Podcast: It’s Time to Tango

Lots of your questions about the future after COVID-19 get answered, and one listener gives us a little history lesson.

The logo of the U.S. Public Health Service: A medical staff with two snakes intertwined and wings is crossed with a Marine anchor; three stars appear, one at left, one at right, and one above
The flag of the U.S. Public Health Service (Wikimedia Commons / The Atlantic)

Now that Jim’s “Quite Possibly Wonderful Summer” is coming to fruition, a lot of listeners have been considering the present and future. Can you go to a tango festival? What should parents be watching for? And why, exactly, is the surgeon general wearing that uniform? Hit play for answers and a short history lesson from Ruth Fairbanks, a listener and history professor, in conversation with hosts James Hamblin and Maeve Higgins.

What follows is a transcript of their conversation, edited and condensed for clarity:

Maeve Higgins: I have to say, you know, since I [have] been hosting this show, I’ve learned that the listeners of the show are extremely smart. And do you remember last week, you know, you’ve been speaking with the surgeon general and we played a clip of Vivek Murthy. That’s his name, right?

James Hamblin: Yes.

Higgins: And I asked you, like, why does he wear a uniform? Like, who is he like? His position was kind of confusing. And you didn’t know exactly either.

Hamblin: Well, I said I didn’t know about the uniform. He’s an adviser to the president, which would clarify. But in general, the surgeon general is sort of a communications job. I said [he], you know, speaks for America’s doctors. I really should have said “America’s public-health institutions.” But the surgeon general has generally been the kind of person who could issue, like … a CDC guideline. It’s more like: He’s everyone’s doctor, and here’s what he’s advising. So it’s more one very smart person’s advice that you might take or leave.

Higgins: But I think during the show you were like, “I don’t know. Maybe a listener could be a bit more accurate about that.”

Hamblin: And then specifically with regard to the uniform, which I wasn’t prepared to talk about. You catch me in so many interesting questions, but that’s why I enjoy chatting with you, Maeve. It’s an interesting role. And we had someone write in about that.

Higgins: Yeah, that’s right. Do you want to give her a call now so that she can tell us properly, once and for all, about the surgeon general? Her name is Dr. Ruth Fairbanks. She’s literally a college professor. She’s a senior instructor at Indiana State University. And I don’t know how to say this—Terre Haute?

Hamblin: Indiana State, isn’t it? Yeah, Terre Haute. Oh, Terre Haute. That’s what we said in Indiana, growing up. I suppose there are other ways it could be pronounced, if you’re not from Indiana.

Higgins: So Dr. Fairbanks teaches history and gender studies, and one of her classes is in the history of American health policy.

Hamblin: Oh, perfect. So she can tell us about the uniform.

Ruth Fairbanks: Hi, Jim. Hi, Maeve. It’s really nice to meet you.

Higgins: Hi, lovely to meet you.

Fairbanks: I’ve listened to Social Distance since it began, and I also remember listening to Maeve in America.

Hamblin: Oh, wow. Longtime Maeve fan.

Higgins: That’s so lovely. Thank you so much. And we absolutely were delighted with your email, because my big question was, what is going on with his uniform?

Fairbanks: Well, one of the classes that I teach is a class on the history of American health policy. And one of the things that we cover in my course is a little bit about public health, as well as how we finance health care in this country. And we start in the colonial period. And so my students cover the establishment of the Marine Hospital Service, which started in 1798. And that is the origin of the United States Public Health Service. It grew out of the Marine Hospital Service, where Congress established and John Adams signed into law that the American government would pay for the direct care of merchant seamen—sailors on merchant ships—would provide for their direct care if they were injured or ill.

Higgins: Was that because nobody was doing that? Or was that from the goodness of their hearts?

Fairbanks: Seamen are a very interesting case. And it wasn’t just the United States. Great Britain had a long-standing tradition also of providing some care for seamen. And it’s because this was an occupation that at once exposed people to a variety of bad weather that could cause serious health problems, and falls, and poor food; and also exposure to disease and poor living conditions. This was a very vulnerable population at the same time that it was a very important population, because for Great Britain, anything related to oceangoing was really essential, as they have this huge empire.

And then the American colonies and the brand-new United States: All of the new states are along the Eastern Seaboard, and the ocean is the highway. And they’ve also just declared independence from the major imperial power. It’s really important that they also have access to the ocean. So it’s essential for the nation, as well as the population is very vulnerable. And then the other thing is that charity care would have only been provided to people who were in that community ,and sailors, of course, when they put ashore, they don’t have a home community. So they were always outsiders. So they would have been blocked off from any access to any charity care.

