Assembly, Malcolm Merrill left USAID to join the American Public Health Association (APHA) as its Director.

American Public Health Association in International Health

Going back to the late 1950s there had been a growing movement inside the APHA to become more involved in the international health scene. This movement culminated at the World Health Assembly in 1967 when 16 member associations, including the APHA, came together to form the World Federation of Public Health Associations (WFPHA). 

Within a year of the formation of the World Federation of Public Health Associations, the APHA began receiving numerous requests for international assistance. Malcolm Merrill knew there were huge healthcare needs in developing countries, needs he saw both when he was at USAID and now at APHA. It was time to act. 

Because APHA was now a player on the international scene, Merrill was able to leverage his working knowledge of the US government to obtain several contracts and grants. The largest grant received was in support of DEIDS. USAID contracted with the APHA to develop DEIDS projects in up to four countries. 

American Public Health Association in International Health

The American Public Health Association’s journey into international health began in the mid-1950s, driven by a growing awareness of global health disparities and the interconnectedness of public health worldwide. This shift in focus, rooted in both humanitarian goals and practical necessity, gained momentum over the following decade. In 1967, APHA’s commitment to global health collaboration crystallized at the World Health Assembly, where it played a pivotal role in establishing the World Federation of Public Health Associations. Bolstered by support from the Rockefeller Foundation and USAID, APHA expanded its efforts to improve public health in developing countries. A prime example of this work was the Development and Evaluation of Integrated Delivery Systems (DEIDS) project in Thailand, which became a model for community-based primary healthcare. This initiative embodied APHA’s dual mission: addressing the moral imperative to assist underserved populations while tackling health challenges that transcended national borders. Through these efforts, APHA demonstrated that local public health interventions could have far-reaching global impacts, setting a new standard for international health collaboration.

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Getting started with DEIDS

In 1971 and 1972, APHA sent small teams on Phase I reconnaissance missions to countries interested in the DEIDS program. One of these missions was to Thailand.

From January 29 to February 9, 1973, a team consisting of Dr. Thomas R. Hood (APHA), Dr. Theodore C. Doege (University of Illinois), Satoru Izutsu, PhD (University of Hawaii), and Dr. Lloyd Florio (USAID) toured Thailand to assess its potential as a DEIDS candidate.

South Korea and the Philippines were also considered, but the Thailand mission showed the most promise. By mid-1973, USAID, APHA, and the University of Hawaii School of Public Health (UHSPH) reached an agreement with the Thai Ministry of Public Health to begin a DEIDS project in Thailand. Dr. Richard Smith was recruited to help initiate the project.

Dr. Richard Smith’s established connection with Dr. Malcolm Merrill during their time together at the World Health Assembly in 1967 likely played a pivotal role in his selection for the DEIDS project in Thailand. Merrill, having witnessed Smith’s innovative approach to healthcare in Micronesia, recognized the potential for Smith to apply these learnings to the rural healthcare challenges that DEIDS sought to address. Additionally, APHA’s strong relationship with Satoru Izutsu and the University of Hawai made Dr. Smith a natural fit to kick off the Lampang Project.

The Lampang Project

Officially starting in September 1974, the “Lampang Health Development Project” aimed to develop and evaluate a healthcare system in Lampang Province. The Royal Thai Government and APHA signed the project agreement, and the University of Hawaii provided technical assistance through a subcontract with APHA.

USAID’s requirements for the project site included a population over 500,000, fair communication systems, non-insurgency, moderate economic status, and support from local officials. Lampang Province, with over 600,000 people, met these criteria.

To aid the planning, Dr. Smith invited Thai doctors to visit Hawaii, Spokane, Seattle, and Truk (Chuuk), Micronesia, to observe medex training programs. These visits helped shape the training curriculum for Thailand. ¹⁷

Shaping the Lampang Project

The success of the Lampang Project hinged on it being initiated and delivered by the Royal Thai Ministry of Public Health to the Thai people. Dr. Smith, as always, was keenly aware of the importance of this perception and took steps to ensure it was addressed. The project built on the foundations laid in Seattle and Micronesia, but required a crucial adaptation to fit the Thai context.

Dr. Smith understood that the term “Medex” wouldn’t resonate in Thailand. Among his many recommendations to the Thai Ministry of Public Health at the outset of the project were two key suggestions:

1. To decide on a Thai term for “medical assistant” or “Medex.”
2. To select a uniform that would promote a professional image for the assistants, requiring them to wear it while working. ¹⁸

The Thai leadership of the Lampang Project ultimately coined the word “Wechakorn” to describe these physician-extenders. The term combined “wecha,” meaning medicine or medical care, with “korn,” meaning provider or practitioner. As in Seattle and Micronesia, the Wechakorn wore uniforms to distinguish them from other healthcare providers. In Thailand, they wore baby blue coats. ¹⁹

Another adaptation to previous implementations of MEDEX was the way the curriculum was delivered. In Micronesia, the didactic portion of the curriculum was directly taught by the MEDEX team from the University of Hawaii, where external trainers played a prominent role. This approach changed in Thailand, where the government wanted the Lampang Project to be seen as a homegrown initiative led by the Thai government for the Thai people. This necessitated a shift in the MEDEX team’s role—what Dr. Smith might have called “training the trainers.”

Lampang Project Predecessors 

The Lampang Health Development Project didn’t emerge in isolation; it built on earlier efforts by the Thai government to improve healthcare in rural areas, where 85% of the population lived. In the 1960s, most rural residents had little access to healthcare, and only a small percentage sought care at government facilities. Recognizing the urgent need to strengthen healthcare delivery in these underserved regions, the Ministry of Public Health launched projects like the Pitsanuloke and Saraphi initiatives. These programs aimed to expand services by building infrastructure, training health workers, and involving local communities in health initiatives.

While these early projects brought valuable innovations, such as recruiting local health workers and establishing child nutrition centers, they also faced limitations, including poor evaluation systems and problems with patient referrals. Despite their mixed results, these efforts provided crucial lessons that shaped the Lampang Project and guided the Ministry’s ongoing work to improve access to healthcare in rural Thailand. By the early 1970s, national surveys revealed that rural health services were still underused, pushing the government to develop new strategies to address issues like service coverage, resource management, and the distribution of health personnel.

University of Hawaii involvement in the Lampang Project

As seen in the Micronesia chapter, Dr. Satoro Izutsu had long been active in Asia and the Pacific and played a key role in bringing the University of Hawaii into the Lampang Project. Several individuals from the University of Hawaii made significant contributions to the project, including Dr. Ronald Wilson and John Rogosch, who were assigned as resident staff.

Dr. Wilson, fluent in Thai, served as Associate Field Director and Chief-of-Party for the University of Hawaii School of Public Health. His experience in Thailand dated back to 1967 when he worked as a Peace Corps physician.

John Rogosch served as Assistant Field Director for Planning and Evaluation. Like Dr. Wilson, Rogosch first came to Thailand in 1967 with the Peace Corps, where he coordinated health programs in rural villages as Associate Director and later Deputy Director of Health Programs.

Three other key members of the University of Hawaii’s Health Manpower Development Staff (HMDS) who contributed to the project were Dr. Michael O’Byrne, Joyce Lyons, and Tom Coles. This team was responsible for adapting the Medex curriculum to the Thai context. Coles, who had served briefly in Thailand with the Special Forces during the Vietnam War, was part of this effort. Lyons, an education specialist with extensive international experience, focused on developing training programs. Dr. O’Byrne, who had worked in Central America and Africa before joining the University of Hawaii, served as Associate Director of Training in Thailand.

Forming the Health Manpower Development Staff

The University of Hawaii was contracted by APHA to provide administrative, managerial, and technical assistance for the Lampang Project. At about the same time the Office of International Health (OIH) on behalf of USAID approached the University of Hawaii with a special proposal to “develop a Health Manpower Development staff to serve as a resource and response unit capable of planning and developing mid-level (MEDEX type) health manpower who can provide basic health services as designated by USAID.”²⁰ 

USAID wanted to take Dr. Smith and his small team’s expertise and expand it around the globe. For many years, USAID and other health organizations that worked with developing nations had tried to put into operation effective healthcare delivery systems for less developed countries. Most less developed and lower-income countries could not afford to build the full-scale Western model of training physicians in medical schools. Leadership at USAID viewed MEDEX as a promising answer to their problem. The system was practical, it was proven to work and it was relatively low in cost. 

The formation of the Health Manpower Development Staff (HMDS) allowed Dr. Smith to grow his team of experts and expand the Medex concept even further.

Adaptation of the Medex in Thailand – Formation of the Wechakorn

Preparations for Wechakorn (“Medex”) training were completed in the third quarter of 1975, and the opening ceremonies were scheduled to take place on July 2, 1975. The Division of Personnel Development, with the assistance and cooperation of members of the Lampang Provincial Hospital medical staff and University of Hawaii Health Manpower Development Staff (HMDS), completed development of the teaching/learning modules and outlined the various supplemental training materials that will be needed.

Dr. Michael O’Byrne, Associate Director for Training, Medex Tom Coles and Educational Specialist Joyce Lyons, all from the University of Hawaii HDMS,  collaborated with members of the DEIDS Personnel Development Division in reviewing and revising the training modules as they were adapted in the Thailand setting. After the general review workshop, Medex Tom Coles remained in Lampang to assist in writing Instructor Manuals for each of the modules and to help catalog the variety of audio-visual materials which supplemented teaching presentations.

In keeping with Project leaders’ desire to continually inform the professional health community of project progress, representatives of various health training and service institutions were invited to Lampang to review the project in general, but more specifically to review and comment on the final plans for the Wechakorn curriculum. All Thai medical schools and relevant Ministry of Public Health departments were represented. The meeting turned out to be very productive because of the interest and relevant experience of the attending members. 

The discussions helped to determine the number of trainees to be selected for the first Wechakorn class of 15 students, and clarified important questions concerning hospital staff responsibilities in training, particularly during the preceptorship (clinical) phase. In addition, a number of the participants offered to make available for Wechakorn training several educational resources and materials that they had successfully used in the past.

As plans for Wechakorn training and deployment evolved, the need to modify and adapt earlier “Medex” concepts developed in Micronesia and MEDEX Northwest became apparent in order to appropriately accommodate the characteristics of the Thai health and administrative environment. This was a natural process associated with introducing non-indigenous innovations into a new setting, and the outcome should be of interest and benefit to the non-indigenous originators of the concepts as well as to the Thai health professionals responsible for development of the Wechakorn innovation and the concerned Thai policy-makers who will determine its replicability.

The fifteen Thai Wechakorn candidates chosen for Class 1 had the following backgrounds:

• 6 Nurses from Lampang Provincial Hospital
• 1 Nurse from the Lampang Midwifery School
• 1 Nurse from the Office of the Chief Medical Officer
• 2 General Health Workers from Hang Chat Health Centers
• 5 Midwives from Hang Chat Health Centers

Of the total, there are two men and thirteen women. 

Photos from the personal collection of Tom Coles.

Outcomes of the Lampang Project

The outcomes of the Lampang Project point to a successful partnership between primary healthcare services and integrated rural health services, benefiting the rural population of northern Thailand. The project fostered a sense of community, self-reliance, and optimism, tapping into local resources and inspiring other aspects of rural development. Health officials and project leaders noted an improvement in the quality of life for rural people. The project aligned with the local belief that equates good health with “perfect fortune,” aiming to make this a reality for the population it served. Through its innovative approach to healthcare delivery and emphasis on community engagement and resource optimization, the Lampang Project demonstrated a potential model for enhancing rural health services and, ultimately, the quality of life in similar settings across Thailand. This suggested that, despite resource constraints, the essential features of the Lampang Project could indeed be feasible and desirable for broader application.

To the Royal Thai government, the Lampang Project was a tremendous success. The work done by the APHA and the University of Hawaii provided a blueprint for the government to expand health services to the entire country. 

Lampang Health Development Project Report
A Thai Primary Health Care Approach

A summary report of the Lampang Health Development Project produced and distributed by the Thai Government in 1978.

View the Report

Honors and Recognition

At a November 1978 ceremony in Thailand, just four years into the seven year project, King Bhumibol Adulyadej conferred Royal Thai honors on three American health professionals for their dedicated services to  the health of the people of Thailand through the Lampang Province Health Development Project. 

The recipients of the Royal honors from the Kingdom of Thailand were Dr. Thomas R. Hood, Dr. Ronald G. Wilson, and Mr. John A. Rogosch. Dr. Hood, formerly Associate Director of International Health Programs for the American Public Health Association, received the Most Exalted Order of the White Elephant. The ceremony marked the first time in 18 years that this award was given to a foreigner by the Thai Government; among Thai people, it is a hereditary honor, being handed down to the eldest son in the family. The white elephant  serves as a part of the Thai official seal, and is a symbol of strength, good judgment and prudence. Dr. Hood was honored for his “leadership role since 1973 in promoting the Lampang Project,” for establishing the collaborative framework for the principals involved in the project, and for his continued service in developing, implementing and evaluating the project until his retirement. 

