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Healthy Times at George Washington High |
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Teaching Wellness for Life in a School-Based Clinic |
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By Sally McLain |
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Through the School of Public Health’s Center for Population and Family Health, Columbia University is making positive strides toward laying the groundwork with youth to ensure healthy life outcomes. The clinic at George Washington High School is one of six school-based clinics based in public middle and high schools in Upper Manhattan and Central Harlem. The students in these schools, in most cases, are economically disadvantaged and medically underserved. Lisa Maldonado, assistant program director of the Center for Population and Family Health, says it is important to have this kind of program within a school because of access. “Adolescents as a rule are generally healthy and don’t seek out health care. In the school, we have a captive audience. We can focus on the preventive health issues most important to teens, such as reproductive health, asthma, and nutrition.” An underlying goal of the school-based clinic at GWHS is to help young people learn how to be involved in their own health decisions. The clinic’s primary function is to take care of each student’s immediate medical and mental health needs, which otherwise might go untreated. But it’s also a continuation of something that was started at the middle school level for most of these kids. All the area middle schools, which are “feeder” schools for GWHS, have their own school-based clinics where Columbia staff have focused on comprehensive health, including pregnancy prevention, through individual and group programs. The high school is in Washington Heights, just a little more than 20 blocks north of Columbia-Presbyterian Medical Center. The school is set in a grand, Palladian-style building with an entrance reminiscent of Scarlett O’Hara’s Tara. Famous graduates of the school include Henry Kissinger, Harry Belafonte, and Tiny Tim. Two magnificent winding staircases and a marble entry hall welcome visitors, although students enter through a side door where they go through metal detectors and run ID cards through an attendance recording machine. In the past four years, GWHS has undergone tremendous changes. With enrollment nearing 4,000 (the school’s official capacity is a little less than 3,000), low test scores, a high drop-out rate, and a somewhat jaded faculty, the school’s principal, Euclid Mejia, stepped in with a state mandate to get things back on track. At the same time, a clinic previously proposed by the Center for Population and Family Health was on the back burner because of space constraints and lack of faculty support. Mr. Mejia recognized the importance of the clinic and actively sought space for it. “When I came here in 1994, I had no doubt in my mind that the clinic would bring benefits to the school and the students,” says Mr. Mejia. Although it wasn’t easy--a wood shop and an administrative office had to give up space--Mr. Mejia allocated for the clinic an area on the first floor with good windows and ample space. “Where to put the clinic was under discussion for years because of the question of space. We were operating at 180 percent capacity,” he says. “Now, people have a place to go to get top-notch quality care.” The clinic is a long space made up of two wings separated in the center by a waiting room. The medical wing looks like any clean and modern medical office, and the mental health wing is a hallway of small private offices where students can meet with health educators, HIV counselors, social workers, and a psychologist. At 10 o’clock on a sunny spring morning, Daysi Rosado, medical assistant, weighs in a 16-year-old girl for a prenatal visit. Although Ms. Rosado is already a medical doctor in her native Dominican Republic, she is the medical clinic’s master of triage, coordinating the walk-ins with the prescheduled appointments. The young pregnant student wears jeans and a snug sweater. You could almost mistake Ms. Rosado for one of the students, from her easy rapport and youthful exuberance, although she’s the mother of two school-aged children herself. “How far along are you?” she asks the girl, who isn’t really showing yet. “Seven months,” the girl tells her. Ms. Rosado looks into the girl’s eyes and says in Spanish, “You have to let that baby have some room, Mommy.” And with that, she helps the girl undo her tight jeans. The girl’s belly expands like an inflated balloon. Ms. Rosado looks for a rubber band to stretch across the girl’s waistband, pulls down her sweater, and says, “Next time you come in, I want to see you in spandex.” The girl smiles.
