Dr. Fitzhugh Mullan has been practicing public service medicine for more than 40 years. He directed workforce programs such as the National Health Service Corps while serving as a member of the United States Public Health Service Commissioned Corps. He is a professor at George Washington University and is a contributing editor to the journal Health Affairs. In the current issue, his essay for the "Narrative Matters" feature, is, in Dr. Mullan’s words, a call for “the fire of the Civil Rights movement” applied to health care.
He writes: "In spite of the accomplishments of the safety net, we still have not closed the gap for many Americans. Equality in health remains an unfulfilled promise and is, in fact, much more complicated now than it was in 1965. Inequity in health care continues to plague not only blacks but numerous other people and communities around the country."
Jackie Judd sat down with Dr. Mullan to discuss his essay, "Still Closing the Gap."
Jackie Judd: Let’s start at the beginning, which is where you start your essay. Back in the mid-sixties, you were a medical student in Mississippi. You were serving what was called a 'medical witness.' What did you see there, what did you experience?
Fitzhugh Mullan: Between my freshman and sophomore years of medical school, I went south as a volunteer for the Medical Committee for Human Rights – a medical civil rights worker. I was in north-central Mississippi. I worked setting up a health association, doing health education and visiting local doctors and hospitals, to raise the issue of segregation, and what we call today huge disparities in health. "Medical witness" was a term used in the movement to refer to bringing focus to an issue of indignity or an issue of disequity ... visiting doctors offices that had 'colored' and 'white' waiting rooms, hospitals that had segregated wings and the very palpable disparities between the African-American population and the white populations.
JJ: As your career progressed, it took you to Chicago, to the Bronx, to New Mexico. It seemed that no matter what part of the country you were in, you saw some variation on the theme of inequities.
FM: Well, you didn’t have to look far, you don’t have to look far, to find inequities in our society and in the health component of our society. In New York, I worked in city hospitals whose clientele was entirely black and Puerto Rican, as it happened, and in our hospital, Lincoln Hospital, we still had a diarrhea room. They didn’t have enough resources to do anything other than put anybody with any type of diarrhea in one part of the general ward. This was not 1970s medicine, this was very primitive. And it was part of the disequities that were built into the health care system.
In New Mexico, as a National Service Corps doctor, I worked with people who had lived there for 400 years. These were Hispanics who lived there when it was Mexico. They were still there and they were out of the mainstream. They, for the most part, did not have health insurance, they relied on public clinics, and they made do, but, again, it was an inequitable situation. So, I didn’t have to be a bloodhound looking for it, wherever I went to practice, there were major problems.
JJ: You obviously appreciate the power of words. You have some ambivalence about the expression ‘the safety net’ – why?
I first encountered the term ‘safety net’ when it was first used in health policy circles, in the early Reagan administration. The notion that the best we could do for parts of our population was to put a thin strand of rope or string to keep them from splashing on the floor seemed – and seems – pretty primitive. It was the same epoch when it was alleged that ketchup was a vegetable for the purposes of school lunches. That kind of cynicism in public policy really rankles.
And as I began to work with the concept (as a practitioner, I’ve always worked in health centers or public sector settings), I became more and more comfortable with it. (I said) "if we’re going to have an underclass, we’ll make it the best damned underclass you can have." And with a variety of programs – National Service Corps, community health centers, Medicaid, we’ve built a safety net in this country. That’s not a great way to do business, but I’m a partisan of it, having practiced in it and worked in it. But it isn’t the end point. It’s a point on a voyage away from that cynicism that 'we have some patients who only deserve a safety net.'
JJ: Let’s fast forward now to 2009, we’re in the midst of this great debate over health care reform. You are making kind of a call to arms, a return to the passion of the civil rights movement. Do you see evidence of it?
FM: I do. It's packaged totally differently. We don't have the freedom riders on buses or tolerating fire hoses. But we do have, across the country, people who are very energized and see this as the chance to really make a branch in the road in American history, where we finally bring all of our citizenry into health care. I see it in a variety of ways. I see it in young people and medicine, who have cleaved to the notion of health care reform, sometimes single payer, sometime the idea of universal coverage. But they believe that's part of their voyage and their life and their purpose in coming into medicine. I see it, funnily enough, in the staff folks on the Hill, where I'm spending a lot of time these days, people working for members of Congress who are doing the gut work of crafting legislation. These folks are enormously dedicated, folks working day and night, seven days a week, into the minutiae and working craftily to put together packages that will work. It's that kind of dedication that really harkens back to the fire of the civil rights movement.
JJ: You've obviously been a close observer and practitioner of health care for decades. Forty-five years after being that young medical student in Mississippi, could you have imagined then that you would still be here, in some way, talking about the same ideas?
FM: If I go back to 1965, would I imagine that I'd be engaged in this same sort of struggle this many decades later, I would have said "no." At the time, the clearest challenge in the civil rights movement was racism, and that meant breaking down institutional walls that were coming down. The civil rights act of 1965, the desegregation of schools, the desegregation of hospitals under Medicare was happening. And it seemed like the edifice of racism was being torn down.
We weren't naive enough to believe there would be no racism, at least institutionalized, publicly-condoned racism would be gone. That, in many ways, has happened. And following on it, there were strong efforts to enact national health insurance, as it was called at the time. I was on a committee of 100 in 1968, convened by Walter Reuther, the labor leader, that had all kinds of American eminences on it, I was the student representative. The belief was, that with this kind of coalition of forces, we would very shortly have - and in fact, President Nixon went for - a form of national health insurance. Didn't happen. So, yes indeed, we are 40 years later and at least two or three more attempts at national health insurance or universal coverage and here we are again today. So I would not have predicted it, but it's had a very linear course from there to here. And I'm happy to be here to fight it.