Dr. Wilson and Mr. Rogosch each received The Most Honourable Order of the Crown of Thailand. Dr. Wilson, who served as Associate Field Director and Chief-of-Party for the University of Hawaii School of Public Health staff in Lampang, was cited for his “untiring service to the Ministry of Public Health for the Lampang Project since its beginning.”

In honoring three of the individuals responsible for the successful Lampang Project, the Royal citation said, “The impressive experience gained in Lampang is guiding the Ministry of Public Health in formulating and implementing national health policies and plans which will bring basic health services to all rural people in the Kingdom, within the next decade, at a cost affordable by the Royal Thai Government. We have developed the potential for good health for all Thai villagers long before the year 2000.”

The Ministry of Public Health and other agencies of the Royal Thai Government began planning nationwide programs that would carry the approaches and key features of the Lampang Project, as adapted, to the whole of the country during implementation of the 1977-1981 and 1982-1986 National Economic and Social Development Plans. Several notable characteristics of project development, planning and implementation had a bearing on the progress of the Project and on the acceptance of its approaches and key features: 

1. The Lampang Health Development Project was viewed from the beginning as a Thai project: project planners, project implementers, and project leaders decision-makers were predominantly Thai. 
2. The project was established and directed by the Thai Ministry of Public Health, the official Royal Thai Government authority that would be responsible for nationwide implementation if the approaches and key features were found to be worthy of “replication”.
3. Project and Ministry leaders developed and maintained a broad base of involvement of Ministry of Public Health personnel and other Royal Thai Government officials in all phases of Project development, planning, implementation, and evaluation. 
4. The Project maintained a continuing dialogue on Project approaches and progress with both Thai and international health agencies by providing project information through periodic progress reports, organizing annual reviews and by conducting special workshops and seminars for review and refinement of project approaches and key features.
5. Project administrative, managerial, and technical assistance from the University of Hawaii and the American Public Health Association was characterized by a spirit of mutualism, a shared commitment, and a collegial collaboration. Technical assistance was not limited to one institution, but involved a number of international organizations, U.S. and Thai institutions and agencies. Project leaders recognized that the Project was dealing with a universal problem of how to achieve “health for all”, and that this problem was best approached through broad collaboration and solid commitment, based on a spirit of mutualism and learning together.²¹

Conclusion

By adapting the Medex model from Micronesia and training local healthcare workers, the Lampang project introduced innovative approaches such as community health volunteers and integrated healthcare services. It also introduced Wechakorn Community Health Paraphysicians to the health care system which greatly extended the level of care available to people in rural areas of Lampang Province by bringing a qualified medical provider much closer to where they lived.

Despite some challenges, the Lampang Project achieved significant success, expanding healthcare access to a large portion of the rural population of Thailand and demonstrating the feasibility of a comprehensive, community-based health system. At the end of the project in 1981, over 7,000 healthcare workers had been trained.²²

The Lampang Project exemplifies how international cooperation, political will, and community engagement can improve health outcomes for all people. For the Health Manpower Development Staff at the University of Hawaii, their work in Thailand was a springboard that inspired future initiatives on a global scale. The Medex Model was becoming widely known in health manpower development circles and had now been tested and adapted in two international settings. 

For Dr. Smith, the successes in Thailand and Micronesia were well-earned. But if we’ve learned anything about Smith and the MEDEX Group, it is that they were not ones to rest on their laurels. Instead, the rolodex was spinning and plans for what lay ahead were busily being made:  

• Laying the groundwork for their upcoming work in Guyana, Lesotho, Kenya, Colombia, South Korea, Philippines, and Pakistan
• Preparing for International Conference on Primary Health Care in Alma Ata, USSR. 
• Continuing to build and recruit the HMDS Staff.
• Reporting and pursuing future funding opportunities with government officials in Washington, DC. 
• Eating Chocolate Mousse whenever possible.

Chapter Eight: Guyana – A Long-Term Success Story

It’s September 1975, another Rolodex moment. Richard Smith sits in the lounge of the by then infamous Watergate Hotel in Washington DC having a drink with his old friend Monte. Dr. Oliver “Monte” Harper and Richard Smith had first met in anatomy class at Howard University in the early 1950s. Harper completed his dentistry degree at Howard around the same time Smith completed his MD, established a dental practice in Brooklyn, NY, and gradually became involved in public health as the Executive Director of the Neighborhood Health Center in Brooklyn. Now, some 22 years later, Harper had returned to his home country, Guyana, where he was serving as Minister of Health. It’s in that capacity that Richard Smith has reached out to him. 

Smith had gotten wind through USAID reports of the many significant healthcare challenges that Guyana was facing. Indeed, USAID was becoming aware of the work that the MEDEX Group was undertaking in Micronesia and Thailand, where word from mission outposts was that the developing MEDEX model was a good and effective tool for effecting change on the ground. USAID contracted Smith with a list of countries of interest, a list that included Guyana. Seeing an opportunity for a MEDEX Group project, Smith soon contacted Dr. Harper, and there in the Watergate Hotel the two of them began formulating a plan to develop a primary healthcare delivery system for Guyana.

Dr. Harper, two years into his role as Health Minister, explained that Guyana had no medical school; Guyanese MDs were trained in Cuba. Access to medical services was severely limited, particularly in the coastal and hinterland areas where Indigenous Amerindians were most at risk. These regions, while rich in natural resources like bauxite, diamonds, and gold, were plagued by health issues such as dehydration, yellow fever, diarrhea, malnutrition, and even leprosy.

As Dr. Smith was beginning to understand the healthcare challenges in Guyana, he was taken on a tour of the country’s resource-rich interior by David Gwaltney, an engineer, in Gwaltney’s Chevrolet truck. Accompanying them were Frank Williams, designated as the Medex Program director in Guyana, and Monte Harper, the Minister of Health. During this journey, Dr. Smith observed the complete lack of healthcare services in these remote areas. It became evident that the Guyanese government was eager to extend healthcare coverage to these regions, not only to address public health needs but also to facilitate the extraction of valuable natural resources such as bauxite, diamonds, and gold. The Medex program aimed to provide essential medical care to rural communities, which was also crucial for supporting the workforce needed for expanding mining operations. This dual purpose of the program would enhance both the health and economic prospects of the country.

Smith reviewed with Harper some of the successes he and his colleagues had experienced in Micronesia and Thailand, and they both soon realized that some of the same methods could work in Guyana. 

However, there was a major obstacle: funding. 

In 1976, U.S. Secretary of State Henry Kissinger, upset with Guyana’s political alignment with Cuba, ordered USAID to withhold all funding to the country. Just like that. This left Dr. Smith with a dilemma: how to fund the MEDEX project in Guyana.

Dr. Smith needed, as he later recalled, “an air bridge” to fund the project in Guyana, something that would serve the purpose at hand but in a roundabout manner. The Guyanese government reached out for help from the International Development Research Centre (IDRC), which was Canada’s equivalent to USAID. Although IDRC could not directly provide funding to an American organization such as USAID, they could fund consultants. And so an initial round of funding from IDRC was provided to support study grants for seven Guyanese health professionals to take intensive courses in the MEDEX training methodology.

Dr. Smith worked on two fronts to establish the receptive framework needed for the acceptance of the new Medexes that were to be trained. 

First, arrangements were made with the University of Guyana to formally recognize the Medex training of the Medexes and the Community Health Workers. 

Second, Dr. Smith worked with Guyanese officials to draft legislation that would provide a legal framework for the newly trained Medexes to operate. In 1978, the Guyana Legislature passed Bill number twenty-one, The Medex Act, which said “the introduction of medex as an extension of the health services now available in Guyana is intended to provide much-needed assistance to medical practitioners, particularly in the rural areas. In providing health care for the people of Guyana.” The Medex Act was meant to substantially reorganize and strengthen the country’s health infrastructure.

The Guyanese government’s adoption of the MEDEX system was based on a commitment to provide basic nationwide healthcare and on the recognition that the country’s physicians could never accomplish this task alone, given the country’s manpower and economic challenges. The government recognized that it was necessary to relieve the pressure on overworked hospital outpatient services, especially in Georgetown, and to provide basic services to the scattered populations of the hinterlands. 

Traditionally in Guyana, health personnel were trained to provide curative, urban-based services. The only official health workers who reached the rural areas were medical dispensers and rangers who did not have enough training to handle the task. The MEDEX approach was adopted to decentralize Guyana’s entire health delivery system and to establish a mid-level category of health workers who had received problem-oriented, competency-based training and who were equipped to provide appropriate medical services throughout the country. The idea was to create a tiered health-manpower system where the mid-level health workers were trained to provide curative and preventive medicine as well as be trained to supervise the community health workers. 

Initially, the Guyana MEDEX Program relied on the country’s established nursing workforce to train as Medex practitioners. “These were the most incredible nurses I’d ever seen”, recalled Smith, “they were doubly trained as nurses and as pharmacists.” ²³ Candidates from remote villages were identified and trained as Community Health Workers, focusing on preventive and basic care. Given the challenges of road travel, an innovative two-way radio communication system was developed for medical consultations and continuing education. This system allowed for the triage of medical emergencies and escalation to the nearest Medex outpost for advanced treatment.

“Two-Way Radio for Rural Health Care Delivery” by Michelle Fryer, Stanley Burns, and Heather Hudson²⁴

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By 1979, 45 Medexes had been placed in rural hinterland posts and 11 in underserved areas around the capital, Georgetown. The remaining five, after gaining field experience, were brought back to headquarters to serve as tutors and supervisors. Supervision posed a challenge due to a shortage of government medical officers, leading project staff to provide most of the supervision. Despite delays in integrating the Medex into the existing health system and training village health workers, the program demonstrated its potential to be effective.

Key players in the Guyana project included Americans Tom Coles, PA-C, and Joyce Lyons, NP, who developed the curriculum and trained local teachers, and local Guyanese Dr. Frank Williams, Jimmy LaRose, Esau Khan, Kenneth Davis, and Melissa Humphrey, aka “Comrade Pinky”, who facilitated local operations. Mona Bomgaars, Director of Development and Evaluation for the Health Manpower Development Staff, periodically visited the Guyana site to evaluate the program’s success.

Frank Williams was the perfect person to run the program in Guyana. Not only was he one of the top doctors in Guyana, Dr. Willliams was also the personal physician to and friend of the president of Guyana, Forbes Burnham. This gave him the connections and clout to start and sustain the new Medex program. As Joyce Lyons recalled in a 2013 interview, “Frank managed all the political connections, and if it weren’t for Frank, nothing would have happened, because…this is a socialist country and you really had to have influence in the country in order to make things happen.”

Dr. Williams had at his side, an iron-fisted administrator named Melissa Humphreys. Her nickname was “Comrade Pinky” because as Lyons recalled, “She ruled with a sharp tongue and an iron fist. She intimidated everyone.” But Humphreys got things done and was a vital part of the reason for the nearly 50-year duration of the Medex program in Guyana.

Melissa Humphrey

• Melissa Humphrey, also known as “Comrade Pinky,” was known for her sharp tongue and iron-fisted leadership, ensuring the Medex program in Guyana thrived for nearly 50 years.
• As a key local administrator, she played a pivotal role in facilitating operations, working alongside Dr. Frank Williams and international colleagues to solidify the program’s success.
• Recognized for her distinguished service, Humphrey was honored in 2007 during the ceremony marking 30 years of Medex services, celebrating her contributions to public health in Guyana.

Dr. Frank Williams

• Dr. Frank Williams, a top doctor in Guyana and personal physician to President Forbes Burnham, used his political connections to successfully launch and sustain the Medex program in the country.
• As the first head of the Medex program, Dr. Williams played a pivotal role in extending healthcare to rural regions, supporting both public health and the country’s economic growth by ensuring healthcare for workers in mining operations.
• In addition to his work with the Medex program, Dr. Williams served as Chief Physician at Georgetown Public Hospital and was a pioneer in addressing public health issues, advocating for comprehensive strategies such as malaria prevention and recognizing stress as a critical health factor in his approach to medicine.

By the end of the initial three-year demonstration program, funded by Canada, the Medexes had come to be accepted and respected by the Guyanese people and other health professionals. With the assistance of a multi-million dollar grant from USAID, the program entered its next stage of large-scale expansion. 

By 1979, diplomatic tensions between the US and Guyana had cooled, allowing USAID to fund projects in Guyana once more. A four-year grant, funded by US AID was authorized in June of 1979, to continue the development of the MEDEX program in Guyana. 