The mental health component of the school-based clinic provides a service as important as vaccinations or sports physicals. The health educators get many referrals from the medical providers at the clinic. For example, a young woman may come to the medical clinic expressing something that gives the provider reason to believe she is having or considering having sexual intercourse. As part of the clinic’s pregnancy and HIV prevention programs, the student is advised to see the health educator. “We see mostly sexually active kids and more girls than boys,” says Doris Roman, one of two health educators in the clinic. “We talk about sexual decision making, birth control, pregnancy options, and HIV risks. As a result, many kids decide to delay sex a little longer, but they know we’re here to talk more.” In some cases, young girls say they don’t really want to be having sex but will do so because they aren’t sure how to say no, says Ms. Roman. Talking about it helps them decide what is right for them. In other cases, the girls believe they are ready for sex, and the health educators provide family-planning and sexually transmitted disease prevention information. “Our pregnancy prevention program aims to delay the first sexual experience,” says Nina Arpante, clinic director. Success of the pregnancy prevention program is already apparent: Pregnancy rates have dropped by 34 percent over a four-year period among 15- to 17-year-olds, according to a Center for Population and Family Health study. The main program, In Your Face, works within the middle schools. Students at high risk for early pregnancy are “followed” on to high school, where further prevention strategies are used. If a girl becomes pregnant and decides to have the baby, she can get prenatal care in the school-based clinic and have her baby delivered at the Allen Pavilion, a Presbyterian Hospital facility. “Most of the girls I see were first seen by the health educators and are then referred to me,” says nurse midwife Joan Hughes. Often, the girls meet with a health educator because they fear they are pregnant, at which point they are tested and then counseled. Washington Heights has the youngest population and the highest birth rate in the city. The clinic sees about 10 to 15 pregnant teens at any given time. The clinic makes GWHS a place where a girl can continue with her education even if she gets pregnant. “We try to follow these kids through their entire pregnancies,” says Ms. Arpante. “We find that if they are healthy, they’ll continue coming to school.” That may be one of the most immediate benefits of the school-based clinic. School attendance has improved while emergency calls have drastically decreased. “The year before the clinic opened, there were 120 emergency calls and the year after the clinic opened, there were only 33,” says Ms. Arpante. “This year, we’ve only had 10 calls to 911.” Emergencies aside, students also miss less school for routine medical care. If a student has a cold or a stomachache, he can stop in the clinic, missing only one class period rather than a whole day. If a student needs a sports physical, she can have it at the clinic. All services are provided at no cost to the students, although clinic administrators bill Medicaid. To be treated, students under 18 must have parental consent. But with 80 percent parental consent, the clinic is used by about 70 percent of the students; the national average for school clinic use is 38 percent. “Most of these kids didn’t have a pediatrician before our program but now they do,” says Ms. Arpante. The pediatric/adolescent medicine staff is made up of a nurse practitioner, a physician assistant, two nurse midwives, and a medical director who is a pediatric adolescent specialist. General health care--including preventive services, STD screenings, and asthma care--is provided to nearly 60 students a day. The clinic also sees emergent cases, like the 19-year-old male student Dr. Karen Soren, medical director, treated this day. “He was sitting in class with his pen in his mouth when he inhaled the cap of the pen and aspirated it into his lung,” says Dr. Soren, assistant clinical professor of pediatrics at P&S. “He started having chest pain and to be safe I wanted to send him for a chest X-ray.” But the young man didn’t have insurance, which didn’t matter in the clinic but would matter at the emergency room. Dr. Soren talked with the boy’s father who said he had Medicaid, which told her the son would probably qualify, too. “As soon as you need backup to our service, having no insurance is a problem.” The clinic staff enrolls eligible students in Medicaid or Child Health Plus. They can also negotiate with the hospital to lower fees in some instances.
