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Dean Vernon Wilson of the University of Missouri School of Medicine learned of the imminent adoption of the Heart Disease, Cancer and Stroke amendments at a meeting of the Association of American Medical Schools Executive Council on February 6, 1965. Dr. William Stewart, HEW staff man for the legislation initiative and soon to be the Surgeon General of the Public Health Service, had come to tell the medical school deans about the legislation. He asked them to testify in favor of it when Senator Hill held hearings -- the very next week.

Vern Wilson had one concern. Since arriving in Columbia from Kansas to become Dean a few years before, he had been making a strenuous effort to build links between the School of Medicine and the practicing physicians of the state. He did so by getting in his single-engine plane and flying off "to meet with every county medical society that would have him."[1] This in itself impressed the doctors of Missouri. One recollection is of a group of doctors, after one meeting, driving Dr. Wilson to Dr. Billy Jack Bass' private airstrip in Salem and turning their cars at right angles towards a make-shift runway so as to illuminate his departure with their headlights.

Dr. Wilson formed an advisory council made up of the medical society presidents. His efforts seemed to be working. He and his staff colleagues were building a statewide network to deal with Missouri's health problems. So he wanted to be sure the new program he heard Bill Stewart describing in Washington didn't mean that he would have to start over, following a detailed and elaborate new set of federal rules and procedures as to how to build a regional medical program. Not at all, Dr. Stewart responded. The idea was to embrace and build on existing cooperative networks whenever possible.[2]

Thus reassured and accepting the word of Bill Stewart that the bill would quickly become law, Dean Wilson returned to Columbia, gathered his colleagues together, and began planning with renewed vigor.

Those on whom Dr. Wilson had already been relying and who now joined the newly focused enterprise recall their early conversations with Dr. Wilson as having occurred before anyone else in the State -- doctors, congressmen, newspaper reporters, lobbyists -- evidenced any awareness of yet another Great Society Health proposal shaping up. Perhaps this is not so surprising, given that only one month had elapsed between the time of the DeBakey Commission report to the President and the submission of legislation to implement it. Further, the attention-grabbing controversy initiated by the American Medical Association had not yet erupted.

Dr. Wilson had only been in Missouri a few years, but he seemed to know the state like the palm of his hand. Forming a team to do a job seemed to have been second nature to him. And though he later denied any awareness of political considerations, he was by all accounts a master strategist and a powerful persuader. One has the image of him as an imaginative but selective, modest but compelling pied piper, playing his tune to one listener, or one small audience, at a time. It was a very different style from LBJ's, but it had the same effect: Almost all who heard his plea succumbed.[3]

Within a few weeks, Wilson had gotten journalists, engineers, computer experts, public relations professionals, nurses and public officials to join medical doctors and osteopathic physicians (the latter combination being in itself an almost miraculous union) to think positive about what a Missouri Regional Medical Program could do for the state, its people and its institutions of higher learning.

One of Dr. Wilson`s first recruits was Bill Allen (Dr. William C.) who until 1965 served with the State Health Department while also a member of the clinical faculty at the University of Missouri Medical School. In that job he had come to be acquainted with many physicians throughout the state as well as all of the hospital and nursing home administrators and those who ran and sat on the boards of the professional health associations such as the Cancer Society and the Heart Association. By the time President Johnson's signature was dry on P.L. 89-239, Dr. Allen was installed in the Dean's office, collecting every piece of information he could about the DeBakey Commission, the legislative history, and the views of affected professionals concerning the Heart, Cancer and Stroke Act of 1965.