Between 1979 and 1983, significant progress was made towards establishing a functional nationwide rural primary health care delivery system in Guyana. Sixty-seven additional Medexes graduated from three classes, nearly reaching the target of seventy-two. This brought the total number of Medexes trained under the IDRC and AID contracts to 129.

Based on the learnings from the first three years of the program, adaptations were made to the Medex curriculum and teaching methodology to encourage active and independent learning, preparing Medexes to operate with considerable self-sufficiency and resourcefulness at isolated posts. Support for deployed Medexes was strengthened, with renewed attention to supportive supervision and continuing education. The Medex Training Unit was now well-established and as Dr. Smith recalls, it was “institutionalized.”

The Ministry of Health’s decision to continue training Medexes, with Class VII scheduled to start in September 1984, recognized the excellence of the training program and the essential role that Medexes played in Guyana’s efforts to provide primary health care throughout the country.

During the four years of University of Hawaii technical assistance under the US AID grant, significant changes were also made in the organization of the Ministry of Health and its managerial systems that support deployed primary health care workers. The HDMS always took great pride in their continual adaptation of the material based on previous experiences. The Micronesia materials were adapted in Thailand, the Thailand adaptations were used in Guyana, and then the Guyana adaptations embodying all the previous permutations were adapted to Pakistan, and so on.  Rodney Powell recalled that “it was in Guyana that we realized a huge component of the MEDEX System was missing, and that was the management approach that we had previously neglected.” Once that realization occurred, management systems were redesigned and strengthened to improve their efficiency across the healthcare delivery system. 

The Guyanese Ministry of Health and the UH team assessed and redesigned the programming and budgeting system, the financial management information systems, the systems of supplies, drug supplies, transportation, and communications, and did similar work in the areas of supervision, continuing education, and regionalization. Operations manuals were written for the management systems, and training in how to use the systems was provided. 

Lorna Smith recalls another important aspect of creating training materials in-country. “The longer we went along, the more we realized we didn’t know everything.” To help a country implement a healthcare delivery system, some intangibles went beyond healthcare. An example of this in Guyana is the development by a MEDEX Group team member named Rich Ainsworth who wrote a booklet on how to repair a bicycle. Lorna Smith recalls, “The country of Guyana is narrow and goes north to south. If you’re not on a river then you’re on a bike. How to repair a bike relates to keeping a cold chain going for vaccinations.”

Tom Coles developed an in-country presentation on Poisonous Snake Identification in Guyana. He went on to incorporate this module in the Emergency Medicine Module in future training materials. Lorna Smith summarized, “We realized in Guyana about the non-health things that we were going to have to start to deal with if your program was going to be useful.”²⁵

{Insert Tom Coles Poisonous Snake Identification slides and script as a visual element}

In brief, the efforts of Ministry of Health personnel, assisted by long and short-term specialists brought in under the contracts with Guyana from 1976-1983, resulted in remarkable achievements. 129 Medexes were deployed to provide basic preventive, promotive, and curative care to rural populations in Guyana. The management systems that supported these and other primary health care workers were strengthened and extended to more effectively meet their needs. The Ministry of Health’s primary health care personnel and health management staff were as a result better able to meet the needs of Guyana’s people for equitable health care.

Still Going Strong

The MEDEX program in Guyana is going strong today, nearly 50 years after it started. In large part, the longevity of the program is due to the nation’s political stability. Wilton Benn is a Health Education Officer in Guyana’s Ministry of Public Health. He is also a nurse and trained Medex. When asked about his country’s healthcare challenges, triumphs, and the significance of the Medex Program, he responded:

“Guyana’s healthcare system faces significant challenges from chronic diseases like hypertension and heart disease, while also addressing issues like malaria and childhood diarrhea. The MEDEX program has been crucial in providing healthcare access, especially in rural areas, by training mid-level providers and Community Health Workers (CHWs) to handle basic and more complex cases. The focus on prevention, community involvement, and promoting healthy lifestyles has been key in improving health outcomes. Despite an increase in medical doctors, the need for Medex practitioners remains vital, particularly in remote areas of the country.” 

The longevity and success of the MEDEX program in Guyana highlight the transformative potential of the MEDEX model when used effectively by a country’s government.  From its inception in the mid-1970s, the program addressed critical healthcare disparities by training mid-level practitioners to provide essential medical services in underserved and remote areas. The success of the program can be attributed to the dedication of key individuals, the adaptability of the training materials, and the support from both local and international bodies, including USAID and the IDRC. The institutionalization of the program, coupled with legislative support like the Medex Act, helped ensure its sustainability and integration into the national healthcare system.

Over nearly five decades, the MEDEX program has not only improved access to healthcare for Guyana’s rural and indigenous populations but also fostered a culture of community health and preventive care. Despite ongoing challenges, such as the rise of chronic diseases and the need for continued capacity building, the program has been pivotal in advancing public health in the country. The commitment to evolving the program in response to changing healthcare needs underscores its enduring relevance and success.

As Guyana continues to navigate its healthcare challenges, the MEDEX program remains a crucial component of its strategy to deliver equitable healthcare services. The legacy of the program is evident in the improved health outcomes across the nation and the strengthened healthcare workforce that has emerged from its ranks. Looking forward, the MEDEX program serves as a model for other nations facing similar challenges, demonstrating that with the right partnerships and vision, it is possible to overcome barriers and achieve meaningful, long-lasting improvements in public health.

Chapter Nine: Alma Ata – “Health for All”

Dr. Richard Smith valued his time at the World Health Organization (WHO) in Geneva immensely, considering it fundamental to the success of MEDEX both domestically and internationally. Close connections with people within and around WHO gave him a front-line measurement of what was happening in international health policy and who the key players were. These connections proved crucial, as they opened numerous doors for the international expansion of MEDEX, allowing it to influence healthcare practices around the world. 

Smith’s involvement with WHO began in 1967 when he was appointed to the United States delegation to the World Health Assembly in Geneva. This role marked the beginning of a deep and sustained engagement with WHO, during which Smith participated in various committees and working groups. Over the years, he contributed to several key initiatives, particularly those focusing on improving health manpower and training in developing countries. His work with these groups positioned him as a prominent figure in the global health community.

Richard Smith and the World Health Organization

Smith’s involvement with the World Health Organization began when he served as a member of the United States delegation to the United Nations World Health Organization Assembly in Geneva, starting in 1967 and continuing in 1968 and 1970. His name, now front of mind for a growing number of people in the international health community, Smith started to participate regularly with various committees and workgroups with the World Health Organization. He served as Advisor to the WHO Classification of Auxiliary Health Personnel in 1972, Consultant to the WHO at the Training and Utilization of Medical Assistants conference in Khartoum, Sudan, in 1974, Consultant, to the WHO at the Medical Assistants Training, New Delhi, India, 1976,  Consultant to the WHO Preparation of 1977 Expert Committee Meeting on Training and Utilization of Auxiliary Personnel for Rural Health Teams in Developing Countries, Geneva, 1976. He became a Member of the WHO Expert Committee on the Training and Utilization of Auxiliary Personnel for Rural Health Teams in Developing Countries and the WHO Expert Advisory Panel on the Development of Human Resources for Health in 1977 and served on each of those committees for over 25 years. 

As the 1970s progressed, the concept of Primary Health Care (PHC) began to gain traction as a pivotal element of international health policy. Dr. Smith was instrumental in these developments, driven by his belief in the necessity of accessible and comprehensive health care for all. His advocacy and expertise helped shape the discussions leading up to the significant 1978 International Conference on Primary Health Care in Alma-Ata.

Photo of three signs welcoming participating in the International Conference on Primary Health Care. The signs are in Russian, English and French. Photo courtesy of Dr. Richard Smith.

Photo of the delegates at the International Conference on Primary Health Care in Alma Ata

The conference itself was a product of its time, situated against the backdrop of the Cold War. The Soviet Union, which proposed and hosted the event in Alma-Ata, Kazakhstan, sought to demonstrate its commitment to international health and extend its influence over the global health agenda. Based on his previous dealings with the Soviets throughout the 1970s and the fact that the Soviets had offered to pay for the event, Dr. Smith was convinced the Soviets would use the Conference as “a massive piece of propaganda.” ²⁶

To counter the propaganda, and in preparation for the conference, Smith spearheaded an ambitious project to articulate a clear, actionable vision for global health care. Within a mere six months, he and his team at The Medex Group authored and published “Manpower and Primary Health Care: Guidelines for Improving/Expanding Health Service Coverage in Developing Countries.” This book aimed at providing a blueprint for nations looking to develop effective, sustainable healthcare systems. Smith sent the book to every health ministry in the world. Dr. Smith later estimated that 10% of the delegates at Alma-Ata brought his book with them!

The Alma-Ata Conference was a watershed moment in global health, bringing together over 3,000 delegates from 134 countries. They engaged in extensive discussions about how best to implement Primary Health Care as a means to achieve the goal of “Health for All by the Year 2000.” The conference highlighted the critical importance of preventive medicine, maternal and child health, and the integration of health services into the community fabric. The resulting Alma-Ata Declaration articulated a bold vision for global health, emphasizing equity, accessibility, and the essential role of community involvement in health care.

Following the conference, the enhanced visibility of MEDEX and Dr. Smith played a significant role in the broader adoption of the Medex system in numerous countries. The Medex system, focused on training and utilizing mid-level health practitioners, was particularly well-suited to the needs of underserved areas, where traditional medical resources were scarce. The success at Alma-Ata acted as a catalyst, propelling the Medex model to new heights of recognition and adoption.

Chapter Ten: Lesotho – Fat Alice Is Ours

Introduction

In the mid-1970s, Lesotho—a small, mountainous kingdom surrounded by the country of South Africa—faced a pressing need to improve its healthcare system, which struggled with inadequate infrastructure, a shortage of medical professionals, and limited access, particularly in the rural areas. It’s against this backdrop that an innovative healthcare training initiative was born: the Rural Health Development Project, which would prove to make significant contributions to improving the country’s healthcare system.

The Rural Health Development Project: Background and Context

The Rural Health Development Project’s roots can be traced back to the ever-present Rolodex of Dr. Richard Smith and to a series of strategic initiatives launched by the government of Lesotho. 

The initial engagement with Lesotho began with a health sector review sponsored by the American Public Health Association. Similar to previous APHA reconnaissance missions, this review as conducted by a team that included Oscar Gish, Eugene R. Boostrom, James A. Franks, and Rodney N. Powell.  ²⁷

This review, conducted from September 29 to November 8, 1975, was crucial in assessing the effectiveness of existing health programs in Lesotho, and in identifying the need for an integrated health delivery system in the country. The APHA team evaluated the significant challenges faced by Lesotho’s healthcare system, such as inadequate infrastructure, limited financial resources, and a heavy reliance on external assistance.

The report emphasized the need for a balance between preventive and curative health services and recommended strengthening planning, managerial, and administrative capabilities within the health sector. It was noted that almost half of Lesotho’s male labor force was employed outside the country, mainly in South Africa’s mining industry, which heavily impacted the cultural dynamics of the country. The team’s recommendations included decentralizing health services, establishing a cadre of trained nurse practitioners, and focusing more on rural healthcare development. These suggestions laid the groundwork for the subsequent establishment of the Rural Health Development Project, the Nurse Clinician program, and other healthcare initiatives in Lesotho.

The success of these efforts, however, hinged on securing strong leadership and support within the country. A key figure in these discussions was Dr. Thomas Thabane, Lesotho’s Minister of Health at the time. Thabane was not only a well-liked political leader in Lesotho but also a highly respected figure in international health circles, particularly within the World Health Organization (WHO). His reputation as a forward-thinking and effective health minister was instrumental in garnering support for the Nurse Clinician program. 

“Dr. Thabane had the respect of people in Lesotho,” remembered Lorna Smith, “and so we were brought in under his auspices. And the more ivory tower professional global health people and World Health Organization in Geneva could see that what we were doing was important because Dr. Thabane was a big supporter of us and brought us in.” ²⁸

Thabane had played a pivotal role during the 1978 Alma Ata International Conference on Primary Health Care in affirming Lesotho’s commitment to primary healthcare. As discussed earlier, this conference was a watershed moment for global health, advocating for “Health for All” and emphasizing the importance of primary healthcare system development at the government level.