Dr. Soren emphasizes the importance of family planning within the clinic setting. “It’s the most important part of primary care although it’s underestimated. Preventing pregnancies may change life outcomes. We teach awareness of health and we are a medical home for our students. In fact the stability here may be what’s missing in some of their homes.” Adolescents really just need someone to talk to who isn’t going to be judgmental, says Dr. Soren. “Teens are ensured confidentiality unless their own or others’ safety is threatened. It’s amazing how honest they’ll be--nothing surprises me anymore. But what breaks my heart, rather than surprises me, is their stories.” The clinic staff members encourage student participation through an HIV prevention program. Students like Robert, a 17-year-old high school junior, sometime become peer educators. A boy with a football-player physique, bookish glasses, and charming smile, Robert is the quintessential boy-next-door, all-American, role model type teachers love. Those winning leadership qualities and a good dose of healthy self-confidence prompted one of the HIV educators at the school-based clinic in GWHS to approach Robert about becoming a peer educator and he decided he’d give it a try. That was more than a year ago. At 11 o’clock on a Wednesday morning, Robert and two male classmates gather visual materials they’ll use in their waiting-room presentation on HIV prevention. Laura Rollins, HIV educator, talks with the boys first about some last-minute ideas, asking them to recite for her the main points of their presentation. Robert is a veteran while Jason and Steve are newer to the program. Robert leads off the informal lecture. “How many of you know what HIV stands for?” Robert asks the dozen or so students in the waiting room. Pointing to a hand-lettered poster, he reads off “human immunodeficiency virus,” stumbling a bit on immunodeficiency. “What are some of the ways you can avoid getting HIV?” “Use a condom,” one person says. Robert then reads off a list of safety precautions, the first of which is to practice abstinence. Some of the kids smirk at that and say, “Sure, yeah.” Robert acknowledges them only briefly with a smile and then continues. “Here’s a novelty condom,” he says, and passes around the room a red latex object covered with spines like a porcupine. “This is just a novelty--it’s not for sex and it isn’t for protection. Can you use Vaseline as a lubricant?” he asks. “No,” says one girl. “Right,” says Robert, “That’s because Vaseline weakens the latex and can cause holes. You have to use water-based lubricant like K-Y Jelly.” Meanwhile, the kids in the waiting room look over the various condoms, including the female condom, that Robert passes around the room. After the presentation, the three boys meet with Ms. Rollins in her office. Among a group of 17 peer educators, these boys conduct presentations in the waiting room and for sports teams and go into classrooms for special programs. The peer educators go through 12 weeks of training and nine weeks of prevention education. “There are a lot of myths out there about HIV,” says Robert. “The advantage of having us talk to other kids is that we’re the same age and they’ll ask us questions.” Robert also admits that his father has asked him questions about HIV and Robert was able to clarify some misconceptions. According to a survey conducted at the end of the 1996-97 school year, 50 percent of the peer educators said they talked to their families or friends about the things they learned.
Pamela Haller, coordinator of the HIV prevention program at the clinic, says adolescents tend to know a lot about the basics of HIV and AIDS, such as how it’s transmitted, but there’s still a lot they don’t know. Although the incidence of HIV is very low within the community surrounding the high school (except among intravenous drug users and their sexual partners), Ms. Haller says these kids are threatened by the trends. “We look at national trends and the increase is among young heterosexuals,” she says. “Nationally, one in four adolescents, meaning under the age of 25, have a sexually transmitted disease. And this neighborhood has a high rate of teen pregnancy, so we know there’s a risk.” The New York City Board of Education made the decision a few years ago to mandate HIV education in its public schools. “In a lot of high schools it doesn’t happen,” says Ms. Haller. “We’re helping this school fulfill its mandate.” The program, though staffed by Columbia personnel, is mostly funded through the AIDS Institute. Through a 12-week curriculum, Ms. Haller and two health educators spend one day a week in each of the 10th grade social studies classes where they have found ways to tie the program with the subject by focusing on the geography of HIV as well as its social implications worldwide. “We tried to word our tests and develop the program to help the kids prepare for the geography section of the Regents Exam,” says Ms. Haller. According to the American Academy of Pediatrics Committee on School Health, the major goals of a school health program are to provide a system that deals with crisis medical situations, mandated screening and immunization monitoring; systems to identify and resolve student health and educational problems; comprehensive and appropriate health education; a healthful and safe school environment that facilitates learning; and access to primary health care. It appears the clinic at GWHS fulfills those goals. The “big picture” of health is certainly on the agenda at the clinic. As Daysi Rosado, the medical assistant, says, those headaches aren’t always solely physical--there’s often a mental and emotional side to the health complaints of adolescents. “We try to set appointments for the very day kids express a need for counseling and then the mental health worker will refer them back to the medical side,” says Ms. Arpante, the clinic director. “We like to make an all-inclusive health plan for each student.” Teaching young people that mind and body are indeed complementary is a certain benefit of the clinic. “We teach kids there’s a psychosomatic side to medical conditions. We teach them to deal with stress and after that the medical issues often go away. They take your help, so it’s a great time to reach them,” says Dr. Patricia Cristina, clinical psyhologist. Before graduation each year, the clinic staff check records to be sure all graduating seniors have had a recent physical. “It may be the last chance before they leave to have free health care,” says Ms. Arpante. And one last chance to encourage a lifelong responsibility and interest in personal health and well-being.
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