Fortunately, he says, the advisory committee to the Dean of the School of Medicine not only had on it the county medical society presidents but all living ex-presidents of the Missouri Medical Association. And it was soon to have other key figures in the medical community, including Mrs. Harry Truman's personal physician. When the law passed, Dr. Allen recalled: "We called the group together and told them about the Heart, Cancer and Stroke legislation and that it appeared it would soon be funded. We asked them to decide whether we should be involved and how we should go about it. So the Medical Advisory Committee said they indeed wanted to give it a try."[4]

Dean Wilson found another advantage. The University acquired a couple of DC-3s. He dispatched teams to Chicago, the Mayo Clinic and other points East to look at some reputedly interesting innovations in patient care delivery being undertaken at several hospitals. He and Dr. Allen took another trip to St. Louis to visit the medical school deans at Washington and St. Louis universities. Missouri ought to have a statewide program, they thought, and they knew that the participation of the other medical schools was essential. Washington U.'s Dean Kenton King and St. Louis' Bob Felix -- earlier the first director of the National Institute of Mental Health -- both responded positively. But both said they would "have to run this by" their faculties.

"Running by" turned out to involve "flying back," with the Columbia initiators returning to St. Louis to talk directly with the medical faculty department heads. Dr. Allen suggests that there was no special resistance to the concept or the substance of the program, but there was one question and answer that thwarted their hopes. The chairmen asked: "Are you going to be involved with the various medical societies?" Dr. Wilson answered: "We will not go one foot without the full cooperation of the medical societies." The chairmen said: "Then we want no part of your program."[5] St. Louis would organize its own regional medical program, serving its traditional constituency in the metropolitan area, including Illinois counties across the Mississippi. Still, there developed regular communication and frequent cooperation between the two programs.

Kansas City would also be a bit difficult. The city straddled a state line and, in Kansas, a regional medical program was also getting underway under the leadership of Dr. Charles Lewis, at the University of Kansas Medical Center. And under the University of Missouri system, on the Missouri side of the line, plans had been laid to build a new and different kind of medical school, a two-year program extending from the basic university curriculum and integrated with it. This concept was novel, and those leading its development had an array of obstacles to overcome, as everybody in the Kansas city area and throughout the state knew. Whether they would lend their weight to a new state-wide program centered in the medical school in Columbia was a serious question. But Dr. Wilson and his colleagues were persuasive. They gave assurances that they would work cooperatively with Kansas RMP, and that the Missouri RMP would give special attention to the needs of the new medical education and training enterprise in Kansas City.

Simultaneously with the visits to his fellow medical school deans, Dr. Wilson and his colleagues talked with medical society chairmen, in group as the advisory council to the dean and, in many cases, individually as well. All agreed on the value of a state-wide approach. In fact, the dean`s advisory council made up as powerful a state-wide network as could be assembled. Consulting with the council meant reaching into every medical community and region in the state.

With wide support thus garnered, the Missouri Regional Medical Program could go forward. The center of planning and strategy was Columbia, but from the very first, ideas for it, including proposals for medical delivery innovations, came from all over the state. There would be programs in every part of the state: Springfield, Kirksville, the Ozark Region, the Bootheel Region, Hannibal, Cape Girardeau, Skaggs, Lakes County, Dunklin County, the Green Hills area in the North Central part of the state, Cedar County, Callaway.

In addition to the medical societies and medical leaders of the various geographical regions, the Columbia team also enlisted from the very beginning the leadership of the health associations, including the Missouri Hospital Association, the Statewide Heart Association, the Cancer Society, and the Kidney Foundation. Dr. George Wakerlin, the first director of the Missouri program, reported that beyond the Advisory Council, the program had established a Scientific Review Committee (which included among others all the medical school deans and representative of the state health agencies) and a Liaison Committee which was composed of representatives of 20 state organizations in the health field including professional societies.[6]

These organizations were enlisted not only for their ideas and political strength throughout the state, but in order that, from an early point, they might run programs in their medical and organizational areas of expertise. Over the eight active grant-making years of the Missouri Regional Medical Program, the Missouri Heart Association, the Kidney Foundation, the Missouri State Medical Association, the Missouri Nursing Home Association, as well as an assortment of general and specialized colleges and schools, organized and ran programs under the aegis of, and with funding through, the Missouri RMP.