Given the sensitive nature of international politics, especially in the context of the Cold War, communication about the program’s progress needed to be discreet. To avoid arousing Soviet suspicion but still convey the successful negotiations with Lesotho, Dr. Smith sent a coded message from Alma Ata home to his colleagues in Hawaii, “Fat Alice is Ours!” The code referred to Fat Alice’s Jewish Deli and Emporium, a unique restaurant establishment in Maseru that was described as “a 19th-century time capsule with decor ranging from Greenwich Village to the Latin Quarter”. ²⁹ The deli, frequented by expatriates and locals alike, offered an unusual mix of Western and local cultural elements. To top it off, Dr. Richard Smith, who was inordinately fond of chocolate mousse, recalled, “Fat Alice’s had the best chocolate mousse in the world!” ³⁰

Lesotho’s political landscape in the late 1970s was characterized by a blend of internal and external challenges that contributed to frequent volatility. Internally, the country grappled with political dissent from opposition political groups. These factions were opposed to the ruling Basotho National Party (BNP) and engaged in sporadic guerilla activities, leading to what Lorna Smith described as a “low-level rebellion”. ²⁸ Externally, Lesotho’s support for anti-apartheid movements and its role as a sanctuary for South African exiles attracted punitive measures from the apartheid regime, including economic blockades and military actions. These external pressures, combined with the internal unrest, created the unstable environment in which the Nurse Clinician program emerged.

The Nurse Clinician Program 

The Nurse Clinician program, adapted from the MEDEX model developed at the John A. Burns School of Medicine, University of Hawaii, was carefully tailored to the Lesotho context. The program’s architects focused first on a “receptive framework” in which nurses were identified as the most feasible group to train given the existing healthcare infrastructure. Or as Dr. Smith put if quite matter of factly, “We co-opted the nurses because they were the only group we could train.” ³¹ This practical decision enabled a swift expansion of healthcare services by building on the skills of the existing healthcare workforce.

The curriculum covered a wide range of medical and public health topics, designed to be both comprehensive and relevant to local needs. Key modules included:

Causation of Disease:³² This module provided an understanding of the various factors contributing to health and disease, from microbial infections to nutritional deficiencies. It equipped trainees with the skills to diagnose and manage diverse health conditions.

Safe Water Supply and Sanitation:³³ Recognizing the critical importance of clean water and proper sanitation, this module focused on practical solutions for ensuring safe water access and effective waste disposal. Nurse Clinicians were trained to build and maintain sanitary facilities and educate communities on hygiene practices.

Nutritional and Infectious Diseases: ³⁴ This module addressed prevalent health issues by teaching the diagnosis and management of a range of conditions, with an emphasis on both prevention and treatment. It included training on managing gastrointestinal problems like gastroenteritis, typhoid fever, and intestinal parasites, which were common due to inadequate sanitation and contaminated water supplies. The curriculum highlighted the use of oral rehydration solutions for dehydration management and stressed the importance of proper nutrition as a foundational aspect of overall health​​.

Training was delivered through a combination of classroom instruction, practical demonstrations, and hands-on clinical experience. The program also emphasized community engagement, preparing Nurse Clinicians to serve as both healthcare providers and public health advocates.

For Richard Smith, working with the Private Health Association of Lesotho (PHAL) revealed the critical need for technology and training at the village level. The PHAL was made up of non-government organizations that worked closely with the Lesotho Ministry of Health to provide medical services.  “It was in Lesotho that I realized that we had to get some technology developed to train people to take care of people at the village level,” he recalled. ³⁵

This realization led to the MEDEX Group’s engagement of Sunil Mehra, a young but highly knowledgeable Indian expert in village health worker training. Despite his youth, Sunil was recognized globally for his expertise. “My contact in the UK, where Sunil was working at the time said told us he was the most knowledgeable person about training village health workers of anyone they knew,” Smith remarked. ³⁵ 

Sunil and his wife, June, proved to instrumental in developing the program in Lesotho. Upon their arrival in Maseru, they chose not to stay in the capital but instead retreated to the mountains to immerse themselves in local village life. “They asked the Minister of Health to take them to a local grocery store, and they bought all of this frozen food and disappeared into the mountains for three weeks,” Smith said. ³⁵

This intensive period allowed them to closely observe and understand the unique challenges faced by remote villagers in Lesotho. Upon returning to Honolulu, they dedicated themselves to developing a comprehensive training manual for village health workers. This manual, praised for its depth and practicality, became a critical resource for training local health workers. Smith proudly noted, “The village-level training book they produced, still today, has no match anywhere in the world.” June’s skills, particularly in providing visual documentation and insights from her photography, added valuable context and clarity to the manual.

Tom Coles also played a pivotal role in the program’s development and implementation. As part of the Health Manpower Development Staff (HMDS) at the University of Hawaii, Coles frequently traveled to Lesotho, where he faced the unique challenges of adapting healthcare training to the local context. He was integral in guiding the practical aspects of the training, ensuring that Nurse Clinicians received the hands-on experience that was essential for their roles. Coles also provided crucial support during the program’s implementation, helping to structure and refine the training modules to align with Lesotho’s specific health needs.

Joyce Lyons and Mona Bomgaars were instrumental in the curriculum adaptation process, bringing their expertise to bear on the MEDEX training methods and materials. They were actively involved in conducting workshops and training sessions that focused on competency-based training approaches. Lyons played a significant role in the Tutor Training Workshop, where she helped draft and field-test a Tutor Training Workbook Manual. This manual was critical in standardizing the training process for tutors, ensuring a consistent and high-quality educational experience for the Nurse Clinicians. Meanwhile, Bomgaars contributed to workshops designed to adapt task analysis tables for nurse clinicians and community health workers, ensuring that the curriculum was contextually relevant and effective. Their contributions were vital in creating a robust training framework that could be effectively implemented in Lesotho’s healthcare setting.

Implementation and Impact

The Nurse Clinician program quickly became a cornerstone of Lesotho’s healthcare system, especially in rural areas where access to medical care was limited. Nurse Clinicians played a crucial role in diagnosing and treating illnesses, managing maternal and child health, and leading public health initiatives.

With the program’s successes came some unforeseen challenges. The high-quality training provided by the MEDEX Group made Nurse Clinicians caught the attention of healthcare leaders in South Africa. Their offers of employment led many Nurse Clinicians to leave Lesotho. Dr. Smith remembered this later in slightly more graphic terms: “South Africa started poaching them.”³⁰

This loss of trained talent was worsened by a Lesotho policy that allowed only one spouse in a marriage of government employees from receiving pensions, pushing many nurses to seek better opportunities in South Africa. Some years later, Dr. Smith reflected, “Had I foreseen the issue with the dual pension, we probably could have done something about it.”³⁵ He regretted not addressing this issue more firmly when he had close ties with the Lesotho Ministry of Health, believing that a different approach could have kept more trained professionals in the country.

But despite these challenges, the program had a significant impact on healthcare in Lesotho. It promoted a culture of preventive care and health education, significantly reducing the prevalence of preventable diseases. The involvement of Village Health Workers (VHWs) and local leaders was crucial in extending the reach of health services and promoting sustainable practices.

Personal Experiences and Reflections

The Health Manpower Development Staff (HMDS) often encountered challenging situations as they traveled around the world to improve healthcare systems. In the case of Lesotho, tales surrounding the creation of the Nurse Clinician program include many personal stories that highlight the human aspects of this work.

Lesotho’s Political and Social Context

Operating in Lesotho during a time of internal political tension was fraught with challenges. The country faced significant internal unrest, including opposition from various factions that often resorted to armed resistance. These internal conflicts made even routine operations, such as travel, potentially hazardous.

Lorna Smith remembered that “getting in and out of Lesotho was difficult because occasionally the airport would take rocket fire.”²⁸ Despite these dangers, she continued, “there was never any plane that was shot down ever, and none of our people were ever hurt.” The aftermath of the attacks on the airport was often more practical in nature: “Occasionally the airport had to close to run a bulldozer over the holes to flatten it out again before the next plane could land.” ²⁸

Racial Injustice and Challenges during Apartheid

Dr. Richard Smith encountered significant challenges related to racial injustice, particularly during his travels through apartheid South Africa. Lorna Smith recalled that navigating through Johannesburg was especially difficult due to the strict racial segregation laws and customs procedures. The airport featured a “no man’s land” area, where international travelers could stay in hotels and restaurants without officially entering the country, allowing them to avoid the complexities of apartheid-era immigration controls.

One specific incident highlighted the stark realities of racial prejudice. While dining at a restaurant in this secure area, Dr. Smith ordered a bottle of wine. The waiter, adhering to apartheid norms, brought the wine to his white colleague instead. The colleague then made a point of passing the bottle to Dr. Smith, who took a sip and remarked on its taste before offering it back to his colleague with the question, “What do you think?” This simple act of sharing a glass of wine between a black man and a white man visibly unsettled the restaurant staff.

This incident not only highlighted the pervasive racial injustices in apartheid-era South Africa but also served as a stark reminder of the broader social and political barriers that the team faced beyond the immediate healthcare challenges in Lesotho. It underscored the complexities of working in a region where racial injustice could impact even the most routine interactions.

An Unexpected Confrontation: A Close Call in Lesotho

Members of The Health Manpower Development Staff (HMDS) frequently faced unexpected dangers on their travels. One such incident involved Eugene Boostrom, Planning and Management Systems Analyst, and Rodney Powell, Deputy Director, in Lesotho. Rodney Powell, a civil rights pioneer who had been actively involved in the non-violent resistance movement in Nashville during the early 1960s, found himself in a tense and dangerous situation. As they walked from their accommodations to a restaurant, Eugene and Rodney were confronted by armed assailants.

Rodney, who had a Rolex watch given to him by his former wife, was approached by a man with a gun demanding the watch. Despite his strong belief in non-violent resistance, Rodney initially felt the urge to resist. However, he quickly realized the gravity of the situation. As he considered the potential consequences of resistance, Rodney thought, “…something told me, you know, his life, my life, and the Rolex watch, it doesn’t compute.” He decided to comply and hand over the watch.

Unbeknownst to Rodney until after he handed over the watch, another assailant was holding a knife to Eugene’s neck. The realization that any attempt to resist could have led to Eugene being harmed solidified Rodney’s decision to comply peacefully. Reflecting on his training in non-violent resistance and the teachings of Dr. Martin Luther King Jr., Rodney later reflected, “Had I taken this action that occurred to me, which was … I won’t describe what I had thought of doing … but to disarm this man probably could’ve cost Eugene his life. And I think somewhere in the back of my head I heard the voice of Dr. King saying, ‘You did the right thing.’”

Lessons Learned and Future Directions

In the nearly fifty years since the inception of the Nurse Clinician program, several key lessons are still apparent:

• Local Adaptation Was Crucial: The program’s success was largely due to its ability to adapt to the local context. Tailoring the curriculum to meet Lesotho’s specific health challenges and cultural nuances was essential.
• Community Engagement Was Essential: Engaging with the community, including the involvement of Village Health Workers (VHWs), proved vital for promoting health education and sustainable practices.
• Sustainability and Retention Challenges: The program faced difficulties in retaining trained professionals, as many Nurse Clinicians were drawn to better opportunities in neighboring South Africa. Addressing this issue in future initiatives would be important for long-term sustainability.
• Holistic Approach Was Effective: Integrating various health services—ranging from nutrition to sanitation—was effective in delivering comprehensive healthcare.

In these ways among others, the Nurse Clinician program laid a valuable foundation for the continued development of Lesotho’s healthcare system. The efforts to expand training programs, enhance community involvement, and improve healthcare infrastructure set the stage for addressing new health challenges in the years that followed.

Conclusion

The Nurse Clinician program in Lesotho made significant contributions to improving the country’s healthcare system, especially in rural areas with limited access to medical professionals. The training and deployment of Nurse Clinicians expanded access to primary healthcare services, including maternal and child health, infectious disease management, and preventive care. The program also emphasized community involvement through the engagement of Village Health Workers (VHWs), which supported the dissemination of health education and the promotion of sustainable health practices.

Although the program faced difficulties, especially in keeping trained healthcare workers from leaving for work elsewhere, it was essential in strengthening Lesotho’s healthcare sector. The comprehensive training manuals developed by Sunil and June Mehra became a lasting resource for educating healthcare workers worldwide and became a significant part of the Primary Health Care Series published in 1983.

As Lesotho continues to improve its healthcare infrastructure, the foundational work of the Nurse Clinician program remains a useful guide for future health projects by showing how adapting training materials to fit the local context can successfully implement community-focused healthcare initiatives.

Chapter Eleven: Pakistan – Promising, and then a Hurried Exit

Introduction

The MEDEX Group’s Health Manpower Development Staff (HMDS) took on the challenge of transforming healthcare in rural Pakistan with its involvement in the Pakistan Basic Health Services Project (PBHSP) from 1976 to 1981. This ambitious initiative set out to tackle the critical healthcare needs of Pakistan’s underserved rural communities by building essential facilities, training local healthcare workers, and creating the infrastructure needed to support long-term improvements in the health of the Pakistani people. In this chapter, we will explore how HMDS shaped the project’s design, brought it to life, and navigated its outcomes—all while sharing some of the fascinating stories and personal adventures from those who made it happen.

