Remembrance for Dr. Richard Smith by Ruth Ballweg and Margaret Chambers

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Physician Assistant Founder, Global Health Innovator, Peace Corps Medical Director and Civil Rights Leader

Global health leader and widely recognized founder of the physician assistant (PA) profession, Richard A. Smith, M.D., M.P.H., died March 10, at his home in Honolulu, Hawaii. He was 84.
In 1968 Dr. Smith created one of the nation’s first PA programs at the University of Washington (UW) to extend the medical care of physicians by training a new kind of clinician who could partner with a primary care doctor in medical practice.  He used the term MEDEX (MEDical EXtension) to denote his systemic approach used to educate and place graduates in medically underserved communities.  Graduates were called Medex and used the abbreviation Mx after their names.

After launching the first MEDEX program at UW, Dr. Smith helped replicate the MEDEX model at seven other universities throughout the United States to validate the program strategies and to broaden support among political and medical leaders. Dr. Smith spent another 20 years adapting the MEDEX concepts and strategies for developing nations.
An officer in the US Public Health Service (PHS) for 25 years, Dr. Smith is remembered for his groundbreaking roles as the second PHS medical officer to go abroad (Nigeria) with Peace Corps (PC) in 1961.  He later served as Deputy Medical Director of Peace Corps worldwide.

As Director of Field Operations for the Office of Equal Health Opportunity (OEHO) in 1966 under Surgeon General William Stewart, Dr. Smith helped to ensure desegregation of 7000 American hospitals after the passage of the Civil Rights Act of 1964 and Medicare. President Lyndon Johnson asked Dr. Smith to desegregate the hospital in Lady Byrd Johnson’s hometown of Marshall, Texas first, and to do it personally. OEHO’s desegregation campaign was described as “perhaps the most peaceful and successful civil rights effort in American history,” by American Legacy magazine in 2000.
As the first Director of International Health Manpower Planning in the Office of the Surgeon General (1965-68), Dr. Smith became the first African American and the youngest person appointed to official U.S. delegations for the World Health Assembly in Geneva in 1967, 1968 and 1970. Over the next two decades he continued to serve on two human resource committees of World Health Organization (WHO).

In 1968 Dr. Smith created the first MEDEX PA program at the University of Washington in Seattle to “extend the healing hands of overburdened physicians” in underserved rural communities of Eastern Washington. More than a training program for physician assistants, MEDEX was his global vision for introducing, developing and deploying new mid-level medical professionals who could handle much of the basic and routine care which physicians provide.
Richard Smith’s lifelong commitment to his vision was inspired at a church work-camp in the mountains of pre-Castro Cuba when he was seventeen. In a rural clinic he assisted a “practical nurse” who was a daily lifeline for families between the few hours each week when an overworked doctor visited. Dr. Smith switched his college major from music to medicine, determined not only to become a doctor but also to “multiply my healing hands” by training others to extend care.
Dr. Smith earned his BS and MD from Howard University in 1953 and 1957 and his MPH from Columbia University in New York City in 1960. As a medical student, he first researched tropical disease at the National Institutes of Health. This led to him becoming the first medical student to be commissioned in the U.S. Public Health Service as an ensign in 1956. During his public health residencies and at Columbia he continued work in epidemiology and tropical diseases.

He put this knowledge to use immediately in the Peace Corps where he developed policies and protocols to keep volunteers healthy and safe. While overseas he validated the need, the possibility and the appropriateness of training non-physician providers to meet health care needs in underserved areas.
Dr. Smith together, with Dr. Eugene Stead, Jr., at Duke University and Dr. Henry K. Silver at the University of Colorado, are recognized as co-founders of America’s physician assistants (PA) profession by the Physician Assistants History Society (PAHx).

However, Dr. Smith’s approach was to develop more than a training program. With a strong collaborative ethic and a desire to make sustainable change, Dr. Smith engaged UW School of Medicine, the Washington State Medical Association, overburdened primary care doctors and the communities they served in planning, development, recruitment, training and evaluation. He shepherded one of the first state laws to permit graduates to practice medicine under the supervision of licensed physicians He worked with the American Medical Association interpreting and evangelizing the concept of doctors teaming with certified mid-level clinicians.
Today the profession of physician assistants is one of America’s fastest growing. Currently over 100,000 PAs are working in the USA and the demand is accelerating worldwide.