The organization of headquarters was equally interesting, perhaps more so. Naturally, Dr. Wilson asked his medical colleagues to join in the effort and enlisted associates in the Schools of Nursing and of Allied Health. But he reached beyond the traditional collaborators and sought out those with professional expertise in what were, at that moment in history, fields utterly unrelated to the improvement of health care and the development of medical programs for people. Among early recruits for the team was Bill Kimel, Dean of the College of Engineering; and department chairs in engineering including Cyrus Harbourt from Electrical and Computer Engineering, Jay Goldman from Industrial Engineering, and Gayle Adams, Director of the Engineering Computer Center.

Dean Kimel remembers Dr. Wilson especially encouraging him and Dean William Moyer of the School of Medicine, both appointed as deans in 1968, to work together and to get their respective faculties to do so. The cooperation was remarkable and productive, and engendered particular teamwork efforts -- such as that between Dr. Donald Lindberg and Dr. Samuel J. Dwyer, Director of Bioengineering, in developing computer applications to medical science.

The University of Missouri is nationally famous for its school of journalism; so its dean, Dr. Will Stevenson, and key faculty were asked to join in shaping the new program. Vernon Wilson knew that systematic communication with various professional and political power centers and with the public was essential. Not forgetting the simpler traditions of communication, Dr. Wilson recruited a public information officer Fred Frazier, whose career had been in public relations.

There was obviously extraordinary talent within the University and within the state, but Dr. Wilson had a long reach as well as a good eye for talent. In addition to Dr. Wakerlin and others with particular specialties, Dr. Wilson also recruited Dr. Arthur E. Rikli, who had worked in regional medical networks for some years as the regional consultant in chronic disease for the Public Health Service and subsequently as chief of the National Heart Disease control program, based in the Washington headquarters of the PHS. Dr. Rikli had also worked on the computerization of electrocardiograms. He had had experience with the Hill-Burton program and truly knew the country as whole. When Dr. George Wakerlin became Director, Dr. Rikli become Coordinator.

Twenty-five years after the close of the RMP, all the Missourians give Buck Rikli great credit for helping insure that what Dr. Wilson, Dr. Allen, Dr. Lindberg and the other remarkable initial team had started continued to run smoothly and consistently and successfully for the next decade. Dr. Rikli continued to carry on regional activities begun under the Missouri RMP, in 1975 becoming coordinator of the Missouri Kidney Program and otherwise remaining involved in health care in the state.

The enterprise authorized by The Heart Disease, Cancer and Stroke Act of 1965 officially only took a few months to organize. The national plan was officially in place -- despite lots of scurrying and almost continual modifications -- by 1966. One of the first regional programs to receive a planning grant was Missouri, on July 1 of that year. By April 1967, the Missouri Regional Program began making grants, putting it ahead of most other regional medical programs in the country by a year.[7]

As has been illustrated, a few others also got off to a strong and rapid start. But the great majority of RMPs did not get organized nearly as early, and even if they did, were not in a position to make grants and start programs until the middle of 1968. Whether its quick start helped Missouri become one of the best recognized Regional Medical Programs in the country is not absolutely certain, but compared to the histories of other programs, the swift, comprehensive and meticulous consultation and planning that took place were extraordinary.

When he had consolidated the support of the professional constituencies and a state-wide community base, Dr. Wilson went to the Governor, then Warren Hearns, and asked him to appoint members the Regional Advisory Group (RAG) to the Missouri Regional Medical Program. The governor agreed, and selected as chairman Nathan Stark. The governor further agreed to appoint one of three names proposed for each spot on the RAG by Dr. Wilson and his colleagues. The Missouri program was deemed to be so promising that another exceptional phenomenon subsequently occurred: The state legislator who represented Northeast Columbia, Representative Harold Volkmer, went to work to get himself appointed to the Advisory Committee, apparently wanting to be a part of a winning as well as a pioneering enterprise.[8] Later Mr. Volkmer was elected to Congress, representing the 9th District of Missouri.