Project Design and Implementation

The Pakistan Basic Health Services Project (PBHSP) was an ambitious initiative designed to improve healthcare access and quality in rural Pakistan. The project was divided into two main phases, each targeting different aspects of healthcare system development. The first phase focused on establishing the foundational infrastructure and training systems, while the second phase aimed at expanding and refining these systems based on the outcomes and lessons learned from the initial phase.

Objectives and Scope

The PBHSP’s primary objective was to develop Integrated Rural Health Service Complexes (IRHCs) across Pakistan’s rural areas. These complexes were envisioned as comprehensive healthcare hubs that would provide a range of services, including preventive, promotive, and curative care. Each IRHC was to consist of a Rural Health Center (RHC) and several Basic Health Units (BHUs), collectively serving a population of 50,000 to 100,000 people. The RHCs were designed to act as the central management and referral points, staffed with a multidisciplinary team of healthcare professionals, including doctors, mid-level health workers (MLHWs), and supervisory personnel.

The project also included the deployment of community health workers (CHWs) at the village level. These workers were tasked with delivering essential health services and promoting health education within their communities. The CHWs played a crucial role in extending the reach of healthcare services to the most remote and underserved populations.

Role of HMDS in Project Implementation

Richard Smith and his colleagues on the Health Manpower Development Staff (HMDS) from the University of Hawaii were instrumental in the successful implementation of the PBHSP, particularly in the areas of training and capacity building. The staff designed and implemented comprehensive training programs for MLHWs and CHWs, focusing on equipping them with the skills necessary to deliver high-quality healthcare services. The HMDS developed a detailed curriculum that covered a wide range of health topics, including maternal and child health, infectious diseases, nutrition, and basic medical care. This curriculum was complemented by practical training sessions, ensuring that trainees could apply their knowledge in real-world settings.

To support the training programs, the HMDS established numerous training centers across the country. These centers provided a structured environment for both theoretical and practical learning. Additionally, the HMDS developed and distributed training materials, including manuals and audiovisual aids, tailored to the local context. The adaptation of the MEDEX model to the Pakistani setting ensured that trainees could easily understand and retain the information, facilitating better service delivery at the grassroots level.

A pivotal moment in the project’s development occurred when Dr. Richard Smith met with Nusrat Bhutto, the wife of Prime Minister Zulfikar Ali Bhutto, at the Presidential Palace in Islamabad. 

The circumstances around how Dr. Smith ended up spending 4 hours with Mrs. Bhutto discussing the healthcare needs of Pakistan are unknown. What is clear, however, is that Mrs. Bhutto was deeply concerned about healthcare in the rural areas of her country.

She saw the MEDEX concept as an ideal solution, particularly for students who hadn’t made it into medical school but still wanted to serve in healthcare roles. Dr. Smith agreed that the program was indeed a great fit but emphasized that it needed to go beyond just those who hadn’t entered medical school. He explained that the focus should be on training individuals who were truly dedicated to serving as mid-level health workers—people who could effectively bridge the gap between doctors and underserved communities. Mrs. Bhutto was enthusiastic about this idea and fully supported Dr. Smith’s approach. This plan then became a cause that she championed.

This meeting was a turning point, as Mrs. Bhutto’s endorsement gave the project the necessary political backing to move forward. The support from the Bhutto family not only provided legitimacy but also ensured that the project could reach areas that were otherwise difficult to access. Dr. Smith’s ability to navigate these political landscapes and secure such high-level support was crucial to the project getting off the ground.

Mona Bomgaars, a key member of the MEDEX team, brought a unique advantage to the project—her ability to speak Urdu, the national language and lingua franca of Pakistan. Mona’s linguistic skills allowed her to communicate directly with local officials, healthcare workers, and community members, breaking down barriers and fostering trust. Native Pakistanis were often surprised and impressed by her fluency in Urdu. In many instances, they expressed their astonishment and delight, as it was unusual for a foreigner, particularly a woman, to speak their language so well.

One memorable incident occurred during a meeting early in the project, where local participants began speaking in Urdu among themselves, assuming Mona wouldn’t understand. They thought they were having a private, off-the-record conversation. However, Mona, a woman Lorna Smith wryly recognized as having “a strong moral spirit”, didn’t keep her language skills a secret.

“As soon as we broke for morning tea,” she recalled, “I initiated conversations with them in Urdu and gave them a chance to sort of regroup before we went back into the meeting.”

This ability not only endeared her to the local communities but also significantly enhanced the effectiveness of the training programs. By speaking their language, Mona was able to connect on a much deeper level, ensuring that the training was culturally relevant and well-received.

Challenges and Adaptations

The Pakistan Basic Health Services Project faced numerous challenges during its implementation, each of which required thoughtful adaptations and responses. By this point “adaptation” was the mantra of the HMDS. Dr. Smith recalled, “We emphasized adaptation, not adoption. ‘Adoption’ was a negative term and a turn-off. ‘Adaptation became our by-word and made our program acceptable to everyone.”³⁰

One of the major issues encountered was the limited number of healthcare workers trained and the difficulty in retaining them in their roles. Some trainees returned to their previous jobs, underscoring the challenge of maintaining a dedicated workforce. Moreover, the training materials initially focused heavily on curative services rather than preventive care, which was crucial for addressing broader public health goals.

To address these issues, the HMDS team revised the training curriculum to place a stronger emphasis on preventive care and community health education. They introduced more flexible training schedules and provided additional incentives to encourage workers to remain in their roles. These efforts helped align the training with the broader health goals of the project and improved retention rates, though challenges remained.

Another significant challenge was the utilization and maintenance of healthcare facilities. The Baseline Health Survey conducted in 1981 highlighted that while a significant number of Basic Health Units (BHUs) and Rural Health Centers (RHCs) were built, their accessibility and utilization were limited. Only a small percentage of the population was within 10 kilometers of a BHU, which hindered access to essential services. Moreover, the survey revealed inconsistencies in the quality of care provided by non-physician workers, such as Lady Health Workers (LHWs), indicating gaps in their training and supervision.

Pakistan 1978. Photo from Tom Coles personal collection.

Lady Health Workers

The Lady Health Workers (LHW) program in Pakistan was started to address the country’s healthcare needs, particularly in rural and underserved areas. It focuses on providing primary healthcare services, with an emphasis on maternal and child health. LHWs are community-based workers, trained to offer basic health education, vaccinations, family planning, and maternal care. They also play a crucial role in public health campaigns, such as polio eradication and disease prevention. The program has been instrumental in improving access to healthcare, especially for women and children, and continues to be a key part of Pakistan’s health system.

In response to these findings, the project team worked to improve coordination across different levels of the healthcare system. They implemented better management practices, provided enhanced training and support for LHWs, and emphasized the importance of maintaining facilities to ensure they were effectively utilized. The team also intensified community engagement efforts, explaining the role of LHWs and ensuring their services were better understood and accepted by the local population.

Cultural Challenges and Adaptations:

Cultural barriers were another significant challenge, particularly in training and deploying female healthcare workers in conservative rural areas. The traditional role of Hakims (local healers) in the communities meant that introducing new healthcare providers like LHWs required careful community engagement. Initial resistance from the community highlighted the need for culturally sensitive approaches.

The HMDS team adapted their training programs to be more culturally sensitive, incorporating local customs and norms into their approach. They organized community engagement sessions to explain the role and importance of LHWs, gradually gaining acceptance from local leaders and families. Training in local languages and ensuring that LHWs were initially supported by male colleagues were among the strategies that helped build trust and improve the program’s effectiveness.

Mona Bomgaars, fluent in Urdu, provided valuable support in these efforts. Her language skills allowed her to engage directly with local officials and communities, helping to ease cultural tensions and foster a cooperative spirit within the project.

However, cultural challenges went beyond just healthcare practices. A unique challenge the MEDEX team faced early on was getting a physician and his wife, along with their two small dogs, into Pakistan. Dogs are not well-regarded in many Muslim countries, and Pakistan was no exception. Lorna Smith and Frank White, the office manager, spent an exhausting amount of time talking to officials and negotiating to get the couple’s beloved pets into the country. The process was long and difficult, and neither Lorna nor Frank had much love for that job, given that they didn’t particularly understand why the couple wouldn’t come without their dogs. Despite these hurdles, they eventually succeeded in getting the dogs into Pakistan, much to the relief of the physician and his wife.

Political Challenges and Adaptations:

Political instability further complicated the project. The coup led by General Zia-ul-Haq on July 5, 1977, resulted in the arrest of Prime Minister Zulfikar Ali Bhutto and created a period of uncertainty. This instability made it difficult to maintain consistent support for the project, slowing its progress.

Despite these political challenges, the project team worked to build strong relationships with local health officials who could provide continuity despite changes in national leadership. They also sought alternative funding and support from international organizations to keep the project moving forward, even when national backing was uncertain.

Months later, the MEDEX team faced another crisis with the storming of the U.S. Embassy in Islamabad on November 21, 1979. The violent siege led to a swift evacuation of all U.S. personnel and other foreigners from Pakistan. Lorna Smith recalled, “Everybody, not just MEDEX, but all the NGOs in the country had to get out fast. They were loaded onto Pan Am 747s and flown to Wiesbaden, Germany.”

Lorna remembered watching the news live from Wiesbaden in the middle of the night, Hawaii time, as one of the first planes arrived. “We were watching the news as one of the first planes, which we knew included our people, was unloading off a stairway. The first creatures off the plane were the two dogs. My phone rang—it was Frank White. ‘You’re watching TV, right?’ he asked. I said, ‘Yeah, there are the dogs.’ He sighed and said, ‘You know we’re going to have to go through all that again.’”

Outcomes and Legacy

Despite the numerous challenges faced by the PBHSP, the project achieved several key milestones that contributed to the enhancement of healthcare services in rural Pakistan. The training of mid-level health workers (MLHWs) and community health workers (CHWs) created a new group of healthcare professionals capable of delivering essential services in areas where access to doctors was limited.

The physical infrastructure, including the construction of Basic Health Units (BHUs) and Rural Health Centers (RHCs), laid the groundwork for a more accessible healthcare system in rural areas. While not all of the facilities were utilized to their full potential, the presence of these centers represented a significant step forward in providing healthcare to underserved populations.

Although the MEDEX team’s involvement in Pakistan was cut short due to political instability, the impact of their work endured. The training programs initiated by the HMDS had equipped MLHWs and CHWs with the necessary skills to continue delivering primary healthcare services. The establishment of IRHCs provided a structural framework that local authorities could build upon.

The introduction of Lady Health Workers (LHWs) also had a lasting impact. Although the project faced challenges in training and retaining these workers, their role in delivering primary healthcare services, particularly in maternal and child health, became an integral part of Pakistan’s healthcare system.

The project’s legacy is also reflected in the continued influence of the training materials and methodologies developed by HMDS. These materials set new standards for health education in Pakistan, promoting a more holistic approach to healthcare that included preventive care, community health education, and the integration of traditional and modern practices.

Conclusion

The Pakistan Basic Health Services Project represents a significant chapter in the efforts to improve healthcare delivery in rural Pakistan. Through the dedicated work of the Health Manpower Development Staff (HMDS), the project made substantial strides in training health workers, constructing healthcare infrastructure, and promoting a more integrated approach to healthcare services. Despite the numerous challenges faced, including political instability, institutional hurdles, and logistical difficulties, the project laid a critical foundation for future health initiatives in the region.

The contributions of HMDS were pivotal in shaping the project’s outcomes. Their focus on developing comprehensive training programs for mid-level health workers (MLHWs) and community health workers (CHWs) helped bridge the gap in healthcare service delivery, particularly in remote areas. The establishment of training units and the development of tailored training materials were instrumental in building a competent health workforce capable of addressing the diverse health needs of rural populations.

While the PBHSP did not achieve all its ambitious targets, it provided valuable lessons for future health projects. The importance of aligning project goals with national strategies, engaging local stakeholders, and ensuring the sustainability of interventions were key takeaways. The project also underscored the need for a flexible and adaptive approach to project management, particularly in the face of unforeseen challenges.

As we reflect on the PBHSP, it is clear that the work of the HMDS has had a lasting impact on health training and service delivery in Pakistan. The experiences and lessons from this project continue to inform health manpower development strategies, not only in Pakistan but in other developing countries facing similar challenges. The HMDS’s commitment to enhancing health systems and building local capacity remains a vital component of efforts to achieve sustainable healthcare improvements worldwide.