He was inducted into the National Institutes of Medicine in 1972, now the National Academy of Medicine.
In 1973, Dr. Smith established The MEDEX Group in the John A. Burns School of Medicine at the University of Hawaii. Smith and his staff assisted eight countries on four continents to strengthen their national health programs through the training and management support of “new” non-physician healthcare providers.

Dr. Smith participated in the milestone WHO/UNESCO conference in Alma Ata, Soviet Kazakhstan in 1978. Smith’s book entitled Manpower and Primary Health Care: Guidelines for Improving/Expanding Health Service Coverage in Developing Countries was distributed to all ministries of health in attendance. The Alma Ata Declaration set a global aspirational goal for 2000–“Health for All” –with an increase in primary health care–then a new concept–as the key to attaining this goal.

With his global health team Dr. Smith produced a 35 volume, 7000 page MEDEX Primary Health Care Series in collaboration with governments of Micronesia, Guyana, Lesotho, Kenya, Costa Rico, Botswana, Liberia, and Pakistan.  The MEDEX Series provided a systemic framework for expanding medical care in underserved and low resourced countries. This 1978 comprehensive guide includes collaborative planning, management, competency-based training and deployment of new clinicians in primary health care. It has been translated in whole or part into 33 languages and used in over 88 countries. At its 1979 meeting in Vienna, Austria, the UN Conference on Science and Technology for Development (UNCSTD) cited The MEDEX Primary Health Care Series as “one of the most promising technologies available for improving the delivery of basic health services.”
In resource challenged areas of the world in the ‘70s and ‘80s the MEDEX model grew into a tested and adaptable technology which could provide networks and support systems in addition to culturally appropriate training. During the following decade Jorge Pena Mohr in The Journal of Health Administration Education called the MEDEX technology the “state of the art” in primary health care training for mid-level health providers and village level health workers. With too few physicians, widely scattered populations in formidable terrain, islands, or areas of intense need, mid-level providers often are the only personnel who can provide health care.

Nelson Mandala and the African National Congress brought Dr. Smith to South Africa in 1994 to assist in designing structure and policy for more equitable health care.

Dr. David Lawrence, former CEO and Chairman of Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals, was chosen in 1973 by Dr. Smith to become the second director of the young MEDEX program when Smith left Seattle. He recalls, “Dick was a critically important mentor to many and especially to me. As a leader in the Global Health movement of the Public Health Service, he paved the way for many of us who followed in his footsteps.

“The MEDEX approach had a remarkable impact on the healthcare delivery systems of the world. He taught me many things:  honoring one’s roots; how to open one’s heart to magic and sadness around the globe; how to balance engagement with challenging ideas while remaining committed to core values and beliefs; even where to find the best chocolate mousse anywhere in the world.” Hunting for chocolate mousse wherever he traveled was Dr. Smith’s hobby which he joyfully shared with friends and strangers.
Richard Alfred Smith was born in Norwalk, Connecticut, on October 13, 1932. He is survived by his first wife of 18 years, Parbattee Spangler-Gangadhar, a Florida resident, and their sons Dirk Smith, Rik Smith and Erik Smith, all residents of the San Francisco Bay Area; and his second wife of 40 years Lorna Carrier Smith and their sons Blake Smith and Quintin Smith living in Honolulu, Hawaii. He has 9 grandchildren: Devin Smith, Brandon Smith, Sumariya Smith, Indar Smith, Ahsha Smith, Eril Smith, Ellie Smith, Evann Smith, and Sienna Smith.

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Photographs: First image, Dr. Richard Smith in front of his display at the Stead Center, NC, 2006. Second image, Dr. Reginald Carter (left), Historian Emeritus and founder of the PA History Society, and Dr. Richard Smith, 2006.

Dr. Richard Smith’s biography can be read here.

MEDEX Norhtwest’s obituary of Dr. Smith can be read here.

 

 

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