One of the original impulses behind RMP was probably related to Lyndon Johnson`s heart attack. The President's excellent and swift recovery, he properly recognized, was due to excellent and immediate medical attention and treatment. In those years, thirty-five years ago, heart attacks were frequently accompanied by death. This was because medical attention was not always swift, particularly outside urban areas where transportation to hospitals was not fast, and because treatment modes were not advanced. The President whose best policies grew out of his own personal experiences -- whether in education, the treatment of minorities, or health care -- did not want any American suffering a heart attack to die simply because the person could not reach the hospital, or doctors could not reach the person, quickly enough.

However the programmatic emphases of RMP might expand and shift over the next few years, the Missouri RMP leaders obviously recognized the central purpose. From the beginning, Missouri RMP spent funds trying to help the President achieve one of his first objectives. Early on, joined by the State Health department, Missouri RMP surveyed the approximately 186 hospitals in the state to determine how many of them had intensive care units or at least an intensive care capability. Out of that number, only 15 had such units or capability in 1966. An obvious question was why, when intensive care units had already shown in other places how effective they could be in restoring desperately ill patients to normalcy, Missouri hospitals had not proceeded to create them. The typical reply was two-fold: not enough money and no trained personnel.

One of the early Missouri RMP programs was to set up an intensive care unit to serve as a model for the rest of the state. It included a training program at the University hospital in Columbia, to which all the other hospitals were invited to select and send appropriate personnel from their staffs, and to pay for that training. Dr. Bill Allen recalls: "They spent two weeks at the model program here in Columbia and then would go back and spend a month at their own hospitals, do correspondence courses in that period of time, work to develop intensive care units in their hospitals, and then come back to Columbia for a final two weeks of advanced training."[9] (Those trained in intensive care included a lot of nurses as well as physicians). The other essential components were: properly equipped ambulances -- provided by hospitals rather than by morticians which up to then was typical Missouri practice; and expanded CPR training so that those first reaching heart attack and other victims would know how to respond. It took other resources to achieve the overall objective, but in the next decade, practically all the hospitals had developed an intensive care capability.

Another problem in medical treatment in the 1960's was, as President Johnson also noted pointedly, the extraordinary range of new medical knowledge being developed. Much of it emanated from the National Institutes of Health, in its laboratories and or with its support at the principal medical school centers across the country. The centers did not often have ways of sharing these advances with primary care physicians in most American communities. Despite some defensive professional views about the matter, there was significant agreement that even the best trained and greatly skilled physicians could have a difficult time keeping up with new advances, if they were not themselves attached to the principal medical complexes of their regions. As Dr. Wilson put it: "Any physician trying to carry around in his head all of the knowledge that is needed for even a single medical discipline is just destined for an end."[10] Various approaches to this problem were developed. In Missouri (as in Alabama, Wisconsin and elsewhere) one of them was a simple matter of installing a telephone link between every community in the state with groups of specialists in Columbia, Kansas City or St. Louis.

Another novelty of the Missouri RMP -- which became a major effort -- was the development and use of computers. Dr. Wilson had a strong hunch that communications with respect to medical problems and solutions could be facilitated and expanded through the use of computers. In this connection, one of the first physicians in his own school he talked to was a young pathologist who had already begun using computers as an aid to the categorization and diagnosis of diseases. That person was Dr. Donald A. B. Lindberg. In one of his last commentaries on Regional Medical Programs, an interview with Dr. Lindberg in 1991, Dr. Wilson said "My initial impression of RMP was that it could be a tool that would help us take technical knowledge and make it work in the health care system."[11] In Missouri, it did.

