What one doctor learned: going from policy making to caring for real patients at an inner-city clinic

Washington Monthly, April, 1998 by Fitzhugh Mullan

Going from policy making to caring for real patients at an inner-city clinic.

I have indicated my career to the U.S. health-care system. For 23 years, I served as a physician in the United States Public Health Service. During that quarter century, from Nixon to Clinton, from erythromycin for Legionnaire's Disease to protease inhibitors for AIDS, I was fortunate to serve in a series of interesting jobs, albeit ones that took me steadily into the realm of policy and away from patients. Starting out in 1972 as a physician in the National Health Service Corps in New Mexico, I came to Washington several years later and had the opportunity to run the program during the Carter administration. Subsequently, I worked at the NIH, served on the staff of Surgeon General Koop, and, in recent years, directed the federal Bureau of Health Professions.

I joined the Public Health Service believing that government service was important work, and I left it with the same conviction. But over the years, the growing anti-government sentiment and the increasing privatization of our health-care system made me wonder. Had the legacy of the government, the public collective, as the ultimate guarantor of medical care been supplanted by market forces and proprietary medicine? Two years ago, I left government to find out.

Today, I am an inner-city doctor working at the Upper Cardozo, Community Health Center at 14th and Irving Streets in Washington, D.C. -- a federally assisted, privately run, community-governed medical clinic. Our neighborhood is made up of a large Central American community, a Vietnamese enclave, an African-American population scattered throughout the region, and a mixture of refugees, legal immigrants, and illegal immigrants struggling to find someone to treat them despite their lack of money and insurance. I have seen Ethiopians, Somalis, Kurds, West Africans, Chinese, Afghanistanis, and Bosnians. Less than a quarter of our patients have Medicaid, almost none have private health insurance, and all are poor. Medical life for our patients -- like their lives in general -- is not easy.

I chose to work at Cardozo, because, having practiced inner-city medicine before, I knew that I liked it, and I knew that I was needed. Moreover, I wanted to see for myself what the forces of medical privatization meant for our poorest citizens and neighborhoods. In my time back on the front lines, I have relearned some lessons that I had forgotten during my years in government -- lessons about the vital role government still plays in health care, and lessons about how it could contribute more.

Disconnected

The majority of patients at Cardozo, are "self pay" -- meaning they have no insurance, no money, and can pay little or nothing. Put differently, if the Cardozo, health center didn't continue to receive several million dollars a year of federal funding based on the vintage 1960's Office of Economic Opportunity idea of a community health center, there would be no payroll, no receptionists, no nurses, no doctors, and no medical care. Grants for the treatment of AIDS and the homeless as well as the Women, Infant and Childrens (WIC) Program round out the budget at Cardozo. Government funding remains the operative principle of health care finance in our neighborhood. Without the programs legislated and managed by the federal government, there would be no medical care at 14th and Irving. The commercial market hasn't found our patients and doesn't seem to be looking for them.

Practice at Upper Cardozo isn't for everyone. It is neither glamorous nor lucrative (a not insignificant deterrent to young people who may have run up serious debts in pursuit of their medical education). In clinics like ours, much of the staff -- like much of the funding -- comes courtesy of the federal government. Two of the top-notch pediatricians I work with are products of government sponsorship: the National Health Service Corps Loan Repayment Program and the Uniformed Services University of the Health Sciences. The Loan Repayment Program provides debt reduction for clinicians who commit to work in underserved areas, while the military medical school trains a certain number of Public Health Service physicians who then do their military duty in settings such as Cardozo. My colleagues at the clinic, and others like them, are superb examples of what government incentives can do to move doctors into settings they might not otherwise choose or be able to afford.

Unfortunately, the recruitment, education, orientation, and socialization of doctors working in poor communities remains an important but neglected mission over which the government has more power than it has chosen to use. Currently, there are about 1,300 physicians serving in the National Health Service Corps -- less than one-quarter of 1 percent of the physicians in America. At its current level, this is a demonstration program only and not a serious strategy to end medical disenfranchisement in the United States. But the program shows that linking community medical service to educational opportunities is a powerful and proven idea that needs to be bankrolled with a much more generous budget that will draw many more physicians to work in an area of undisputed national need. Government programs that work need to be expanded -- and this is one of them.