Chapter Twelve: The MEDEX Primary Health Care Series

Introduction

The MEDEX Primary Health Care Series is a monumental achievement in global health, representing years of dedication, innovation, and collaboration by thousands of contributors worldwide, including village health workers, nurse clinicians, community health workers, wechakorns, medexes in Guyana and Micronesia and others. Developed over ten years and first published in 1983, this 35-volume series was designed as a versatile and practical tool for training and managing primary health care (PHC) programs. Its impact on healthcare delivery in developing countries has been profound, bridging gaps in health services and empowering health workers at various levels of care.

The Evolution of the MEDEX Primary Health Care Series

The MEDEX Primary Health Care Series has its roots in the pioneering efforts of Dr. Richard Smith, who launched the MEDEX Northwest PA program at the University of Washington in the late 1960s. Dr. Smith’s innovative ideas aimed to address the critical shortage of healthcare providers in rural and underserved areas of the United States by focusing on training military medics returning from the Vietnam War to serve as mid-level health practitioners, later known as physician assistants (PAs). These practitioners were equipped to provide a wide range of health services, effectively extending the reach of physicians into underserved communities. The success of the MEDEX Northwest program demonstrated the effectiveness of what has come to be called the MEDEX model and laid the groundwork for its global expansion.

For a detailed look at the creation of the MEDEX Northwest PA Program, click and read Multiply My Hands: Dr. Richard Smith and the Founding of MEDEX Northwest.

Global Expansion and Field Testing

Building on the success of the MEDEX Northwest PA program, Dr. Smith and his team recognized the potential to apply the MEDEX model on a global scale. The first international adaptation of the MEDEX program occurred in Micronesia, where the challenges of delivering healthcare in remote, resource-limited settings were apparent. This work focused on training mid-level health workers who could provide care and serve as trainers and supervisors for community health workers. The success of their efforts in Micronesia demonstrated the adaptability of the MEDEX model to diverse environments, laying the groundwork for future international applications.

In Thailand, collaboration with the Lampang Health Development Project emphasized integrating curative, preventive, and promotive health services within the training of mid-level health workers. This comprehensive approach ensured that health workers were equipped not only to treat diseases but also to prevent them and promote overall community health.

Guyana presented unique challenges, including a highly dispersed population and limited health infrastructure. Here, the focus was on management skills for mid-level health workers, enabling them to effectively manage health centers, supervise community health workers, and lead health promotion activities. The success in Guyana demonstrated that health workers trained under the MEDEX model could serve as both providers of care and community leaders.

In Pakistan, the integration of the MEDEX model into the country’s Basic Health Services Program highlighted the importance of scaling up the training of community health workers and mid-level providers to deliver essential health services nationwide. This experience reinforced the need for robust training materials and support systems, crucial for expanding the MEDEX model across large populations.

Lesotho played a pivotal role in refining the MEDEX Primary Health Care Series. The country’s commitment to improving its primary healthcare system provided an ideal setting for further development. Collaboration with the Ministry of Health in Lesotho focused on enhancing the planning and management components of the program, shaping the content and structure of the MEDEX manuals.

Assembling the MEDEX Primary Health Care Series: The Importance of Culturally Informed Adaptability

It’s from these field-based global experiences of the MEDEX Group that the MEDEX Primary Health Care Series emerged. “The writing didn’t happen until after these programs,” Richard Smith remembers. “On the ground in the countries where the work was done, we would write the initial materials, adapt them based on the local context, and then bring those adaptations to another country, where they would be further refined. This iterative process of writing, adapting, and re-adapting was what eventually led to what we called the series.”

Tom Coles and Joyce Lyons played pivotal roles in transforming these practical experiences into written form.

As one of the longest-serving members of the MEDEX team — remember that he was a member of the first graduating class of PAs from MEDEX Northwest before joining the Hawaii team — Tom Coles contributed 20 years of his career to MEDEX. Lorna Smith tells a humorous and memorable story that marked his entrance into the program in 1969.

“Tom Coles listed ‘tuping’ as one of his skills on his MEDEX Northwest application. At the time, none of us had any idea what ‘tuping’ meant. We were intrigued, thinking it was some kind of exotic or specialized skill. Since there was no way to look it up, we waited until we met Tom to ask him in person. When we finally did, Tom was as puzzled as we were. It turned out to be a simple typo—he had meant to write ‘typing.'”

As things went, Tom’s actual typing skills became a crucial part of his contribution to the MEDEX program in those years of manual typewriters. Indeed, he became known for spending countless hours typing and re-typing documents to ensure they were ready for publication.

But of course Tom’s role extended far beyond just typing. He was frequently on the ground in most of the 22 countries that contributed to the development of the MEDEX Primary Health Care Series. Besides Micronesia, Thailand, Guyana, Lesotho and Pakistan, the contributing countries were Afghanistan, Belize, Cameroon, China, Colombia, Ethiopia, Gambia, India, Indonesia, Jamaica, Liberia, Nepal, Nicaragua, Senegal, Sudan, Tanzania, and Venezuela.³⁷

In each of these locations, Tom immersed himself in the local cultural and social contexts in order to understand the specific challenges and needs at play. His work in adapting the training materials to fit these diverse environments, and in turn educating the trainers who would implement the MEDEX model, was instrumental in ensuring the series’ global relevance and effectiveness.

Joyce Lyons was hired by MEDEX Group not only because of her background as a nurse but her MA in Education. Not surprisingly, Joyce was actively involved in shaping the educational content of the series. 

“I helped with organizing the materials,” she explains, “preparing the testing, and sequencing the learning.”

But of equal importance, she ensured that the materials were relevant and accessible and appropriate by working with the local health professionals to adapt them to the specific cultural and healthcare contexts. In these ways, her contributions were essential in transforming what were loose-leaf initial materials into the organized, structured manuals that form the MEDEX Primary Health Care Series we know today.

Together, Tom and Joyce were instrumental in ensuring that the MEDEX Primary Health Care Series was not only comprehensive but also adaptable, allowing it to be used effectively in diverse global contexts.

Reflecting on Foundational Texts

Dr. Richard Smith would be among the first to remind us that most all good ideas and work is based on ideas and work that came before, and that the MEDEX Primary Health Care Series was no exception. 

A particularly important foundational text that predated the publication of Primary Health Series was the 1978 book Manpower and Primary Health Care: Guidelines for Improving/Expanding Health Service Coverage in Developing Countries, edited by Dr. Smith. This book offered comprehensive guidelines for developing primary health care systems, focusing on flexibility, adaptability, and meeting local needs, all essential ingredients to the efforts of the MEDEX Group. 

Mona Bomgaars points specifically to the flexibility of the early materials used in the MEDEX program which allowed for adaptation to specific needs in different countries. “For the first few countries, we did not have books. We had loose-leaf papers on these materials. We had a whole system. [This process allowed us to] set up a system within a country, have people look at these materials, translate them if necessary, fix them up for the needs in their countries, and then essentially rewrite the teaching materials and the content.”

This flexibility was crucial in the early stages of the MEDEX program, allowing the training materials to be tailored to the specific needs of different countries.

How interesting to note, then, as Bomgaars does, that the publication of materials in bound volumes, which was mandated by the governing and funding agency USAID, in fact served to reduce] this adaptability, stagnating the process and making it less responsive to changing contexts.

“None of us wanted to publish books,” she reflected. “But USAID made it that product, and that’s why we have the volumes you see now.”

The Link Between Support and Performance

The MEDEX Primary Health Care Series placed considerable emphasis on the crucial link between the performance of health workers and the management support they received. The Series was among the first publications to emphasize and detail this connection, providing a systematic, practical approach to the management of primary health care.

The Significance of Nurses

Additionally, the Series recognized the significant role of nurses in primary care, particularly in training and supervising community health workers. The diagnostic, curative, and community health skills covered in the Series were designed to align with the expanding role of nursing in primary care, making it a valuable resource for nursing programs.

The Comprehensive Resource: The MEDEX Primary Health Care Series

The MEDEX Primary Health Care Series was divided into three main components:

1. Systems Development Materials: Comprehensive tools for healthcare managers and administrators to analyze and improve healthcare management support systems.
2. Mid-Level Health Worker Training Materials: Focused on equipping health workers with the skills necessary to deliver primary health care services, manage health facilities, and train community health workers.
3. Community Health Worker Training Materials: Designed to be accessible and easy to use, emphasizing practical skills and knowledge for frontline health workers.

The Series’ competency-based methodology allowed for detailed activities to be conducted in short periods, making the training adaptable to various schedules and contexts. The materials on community health and maternal and child health were among the most widely used. They addressed the practical needs of many health programs.

Recognizing the importance of sharing knowledge and experiences, the MEDEX Group established the MEDEX International Network (MEDINET). This network aimed to connect users of the Series worldwide, facilitating the exchange of best practices and promoting continuous improvement in primary health care training. The MEDINET was supported by a mailed newsletter titled “2000,” paying homage to the Health for All pledge of Alma Ata, which aimed to achieve global health by the year 2000.

To further support the global application of the Series, a mini-MEDEX Series was developed and translated into Spanish. This version focused on community health, maternal and child health, and health center management, and was distributed in Latin American countries for use in nursing and primary care programs. Interest in translating the Series into other languages, including French, also grew, demonstrating its broad appeal and adaptability.

Legacy and Global Impact 

It’s fair to say that since its publication, the MEDEX Primary Health Care Series has made a significant impact on healthcare systems worldwide. Take, for example, what this 1984 newspaper article in the Honolulu Star Advertiser had to say about the series:

By 1985, the series had been distributed to 114 countries and was actively used in 267 primary healthcare programs across 53 developing countries. ³⁸ It gained recognition from international organizations such as WHO and UNICEF, which integrated its materials into various health initiatives, including those focused on oral rehydration therapy, immunization, and nutrition.

Sunil Mehra recalled the widespread adoption of the series: “You couldn’t plonk it on a minister’s desk and say, ‘We’re running with the whole show.’ People would enter that space at different points—some took the community side, some took the management side, some took the training side—but in the end, many still asked for the whole thing.”

For Rodney Powell, adaptability was key to its success: “It was always adapted. Some countries picked up the series, translated it, and adapted it to their own needs without any support from us, and it was still very useful.”

Demand for the MEDEX Series

By the early 2000s, the MEDEX Primary Health Care Series had become an invaluable resource worldwide. Despite its limited print run of just 6,000 sets in 1983, the series continued to be in high demand decades later. Dr. Richard Smith often reflected on the unexpected reach and enduring legacy of the series, recounting stories that illustrated its profound impact across the globe.

One such story took place a few years after the last copies had been distributed. Dr. Smith received a phone call from a doctor in Sichuan Province, China. The doctor was in urgent need of a set of the MEDEX series. Dr. Smith explained that all the sets had been distributed, and none were available. However, the doctor insisted, explaining that he had been ordered to begin training 10,000 mid-level healthcare workers starting the following Tuesday. The urgency in his voice left no room for doubt—he needed the series, and he needed it immediately.

Dr. Smith, recalling that he had one last set stored in his son’s basement in California, informed the doctor of its location. Within an hour, the doctor called back, eager to secure the set. The next morning, someone arrived at Dr. Smith’s son’s house, collected the series, and hand-carried it across the Pacific to China. 

But the story didn’t end there. Just two weeks later, Dr. Smith received another call, this time from a woman named Dorothy Chen in southern China. She, too, was desperate for a set of the MEDEX series. Dorothy was the director of a program called The Cobbler Project, which focused on “putting shoes on the barefoot doctors.” She explained that the series was essential for their work.

With no more sets available, Dr. Smith suggested that she contact institutions in Taiwan that had copies. Dorothy took his advice, and her team traveled to Taiwan, where they painstakingly photocopied the 7,000 pages of the series. The effort was immense, but so was their need. This determined pursuit underscored the series’ critical role in global health training and its influence on healthcare systems far beyond its original scope.

Reflecting on the Series Nearly 30 Years Later

Nearly 30 years after the series was published, Mona Bomgaars reflected on the enduring impact and the challenges posed by the lack of updates to the series:

“Books are not very adaptable. They never have been, and they certainly are not now. As you’re moving to a higher communication technology, that’s very good. Even so, when you start designing this sort of thing, be sure you have put into your, at least, 20-year design, a very clear updating process.”

Mona’s reflections highlight the importance of continuous updating in educational and training materials, especially as technology advances. While the MEDEX Primary Health Care Series was groundbreaking in its time, the need for ongoing revision and adaptation is critical to maintaining the relevance and effectiveness of such resources.

The Unexpected Reach of MEDEX

The legacy of the MEDEX Primary Health Care Series is perhaps best illustrated by an unexpected encounter that occurred years later. Lorna Smith recalls an airplane conversation between her husband, Richard Smith, and a fellow passenger who worked in an anti-terrorism program. As they talked, Richard was struck by the man’s description of a highly effective medical program used by Al-Qaeda. It was only as the conversation progressed that Richard realized, with a mix of emotions, that this program was based on the very materials developed by MEDEX.