From his side, when Don Lindberg was invited to join the University of Missouri School of Medicine Pathology Department in 1960, one of the early conversations that intrigued him was with the Dean-designate of the school, Vernon Wilson. Dr. Lindberg had already been impressed with the opportunity the department chairman had offered, namely that he could continue to carry out his biological research and also run the clinical pathology laboratory for the University Hospital. But he and Dr. Wilson talked about the need for putting electronic communications systems, still in their infancy, to work to serve medical needs.[12]

Earlier that year, Dr. Lindberg had been on the site visit team for the National Institutes of Health, looking at a potential grant to Massachusetts General Hospital and its medical director, Dr. John Knowles, for exploring possibilities of the use of computers in medicine. That early work had gone on relatively well, if in very rudimentary ways. But the real question, in those days, was whether there was any market for using computer systems in medicine. Dr. Lindberg was impressed that Dr. Wilson, himself trained in pharmacology, thought the answer was definitely a yes. This was unusual, because outside of "Mass General," nobody in medicine seemed remotely interested in the matter.

Missouri proved a challenging place. But for a young man with a wide range of interests and enormous energy, it also proved to be frustrating. Running two labs was somewhat tougher than Dr. Lindberg had imagined, especially since he felt so keenly the dual obligation involved, one to his NIH supporters and one to the patients. The diagnosis of those patients' conditions and the analysis of what treatment might work was at least a matter of sickness or health, if not of life or death. Related to all of this was a philosophical conviction about medicine, and how the University of Missouri Hospital approached medical care. That approach was that the hospital ought to be able to provide every person that came into it with excellent care across the board. Other hospitals, including notable ones in the East where Dr. Lindberg had served, in fact had the capacity to provide the very best care in the world. And they did so for anyone who could pay for it. But Missouri had good specialists, good facilities and, in those days, even before Medicare and Medicaid reimbursements, the inclination to take care of its patients in a comprehensive way.

The dual laboratory burden accelerated Dr. Lindberg's interest in computer sciences. In order to speed up the testing of blood samples, for example, he developed a machine which tested the sensitivity of bacteria to antibiotics in liquid; the results were recorded in another machine which defused the light by particles. Working with a student physicist, Garst Reese, he developed a series of devices. One reflected needle sensitivities on a meter; a Richter adding machine then printed numbers corresponding to the needles on paper tapes. With tapes applied to walls and using rulers to measure across, the pattern of the bacteria's sensitivity to particular antibiotics could be seen over time. There was a computer center at the University, although not at the medical school, and between midnight and 12:15 a.m. -- the time available on the computer -- Dr. Lindberg could feed the cards (onto which information had been applied) into the computer and get a summary of results. It still took two days to process data from one day's experiments. Despite the Rube Goldberg character of the devices and processes then available, it was obvious that if more sophisticated machinery could be developed, the recording and analysis time could be reduced by extraordinary amounts. Already the rough mechanistic system was much faster than performing each step by hand. It was also more consistent in quality -- the infamous handwriting of physicians and lab personnel always being a problematic factor in assuring accuracy in lab tests.

The experiments brought more support from the university and from outside sources. In short order -- within the first two years of his presence at the University of Missouri -- Dr. Lindberg and Dr. Gwilyn Lodwick developed the first electronic reporting system for use in hospitals. The process became more sophisticated so that the automated testing of blood samples led to mathematical modelling and subsequently to instant feedback. The by-products included the compilation of files on particular cases, both of particular bacteriological strains and their pathological effects, and of particular patients. The new approach also led to an automated billing system.

Thus, a few years later, while the computer science effort was still in its infancy in Missouri, the Regional Medical Program possibility gave this approach to the modernization of health care a boost. One of the distinctive features of the first grant proposal submitted by the Missouri RMP and approved by the Office of Regional Medical Programs was its emphasis on automated information systems and their potential capacity to link bedside to laboratory, and to link small towns to medical centers. Indeed, over the next decade, it was pioneering work in computers and automated information systems on the one hand, and very fundamental training of physicians, nurses, and other health care personnel in intensive care procedures and other lifesaving modes, that made Missouri one of the most prominent of the RMPs.

