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

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.

The government has a right (and a responsibility) to demand more for its money. Few people know that the largest single government program of funding for medical education is the $7 billion a year that Medicare pays to hospitals with residency programs. These hospitals, however, tend to focus on specialist-heavy, hospital-based training -- meaning that this huge injection of public money does little to get doctors into communities where they are most needed and where they can learn primary care and community-oriented medicine first-hand. Recent changes in the Medicare law have finally eliminated provisions that actually discouraged hospitals from allowing residents to practice with private physicians or in community health centers, but the law still does nothing to encourage or reward these important, formative medical experiences. The message here is straight-forward: We need doctors to go where the problems are, and our public dollars should be managed in a fashion that rewards community-based training and practice.

Finally, I have been struck by the lack of communication and coordination among government-funded organizations with similar or complementary goals. Programs of public support in sectors such as education, social services, or even the police are another world to me. Each of us resides within our own silo. I have visited the local high school, many of whose students come to Cardozo as patients. The principal and I, understandably, have a lot in common -- worries about teen pregnancy and sexual activity, drug and alcohol use, immunization status, and health literacy. Yet we continue to live in separate worlds, one block apart, both funded by agencies of government but with little in the way of incentives to bring our enterprises closer together. We need that push. Government funding needs to battle the tendency of all programs to become narrow and self-centered by making dollars and people available at the local level in a way that requires community-based programs to work cooperatively. Smart public funding should pull community programs together, resisting the ever present drift toward parochialism.

The Leaky Lifeboat

My time back in practice has led me to the inescapable conclusion that health-care reform has not happened. Despite what pundits say, the managed-care explosion has not brought any relief to the medical problems of the inner city. The mission of government and government workers remains critical to medical care and life in such areas. Sadly, my concerns about the unevenness and unfairness of the medical system in the United States are not just paleoliberal gripes. Whatever the advances in the health-care system, the government rather than "the market" still stands as the only Samaritan with the resources and the license to do something about the underserved.

When I sit in my windowless office at Cardozo, it amazes me to think that I am less than two miles from the Old Executive Office Building conference room, where I spent the better part of 100 days serving on the President's Task Force on Health Care Reform. I can remember looking out of the window of that room at the West Wing of the White House and thinking that I felt the pulse of history. My office at Cardozo offers no such views or sensations. What it does provide, however, is a clear sense of people and their pains, the world at ground level without distractions or camouflage.

During my years in government, I forgot how complicated life can be in a poor community. From the deck of the great ship of state, programs of medical or social support are developed and cast overboard into the community like so many lifelines -- each with its own buoy and a rope of trailing eligibilities, requirements, and provisos. Viewed from the deck, each lifeline is logical, coherent, and well intended. Viewed from the water, the lifelines often tangle, get thrown in the wrong direction, or support some members of a family while leaving others to drown.

Now back at the water level, I am acutely aware of the quandaries created by programs that, despite their excellent intent, are poorly coordinated, overlapping, or ignorant of other initiatives affecting the same people or community. Under the current welfare law, for instance, undocumented immigrants with children born in the United States can enroll those children in Medicaid, but they run the risk of putting their own names on deportation lists by doing so. When the D.C. Medicaid authority awarded its initial contracts for Medicaid managed care, they bypassed Cardozo and the city's other federally supported community health center. Cardozo had to go to court to get a piece of the action and prevent its publicly supported budget from being driven further into the red.

Government doesn't always make the right decisions but it makes important ones. Amidst all the clamor about "the American Century" and the triumph of capitalism, about managed care and the market place, it is the people working in government who run the programs that make medical care at Cardozo possible. They need to keep a vision of an active and compassionate government, but they also need to come and visit us occasionally and see the world from the waterline.

Fitzhugh Mullan, M.D., a former assistant surgeon general in the U.S. Public Health Service, is a staff pediatrician at the Upper Cardozo Community Health Center in Washington, D.C.