While the realization was unsettling, it underscored a powerful truth: access to healthcare is a universal need, transcending borders and ideologies. The MEDEX Primary Health Care Series had reached places and people far beyond its original intent, a testament to its enduring relevance and impact.

Conclusion

The MEDEX Primary Health Care Series is more than a collection of training manuals; it is a living legacy of a global movement to bring healthcare to those who need it most. Born from the vision of Dr. Richard Smith and nurtured by the dedication of countless contributors like Tom Coles, Joyce Lyons, Mona Bomgaars, Sunil Mehra, Rodney Powell, Frank White, Lorna Smith, and dozens more, the series has touched lives in ways its creators could never have imagined. As we look back, four decades after its publication, the lessons of the MEDEX series continue to resonate, reminding us of the power of innovation, collaboration, and the unwavering belief that healthcare is a right for all.

Chapter Thirteen: The Legacy of a People Collector

Introduction

Richard Smith was known by many titles throughout his life—doctor, innovator, leader. But as we have tried to show in telling the history of his professional life, Smith is perhaps most aptly described as a people collector. From the earliest days of his career, Smith demonstrated an extraordinary ability to bring people together and forge connections that would become the backbone of his life’s work. This approach proved to be about much more than mere networking or the simple assemblage of teams. It was about recognizing the potential in individuals and creating an environment where they can thrive and contribute to something greater than themselves. Rooted in the belief that people are the core of any successful endeavor, the legacy of Dr. Richard Smith stands as a testament to the power of human connection and collaboration.

The Collected

As we’ve seen, the practice of people collecting was central to the creation and success of both the MEDEX Northwest PA Program (1969-present) based in Seattle, WA and that of the MEDEX Group (1972-1992) based in Honolulu, HI. Consider again some of the key figures from the MEDEX Group and what they each brought to mix: 

The individual skills and experience each of these collected people people represented and the working relationships that developed among them were not incidental, and certainly not accidental. Woven together, they formed the very fabric of everything Richard Smith intended to accomplish. By empowering these people and others, Smith “multiplied his hands,” creating a ripple effect that reached across continents and generations. In this way, Richard Smith’s legacy is as much about the people he inspired as it is about the systems he helped to build.

The program’s expansion into diverse regions, like Micronesia, Thailand, Guyana, Pakistan, and Lesotho, was made possible by the collective efforts of Smith’s team. While Smith provided the vision and leadership, it was the contributions of individuals like Powell, Coles, Mehra, Lyons, Lorna Smith, Bomgaars, and so many others that brought that vision to life. Each brought their own expertise, dedication, and ingenuity, ensuring that MEDEX could be adapted to new and challenging environments.

Smith’s approach was always personal, as much with students and trainees as with colleagues. He didn’t aim to just train his students, that is, but to connect with them, instilling in each a sense of ownership over their work. By the time MEDEX graduates entered the field, they were not just carrying out a job; they were fulfilling a vision—Smith’s vision—that had been passed on to them through those personal connections. He understood that for MEDEX to succeed, it needed to be driven by individuals who were not only competent but deeply committed to the mission. This personal touch allowed MEDEX to expand and adapt successfully in so many different cultural contexts, as it was a program rooted in relationships, each one carefully cultivated by Richard Smith and his team.

The MEDEX Model: A System Built on Relationships

Always at the heart of this network of relationships and the results it yielded was an essential strategic tool: the MEDEX model. Initially pioneered in the U.S. to address rural healthcare needs, the MEDEX model showed remarkable adaptability and potential for global implementation. The success of the program in Alaska and Micronesia demonstrated its scalability, while its expansion to countries worldwide illustrated its relevance to both developed and developing nations. By consistently incorporating this model, Smith and his teams proved that effective healthcare training could be accelerated, allowing more communities to benefit from trained medical personnel even in the most remote locations.

Navigating Crisis: The Oracle of Delphi

Richard Smith also understood that walking the path to innovation included coming upon challenges, especially in the unstable environments where MEDEX sometimes operated. He didn’t go out looking for them, of course, but he was usually ready for them when they appeared. 

Lorna Smith relays an anecdote that encapsulates this reality with both humor and insight. She and husband Richard were visiting the site of the Oracle of Dephi, a shrine in ancient Greece that was dedicated to the Greek god Apollo. The Oracle of Delphi was served by a priestess named the Pythia, who was the high priestess of the Temple of Apollo. Pythia was known for her cryptic answers to questions asked of her. 

In the spirit of this place and its history, a visiting friend and consultant of the Smiths posed this question to the Delphic Oracle: “Well, is MEDEX surviving the latest crisis?” The Oracle’s response was both profound and prophetic: “There is no MEDEX without crisis.”

Here was the essence of the MEDEX experience, then: crises were not unusual. In fact, they were the norm in the politically and economically unstable countries where MEDEX sometimes operated. Yet, these crises were also opportunities—for innovation, for testing the resilience of the systems the MEDEX Group had helped build, and for the people Dr. Smith empowered to step up and make crucial decisions.

“We welcomed challenges,” Lorna Smith suggests. “We dealt with them, we didn’t duck them. We faced them.”

As we’ve seen in unfold Pakistan, Lesotho and South Africa, contingency planning became a critical part of the MEDEX approach.

And then, sometimes, crises emerged with shocking intensity, testing the MEDEX Group in ways that no amount of planning could fully prepare them for. Perhaps nowhere was this more true than in Liberia. What began as an ordinary workday for Richard Smith in April 1985 quickly spiraled into a life-threatening ordeal that perfectly illustrated the unpredictability of working in politically unstable environments.

The Tale of Two Richard Smiths

Dr. Richard Smith never imagined that his work in Liberia—dedicated to training physician assistants as part of the MEDEX program—would nearly cost him his life. What began as an ordinary day in April 1985 turned into a harrowing ordeal involving an assassination attempt, a nationwide manhunt, and an escape that would leave a lasting mark on him.

On April 1, 1985—ironically, April Fools’ Day—after finishing his rounds with the Medex staff, Smith’s colleagues took him out for his favorite dessert: chocolate mousse. Strangely, it was the worst he had ever tasted. This seemingly trivial detail would later feel like an eerie foreshadowing of the chaos to come.

The next morning, Smith awoke to alarming news. There had been an assassination attempt on the president of Liberia, and the would-be assassin, a man named Flanzamaton, had been captured. But what sent chills down Smith’s spine was hearing his own name on the radio—Flanzamaton had implicated “an American named Richard Smith” in the plot.

Suddenly, Smith found himself the target of a nationwide manhunt. In a panic, he contacted the American embassy, which swiftly moved to arrange his safe departure from Liberia. Embassy officials rerouted his planned travel to Abidjan, Ivory Coast, securing a flight to London instead. However, before he could leave, word came that the Prime Minister wanted to see him.

Fearing for his safety, Smith gathered some American colleagues and headed to the Minister of Health’s office for support, as the Minister was a trusted ally. From there, the Minister personally escorted him to the military headquarters, where they found Flanzamaton in custody. As soon as Smith’s colleague, Rosemary DeSanna, recognized the man, she fainted and collapsed against the wall.

Smith was then led into a room filled with armed soldiers. In the center sat Flanzamaton, surrounded by guards, while the Commander in Chief of the Liberian army observed from behind a desk. Silence fell over the room as the commander asked Flanzamaton, “Is this the man who planned with you and paid you to kill our president?”

Time seemed to freeze. Flanzamaton, appearing drugged and disoriented, slowly scanned the room. The tension was unbearable as soldiers gripped their weapons, awaiting his response. After what felt like an eternity, Flanzamaton shook his head. No, Smith was not involved.

Though relieved, Smith’s danger was not over. He was rushed to the airport in a heavily armed vehicle, passing through numerous military checkpoints. The embassy had acted swiftly, but the process of changing his flight was agonizingly slow. The security checks dragged on, and Smith remained on edge, fearing something might still go wrong. Even as he boarded the plane, the nightmare wasn’t entirely over.

As Smith settled into his seat, a soldier boarded the plane, scanning the passengers. Smith held his breath. The soldier called out a name—thankfully not his—and after a tense moment, exited the plane. Smith had changed his flight to London just in time, narrowly avoiding potential danger.

When Smith finally landed in London, the story had already made international headlines. His first act was to call his wife, Lorna.

For Lorna Smith, this incident had been a nightmare. She vividly recalled the moments leading up to that call:

“So, the Liberia story is the one really terrifying nightmare for me. When Richard traveled, the protocol between the two of us was, ‘No news is good news.’ He would phone when he could—not very often—but if everything was fine, we trusted it was fine. But the other part of that protocol was that if there was a problem, I expected a phone call.”

Years earlier, Lorna had learned the importance of this system when another “Richard Smith” had died in a plane crash. After fielding panicked calls from people all over the world, she realized that even events unrelated to her husband could cause confusion and worry. From that point on, they agreed: if something happened, even if it didn’t directly involve him, Richard had to call.

In 1985, with a 5-year-old and a 3-year-old at home, Lorna learned about the attempted assassination of the Liberian president and knew that Richard was in Liberia. “I didn’t get a phone call,” she said. “And I knew absolutely that something terrible had happened.”

Still, Lorna couldn’t be sure of Richard’s fate, and she feared trying to contact him might make things worse. “I just had to wait. It felt like days and days, and I didn’t even know if Richard was alive or dead,” she said, describing those days as “truly terrifying.”

Finally, in the middle of the night, Lorna received a collect phone call from London. She accepted the call immediately, hearing Richard’s voice on the other end. “Lorna, I’m fine. Nothing hurt me,” he reassured her.

Lorna, still shaken, responded, “Richard, please tell me what didn’t hurt you.” That’s when Richard explained what had happened in Liberia.

Days later, Smith’s colleague Sunil Mehra, who had also been in Liberia at the time, met him at Waterloo Station in London. “I walked up behind him,” Sunil recalled, “and said, ‘Are you Dick Smith?’ He nearly jumped out of his skin, thinking he’d been followed to London.”

The ordeal left a lasting impact on Smith. He spent about three weeks in London, unable to focus on much else as he processed the traumatic events. “It was the worst thing that’s ever happened to me, thanks to MEDEX,” he later reflected.

The Power of Collaboration and Collective Leadership

An important component in people collecting is to identify and unite individuals who were already making significant contributions in their fields. As we’ve seen, each member of the MEDEX Group brought a wealth of experience with them. But Smith’s approach wasn’t about guiding protégés as they brought their smarts and experience to bear, but rather in creating a powerhouse of collaboration among equals—professionals who could bring their unique expertise to the table and collectively advance the mission of MEDEX.

This collective approach to leadership was in fact a hallmark of Smith’s strategy. He understood that real progress in global health required the combined efforts of many skilled individuals, each contributing their strengths to a shared goal. The success of MEDEX was a direct result of this collaborative ethos. This was certainly the case in their shared work Micronesia with Ngas Kansou, the Truk Health Minister, or with Tom Thabane, Minister of Health in in Lesotho, or with Dr. Frank Williams, Chief Physician at the Georgetown Public Hospital in Guyana. 

The following excerpt from the obituary of Dr. Frank Williams (1916-2015) makes clear what led Richard Smith to seek him out to help lead their work in Guyana. 

“Dr Williams’ passion about medicine was undeniable. He held many powerful positions in the local medical establishment and was a pioneer in treating certain illnesses in Guyana. He was the first head of the Medex Programme, of which he was enormously proud since he believed that the work of ‘barefoot doctors’ deserved the highest respect. He was also the Chief Physician at the Georgetown Public Hospital. Dr Williams was one of the first (if not the first) physicians in Guyana to regard stress as a health factor. He stressed the value of breastfeeding and inspired a ‘Back to the Breast’ campaign, a critically important factor in infant health and mortality. He also stressed the need to prioritise control measures to eliminate and prevent malaria. Dr Willliams was also the personal physician to and friend of former president of Guyana, Forbes Burnham.”³⁹

A Family of Staff: The Heart of MEDEX

The work of the MEDEX Group was further characterized by a unique sense of camaraderie and commitment among its staff. Dr. Smith often reflected on the “aura” that surrounded the MEDEX teams, noting the deep commitment not just to the idea but to effecting change and helping people solve life’s larger problems.

For Rodney Powell this commitment aligned with the concept of “Ohana”—a Hawaiian term for family—that sustained the MEDEX staff and their families. Ohana, a Hawaiian term meaning family, goes beyond blood relations. It speaks to the idea of a supportive community where everyone cares for one another. In the MEDEX program, this concept was embodied not only by the staff but also by their families, who stepped in to support one another during long absences. It was a true reflection of the Ohana spirit, where everyone’s well-being was interwoven, and no one was left to carry the burden alone.