One special computer program that got national attention involved taking medical histories from patients. This was field tested in the office of Dr. Jack Bass and his private practice in Salem, Missouri. Many were skeptical: Would not persons who were generally unsophisticated, and especially unsophisticated with respect to technology such as personal computers, be intimidated by talking to machines? Actually, in a little informal "control study", Dr. Bass found that people were generally more forthcoming when "punching in" answers posed by a computer than when elaborating their conditions and symptoms and concerns and histories directly to a nurse or physician.[13] This extraordinarily useful lesson, today applied on a wide scale, has made one part of the diagnosis process simpler and more comprehensive, probably without adding cost to that process. More immediately, it brought some fame to Dr. Bass and the Missouri RMP when CBS TV Morning News took its cameras into what quickly became known as "Dr. Mock's Office" to record the pioneering procedure. Parade magazine did a story on the project.[14]

This experiment was followed by others, including computerized searches for symptoms and diagnosis of medical conditions, where individual physicians or other professionals could, through computers, link to base lines of advanced medical and biomedical information.

Another pioneering program was a computerized information bank which facilitated matching heart and kidney patients' vital information (i.e., blood type) with potential organ donors.

In its eight years of actual operations, the Missouri program invested almost $19 million in federal funds in over 100 projects. Some of its programs were very sophisticated. Many were relatively simple. Some helped to develop new technologies from diagnostic capacities to treatment modes. Most did exactly what the authors of the legislation, and the President who inspired it, expected: They brought more doctors, nurses and other health personnel up to speed with advanced knowledge, and so permitted the delivery of that knowledge, through more sophisticated care, to people.

All the hospitals in Missouri and most of the health care professionals in the state were involved in some way or another in the Missouri Regional Medical Program. All the professional associations -- 22 in all, plus the Missouri Farm Bureau Federation and the Missouri Federation of Women's Clubs -- were partners in the enterprise. Most communities in the state participated in some direct way.[15]

As those who developed its RMP are the first to assert, Missouri already had some traditions of cooperation in the health field. The rivalries between medical schools were not overly intense, except perhaps in St. Louis. As a state with strong Democratic and Republican party organizations, bipartisan cooperation was not unheard of. Even the medical doctors and the osteopaths had begun to talk to each other at the time Regional Medical Programs came along. The State Board of Health Registration for the Healing Arts licensed physicians and all other health professionals except, as Dr. Allen notes, Christian Science practitioners, nurses and chiropractors -- which had their own boards.

Underlying the Missouri story is an obvious predilection -- regardless of bureaucracies and specializations and regional differences and rivalries -- which was to help people. Also obviously, a group of committed, even enthusiastic individuals from a variety of disciplines joined in a common cause and made the Missouri Regional Medical Program work well.

The exceptional volunteer service rendered by the Regional Advisory Group was a most important factor in the success of the program. This group, about 50 strong, was representative of producers and consumers of health services in Missouri. Included were a Project Review Committee which concerned itself with the technical merits of proposals, and a Liaison Committee which represented the interests of professional disciplines and special health concerns of consumers.

When the political handwriting on the national wall became visible, suggesting that congressional support for Regional Medical Programs was fading, the Missourians took steps to insure that some of the programs begun under RMP would continue. The University itself invested more in the development of computer systems related to medical diagnosis and treatment and the retrieval of information. The Missouri Kidney Foundation took over programs begun under RMP but which had always benefitted from its own expertise. The Heart Association and Cancer Society did the same. The medical schools did not automatically drop programs just because federal funds from RMP ceased. Community hospitals have gone up and down in their financial fortunes and in populations served, but some programs begun under RMP still continue. Networks expanded under RMP (even if, in the case of this particular state) they did not originate with it, still function.

Missouri is not necessarily now, and was perhaps not then, the perfect model of cooperation and medical advance. But it was, in the case of RMP, a model of what a determined group of professionals can do for the people at large if they have a deep concern and a genuine desire to serve.

It was no surprise to those who knew him that, in 1971, Dr. Vernon Wilson should be asked to come to Washington to be administrator of a newly-formed bureau of the U.S. Public Health Service, the Health Services and Mental Health Administration. That Bureau by then housed the Division of Regional Medical Programs.

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