And some of these are still typical of American health-care delivery that we deliver— some of it according to a group that we’ve sort of picked apart as like: This group is eligible for health care, not the whole population, but just this group is. And then also we typically do organize our health care, a lot of it, based on location and your membership in a community. That’s why some states, of course, have expanded [Medicaid] under the [Affordable Care Act] and some states have not. This tradition dates back to the colonial period in the United States, where people who are defined as outside, then … they don’t get the same access. But then over the course of time, the Marine Hospital Service begins to accept quarantine responsibilities, because they’re doctors who are paid by the government. So they’re an existing thing that can be used for this other job. And then they gradually begin to take on other responsibilities too: investigations [of] diseases like hookworm and pellagra and attempts to control the spread of malaria, to control mosquitoes, and then gradually take on more and more of these responsibilities. And sometime around the turn of the century, the name changes first to the Public Health and Marine-Hospital Service, and then just the Public Health Service.

Hamblin: From the 19th to 20th century.

Fairbanks: Around that time. It goes through stages. And one thing is: You can watch the effects of wars on the expansion of American public-health efforts. And a big expansion was around the First World War, an effort at malaria control, and also coming out of the First World War. The Public Health Service was the origin of the Veterans Administration, the VA system. And also efforts to control the spread of venereal disease, both in the First World War and especially in the Second World War. A lot of those focused on the areas around military bases.

Hamblin: And I think we even skipped over the Civil War. Some developments there with U.S. Sanitary Commission and the Union Army trying to keep people from dying of unsanitary conditions, actually leading to creation of an agency there.

Fairbanks: Actually, this is an excellent point. The U.S. Public Health Service is not just physicians or health-care providers. It encompasses a lot of other professions and expertise. A lot of engineers, for instance, work in the Public Health Service and also veterinarians, statisticians, mathematicians.

Higgins: So you can actually be a “vet” vet.

Fairbanks: Yes. [Laughing.]

Higgins: Did you get that?

Hamblin: So I did misspeak when I said “represents the nation’s doctors.” That was a comment that kind of figuratively—like, just one voice for doctors. But in fact, at an official capacity, the surgeon general speaks for all these people, engineers, veterinarians.

Fairbanks: And while most of the time they have been physicians, before Dr. Murthy was confirmed a second time, there was an acting surgeon general and that surgeon general was, by training, a nurse. I’m not sure if any of the ones who have been actually confirmed have not been physicians, but this wasn’t the first time that a nurse was the acting surgeon general.

Hamblin: And do people in the Public Health Service wear uniforms, or just the surgeon general?

Fairbanks: They all wear uniforms. That’s one of the uniformed services of the United States. Their uniform is more like that of a Navy uniform and their ranks, because you progress quite similar to military ranks. And the ranks are based more on Navy ranks than on Army ranks. The rank of the surgeon general, I think, is a vice admiral or some sort of admiral, and you look at the bars on the sleeves [that] indicates the rank. But just above the bars, on the sleeves of that dress uniform, you see the insignia, the symbol of the Public Health Service is a caduceus, which is the medical symbol with the two snakes and the wings, but it’s crossed with an anchor. And the anchor is hearkening back to the origins of this being the Marine Hospital Service.

Hamblin: So we have this branch, which is a uniformed service, sort of on par with Army, Navy, Air Force, and yet is devoted to health. And we just don’t hear about it quite as much, apart from the surgeon general.

Higgins: Why is that? Why don’t we?

Fairbanks: We just maybe don’t realize who we’re hearing about. For instance, a few years ago, when there was the Ebola outbreak in Liberia and the United States sent people to help in Liberia. Those were Public Health Service officers. Those were commissioned officers in the U.S. Public Health Service … when people from the CDC had these strike teams that would go around the world when there was an outbreak and they would do ring vaccination to try to prevent the spread and ultimately eradicated smallpox. The CDC is part of the Public Health Service. National Institutes of Health also started out in the Public Health Service. The Indian Health Service started out in the Public Health Service. And a lot of the people who staff Indian Health Service facilities are commissioned in the U.S. Public Health Service.

Hamblin: Instead of carrying weapons, people—uniformed members of the health service—carry, I assume, vials of antibiotics or vaccines.

Fairbanks: Or the engineers carry whatever engineers with shovels, construction equipment.

Higgins: Okay, so I’ve seen more movies about SEALs.

Hamblin: We like to have movies about elite teams like SEALs, like, the elite of the elite. Maybe if there is or could be a section of the Public Health Service that’s just these highly trained 12 people.

Higgins: But those are the lot who went to Liberia probably.

Fairbanks: Yeah, they do it all the time.

Hamblin: Well, it’s just a branding thing then, I guess.

Higgins: Well, it’s fascinating to learn the origins. And it’s also so ironic to me that, you know, from conflict comes this expertise almost like the opposite of preventative health. If it wasn’t for the Civil War, then they wouldn’t be so good at dealing with dysentery. You know, it’s like in Northern Ireland during the Troubles, the doctors in Belfast were the best ever at dealing with kneecaps. You know, they’re, like, world-renowned because so many people had their kneecap shot.

Hamblin: Oh, it’s quite true. So many advancements in public health have come through times of war. And hopefully we can continue to invest in public health even when there’s not war. Just pandemics.