“You know, that’s a critical aspect of what happened here,” Rodney reflects. “First of all, it wasn’t just the people who were employed by MEDEX but their families were involved because a great deal of our activities were overseas. Here in Hawaii we’re the most isolated, populated land mass anywhere in the world. And, you know, it takes five-six hours just to get somewhere to start your journey from that point. And so, our staffs frequently were away from their families for not just weeks but months at a time. Our being able to forge this Ohana concept is what sustained everyone and led us to look out for each other. It was a very important aspect.”

In a roundtable discussion held with the MEDEX Group in 2017, Barbara Coles, wife of Tom Coles, playfully described how the MEDEX community became her family. She played a significant role in helping new staff members and their families acclimate to life in Hawaii, ensuring they felt supported and welcomed in a culture of care and mutual support.

Barbara Coles: I’m Barbara Coles and I married MEDEX. [laughter]

Mona Bomgaars: Very good.

Rodney Powell: Sorry. [laughter]

Barbara: And Tom Coles was in the first MEDEX class and then started with MEDEX International February of ’73. And that’s all I have to say.

Rodney: No, I think you should also say that not only did you marry MEDEX, but you supported MEDEX with every fiber of your being and allowing Tom to be so devoted to taking this concept forward.

Barbara: Without me, it wouldn’t have been successful. [laughter]

Lorna Smith: Congratulations. [laughter]

Mona: I agree, I agree, good.

Barbara: It was a family. And when you move to Hawaii, you form … I mean, everybody comes up with their calabash family. And to our son, Dick was Uncle Dick.

Lorna: And when new people came onboard, Barbara helped them get settled in Hawaii. You did a lot of that for people.

Barbara: In the very beginning of MEDEX, the people that came in early ’70s, they’d stayed our house. I don’t even remember their names but they’d come and spend a week or two doing something at MEDEX.

The Spirit of Collaboration and Inclusion

In a 2001 interview, Dr. Smith remembered a staff member who suggested that the MEDEX team interacted in a way reminiscent of the scientists and engineers who worked on the Manhattan Project, whose collaborative spirit has been noted by historians. “Someone in the collaboration always knew there was something that had to be done and went and did it, without having to seek the permission of the overseer,” Smith recalled, highlighting the initiative and autonomy that characterized the MEDEX teams

Dr. Smith’s approach to leadership was rooted in his belief in the power of connection and inclusion. As we saw at work in places like Guyana and Lesotho, and even in his early work of establishing the MEDEX Northwest PA Program, Smith engaged the most influential physicians and healthcare professionals in each country not by imposing new ideas, but by aligning with their existing goals and showing how MEDEX could strengthen their efforts. This method of “togetherness” created a sense of ownership and involvement among local leaders, making them eager to be part of the MEDEX initiative.

Sustaining Dr. Smith’s Legacy

As we consider Richard Smith’s legacy, it becomes clear that his most enduring contribution is found in the people he inspired and empowered. The individuals who worked with him, learned from him, and were shaped by his vision are now the ones who sustain and expand his legacy. They have taken his principles and applied them in new ways, in new places, ensuring that his influence continues to grow even in his absence.

MEDEX graduates, his international colleagues, and countless others who crossed paths with Smith are now the custodians of his work. They continue to innovate, to adapt, and to push forward the boundaries of healthcare, all while carrying with them the lessons and the spirit of the man who believed so deeply in their potential. This is the true power of Richard Smith as a people collector: his ability to create a living legacy, sustained by the people who continue to build on the foundations he laid.

South Africa: A Career Bookend

A significant bookend to Richard Smith’s career came in 1993-1994 when he was invited by Nelson Mandela to help write the health-related portions of South Africa’s constitution after the end of apartheid. Smith helped draft the document, “A National Health Plan for South Africa,” published on May 30, 1994. His work in South Africa came at a time when the country was dismantling the entrenched systems of apartheid. It was reminiscent of his earlier work in the United States, where he fought to desegregate hospitals, ensuring equal access to healthcare, regardless of race. In both cases, Smith worked to dismantle the obstacles that prevented marginalized communities from accessing the healthcare they needed.

These two defining moments—on different continents and decades apart—showcase Smith’s unwavering belief that healthcare should not only heal the body but also serve as a force for social justice.

The Global Reach of MEDEX

Under Richard Smith’s guidance, the MEDEX program didn’t just thrive in a single location or two—it spread across the globe. The Primary Health Care Series, a cornerstone of MEDEX, was translated into 33 languages and sent to over 120 countries, demonstrating the global impact of Smith’s vision. The MEDEX movement remains strong in countries like Guyana, where the program is still recognized in newspaper articles, hailing Dr. Smith as the father of MEDEX.

The MEDEX model has also spread to countries such as Australia, the Netherlands, and the UK, where relatively new programs have been inspired by the original framework. This expansion is evidence of the model’s enduring relevance and adaptability. Indeed, while selective healthcare—focusing on specific diseases like malaria, tuberculosis, and HIV/AIDS—dominated the global health landscape for decades, primary healthcare is making a comeback. The comprehensive and systemic approach that MEDEX embodies is gaining favor again, putting the feasibility of achieving the 1978 Alma-Ata Declaration’s goal of “Health for All” back into view.

Conclusion

After retiring from his work with MEDEX Group in 1992, Smith remained on the island of Oahu with his wife, Lorna Carrier Smith, his partner since the earliest days of MEDEX Northwest in Seattle. Just three months before his passing in 2017, Richard Smith met President Obama—an encounter that once again underscored the vast scope of Dr. Smith’s influence, from desegregating America’s hospitals to transforming healthcare systems across the globe.

When asked what he was most proud of when looking back over the years, Dr. Smith took a moment to reflect. The heart of his life’s work, he reflected, was rooted in a deep understanding of what it meant to serve others, beyond the accolades and recognition. “Making a decision to commit my life to the benefit of others follows an understanding and an appreciation that my biological imperative is to procreate and replace myself and to prepare and nourish the environment that my offspring will inherit,” he said. It was a philosophy that guided his every step, both personally and professionally. While he could have pursued wealth or personal gain, that was never his priority. “I’ve never had an aspiration to make a lot of money although I’ve had the life of an extremely wealthy person,” he added. The richness of his life, he believed, came not from material success but from the connections he fostered and the impact he made on communities worldwide.

When pushed to reflect a bit further on his legacy, Dr. Smith listed the achievements that held the most meaning for him, ranking them in reverse order as though to emphasize their true significance. At the top of his list was “the desegregation of community hospitals,” a mission that had defined much of his early work and carried deep moral and societal importance. Second on his list was “MEDEX, domestically and internationally,” a testament to the reach and influence of the program he pioneered, which revolutionized healthcare in both the U.S. and abroad.

As he thought about these milestones, Dr. Smith concluded with a sentiment that encapsulated his lifelong dedication: “I have this commitment to making things better not just for my children, but for everyone! I took every opportunity and I got it back in terms of satisfaction.” For Dr. Smith, success wasn’t about personal accolades—it was about leaving the world better than he found it, and knowing that the work he began would continue through the hands and hearts of those he inspired.

As we look to the future, it is clear that Richard Smith’s greatest accomplishment is found not only in what he achieved during his lifetime, but in how he empowered others to carry his vision forward. His legacy is a living one, sustained by the people who continue to build on the foundations he laid, proving that the most enduring impact is one that is shared and multiplied through the connections we make.

References

1. 1930 US Census[↩]
2. Connecticut Death Records http://ctstatelibrary.org/death-records/[↩]
3. https://www.youtube.com/watch?v=4mkBYdMUxNc[↩]
4. Grossberger, Lewis (1978-03-16). “Ellery Queen”. Washington Post. [↩]
5. Oral Interview – Ballweg, Cawley, Hooker, 2006. Page 2 “Dick 7/21/06”[↩]
6. Historic American Buildings Survey, Creator, et al., photographer by Mahon, Dynecourt. Howard University, Founders Library,Sixth Street Northwest, Washington, District of Columbia, DC. trans by Hoagland, Alison K.Mitter Documentation Compiled After. Photograph. Retrieved from the Library of Congress, <www.loc.gov/item/dc0149/>.[↩]
7. The National Black Caucus of Health Workers of the American Public Health Association presents the Hildrus Augustus Poindexter Award Dinner Living History: Honoring our Past, Uplifting our Future. Nov 5, 2019. https://sakai.unc.edu/access/content/user/vschoenb/Public%20Library/Organizations/PHprofSoc/BCHW/BCHW2019-PoindexterProgram.pdf[↩]
8. Oral History, Ballweg, Cawley, Hooker 2006. Page 4. [↩]
9. John Burgess elected Bishop of Massachusetts; first black to become bishop of a predominantly white diocese (November 8, 1962) Episcopal Church History From 1940-1980: A Brief Chronology Author(s): David E. Sumner Source: Historical Magazine of the Protestant Episcopal Church, Vol. 54, No. 1 (March 1985), pp. 83-89 Published by: Historical Society of the Episcopal Church Stable URL: https://www.jstor.org/stable/42974060 [↩]
10. Journal of the National Medical Association. 1965 Jul; volume 57(number 4): pp 325–326. [↩]
11. University of Washington Department of Family Medicine 2008 Grand Rounds[↩][↩]
12. 2012 Oral History – Dr. Smith with Dennis Raymond, Eric Larson & Ruth Ballweg in Honolulu. [↩]
13. MEDEX Northwest Oral Interview with James Van in 2017[↩]
14. “Ex-Green Beret ‘doctors’ Trust Isles” Newspapers.com, Honolulu Star-Bulletin, May 11, 1975[↩]
15. OIH Project Proposal – RSSA HEW/OIH 13/74 – April 1974.[↩]
16. From a chapter on Rodney Powell in the book “Crisis: 40 Stories Revealing the Personal, Social, and Religious Pain and Trauma of Growing Up Gay in America”[↩]
17. APHA proposal to USAID – Proposal for development and evaluation of an Integrated health delivery system In Thailand (DEIDS) – 1973. PNAAB538.pdf[↩]
18. APHA proposal to USAID – Proposal for development and evaluation of an Integrated health delivery system In Thailand (DEIDS) – 1973. PNAAB538.pdf[↩]
19. THE LAMPANG HEALTH DEVELOPMENT PROJECT-PNAAL152.pdf[↩]
20. OIH Project Proposal – RSSA HEW/OIH 13/74 – April 1974 [↩]
21. DEVELOPMENT OF AN INTEGRATED RURAL HEALTH SERVICES AND PRIMARY HEALTH CARE SYSTEM IN LAMPANG, THAILAND. Published by the MINISTRY OF PUBLIC HEALTH THAILAND 1981 [↩]
22. THE LAMPANG HEALTH DEVELOPMENT PROJECT – THAILAND’S FRESH APPROACH TO RURAL PRIMARY HEALTH CARE – Prepared for ICED by Lampang Project Personnel, 1979 – p. 50[↩]
23. Richard Smith Interview – July 2006. Cawley, Ballweg, Hooker. [↩]
24. Reprinted from the USAID Development Communication Report – Autumn 1985 *permission not required to reprint as per the source*[↩]
25. Lorna Smith Interview – March 17, 2012 – pg 13[↩]
26. Oral History Project III – Dick Smith – 23 July 2006 – The Post Medex Years[↩]
27. A REVIEW OF THE HEALTH SECTOR OF LESOTHO – published by American Public Health Association – Authorized under Contract AID/csd 3423[↩]
28. Oral Interview with Lorna Smith, March 17, 2012.[↩][↩][↩][↩]
29. The Miami News – Miami, Florida – Sat, Aug 23, 1980[↩]
30. Oral Interview with Richard Smith – by Hooker, Cawley, Balweg, July 2006.[↩][↩][↩]
31. Oral Interview with Richard Smith – by Hooker, Cawley, Ballweg, July 2006.[↩]
32. Causation of Disease Module – Student Text – Rural Health Development Project – Maseru, Lesotho[↩]
33. Maintaining Safe Water Supply – Student Text – Rural Health Development Project – Maseru, Lesotho[↩]
34. Gastro-Intestinal Problems Module – Student Text – Rural Health Development Project – Maseru, Lesotho[↩]
35. Oral Interview with Richard Smith – April 16, 2012[↩][↩][↩][↩]
36. (source: “The MEDEX Primary Health Care Series – An Overview”)[↩]
37. “The MEDEX Primary Health Care Series – An Overview”[↩]
38. USAID Development Communication Report No. 51, Autumn 1985, “A Guide for Primary Health Care: The MEDEX Series”, by Richard A. Smith, John Rich, and Sunil Mehra[↩]
39. (source: https://www.stabroeknews.com/2015/09/26/sunday/obituary-dr-frank-middleton-warner/)[↩]