Public Health Magazine: Spring 1996, Vol.4, No.1
School-Based Clinics: Making the Grade

By Mary Jane Fine

Nineteen-year-old Leonel is a sophomore at George Washington High School in Washington Heights, a predominantly Dominican immigrant neighborhood at the northern tip of Manhattan. A new school-based clinic, operated by CSPH's Center for Population and Family Health, is helping keep Leonel and hundreds of his peers healthy for the long haul to graduation.

It's 11:20 on a frigid school morning, just one week after the Blizzard of '96 double-dared New Yorkers to get on with their lives as usual. Behind the imposing exterior of George Washington High School in Washington Heights, the corridors are all but empty and almost serenely quiet. Citywide testing confines some 3,700 students to their classrooms for the day.

But there are a few exceptions at this hour. One is Leonel.

A 19-year-old sophomore sporting a black knit stocking cap, a thin mustache and an uncertain smile, Leonel has just accepted a cheery invitation-"Hi, c'mon in"-from Dr. Alwyn Cohall to enter one of three examining room in George Washington's school-based clinic.

"I did a physical on Leonel about a month or two ago," Cohall explains to a visitor, as Leonel listens and taps an envelope against his upper lip. "He had a lot of problems, and I recommended that he get a hearing aid. Now he has it and sometimes doesn't want to use it."

Leonel nods in agreement. The doctor continues outlining Leonel's situation, which grows increasingly tangled and problematic. Bottom line: the doctor wants to know how Leonel is doing in his classes. He learns that Leonel has been ducking gym class because the teacher failed him.

"What else did you fail?" Cohall asks.

"Spanish."

"Spanish!?" the doctor exclaims.

Leonel, who is from the Dominican Republic, smiles sheepishly, then chews on the corner of the envelope that he clutches like a security blanket. Under the doctor's gentle probing, the young man admits also to having failed English and reading.

"Leonel," Cohall says, "you already did the most important thing, you got a hearing aid. Now, the next most important thing is you gotta use the hearing aid. It's 1996. It's a new year, a new start. So what're you gonna do differently?"

"Everything." answers Leonel.

Leonel has come to the right place. The focus of George Washington High School's fledgling clinic is everything-everything related to a student's health, whether physical, mental or psychological. And, because a single approach or strategy is unlikely to be successful, given the multitude of problems confronting these students, the clinics are part of a larger design of medical, education and social support programs and services provided by the CSPH center and the hospital. For example, a parent of a student visiting the clinics might learn of the parent education course and decide to put his or her name on the waiting list (yes, a waiting list) for the next term. Or a young person needing structured enrichment activities might find the Workers of Wonder (WOW) program gives him an edge on a better future. Actually, the students and their families find that the clinics provide a gateway to the health care system, a connection to the full array of medical and mental health services available at the Columbia-Presbyterian Medical Center.

As a gateway to the medical and mental health services of the Columbia-Presbyterian Medical Center, the CSPH-affiliated clinic at George Washington High School provides everything students need for their physical and psychological well being, including immunizations.

As the newest of the Columbia School of Public Health comprehensive school-based clinics, George Washington joins a quartet of junior high school-based clinics (IS 52, IS 164, IS 143 and IS 136) that opened between 1987 and 1991 and were among the nation's first junior high school-based comprehensive health clinics.

The clinics grew out of the School's sense of commitment to the surrounding area, according to Allan Rosenfield, M.D., CSPH dean.

"We felt that in addition to our academic role we have a responsibility to the community," he says. "It is an excellent program with a very committed team."

The annual funding for the five school-based clinics and the community-based reproductive health programs flows from a combination of sources: private, federal, state and city. At present it is about $5 million, an amount that can fluctuate with the changing political tides.

Wensi Guzman, a health care advocate with the Columbia-based Coalition for School-Based Primary Care, a group of 128 school-based clinics in New York State and their 32 sponsors working to secure the clinics' permanence, characterized the clinics as "demonstration projects [that] live from year to year." A major sticking point is the politically volatile reproductive health issue which, he asserts, "always holds up the clinic funding in the legislature."

Despite the obstacles, however, it is money well spent. One reason is that few students in this largely Dominican enclave have health insurance or primary care physicians. As a result, they would go to the emergency room, a costly alternative. At George Washington, calls to 911 have decreased from nearly a call a day to just four or five calls a month, an improvement attributed to the clinic's arrival.

"The clinics save money in two ways," Guzman points out. "They provide less expensive care and they keep the kids healthier in the long run." And that leads to overwhelming parental support.

"Once the parents learn, they say, 'Oh, that's available? Why don't we have one in my school?'" Guzman says.

Reading, 'Riting and Immunizations

chool-based clinic" is not simply a new name for what used to be the school nurse's office. In fact, the so-called "traditional school nurse" has not existed in New York City Public Schools since the early 1970s. The case for school-based clinics is a dire one and goes far beyond the fevers, cramps and schoolyard scrapes that were the province of the school nurse. As Lorraine Tiezzi, director of community health and education, suggests: "A day at George Washington will give you the picture. Take a hypothetical look behind very real doors and you will see a clinic capable of handling severe and complicated health problems." At her invitation, take a walk down the freshly painted new hall to the first door on the right where the clinic's first nurse-midwife is discussing diet with one of five young school girls who rely on her exclusively for their prenatal and maternity care. Next door, Dr. Stewart Adelson, a psychiatrist, counsels a girl who recently swallowed a cup of Clorox in a suicide attempt. Across the hall, a would-be ball player receives a sports physical which presents opportunities for discussion of many health related issues from drugs to HIV. The absolute need for these clinics becomes increasingly apparent.

"We see an average of 50 to 80 students a day," says Beverly Colon Torres, the assistant director for clinical and program operations for the George Washington High School clinic. Since the high school clinic's 1995 debut, there has been an increase in the school's immunization level and a decrease in the number of students going home sick, she says. "Parents are coming in to see the social workers who are seeing their kids," she adds, "and they're coming in to learn about their (children's) illnesses."

Another advantage of the clinics, according to Cohall, is that they make follow-through easier for students who once would have fallen through the cracks.

"What's amazing," the doctor says, "is how little attention is paid to kids who fail. Some fail because of major health problems like Leonel's. Others fail because of significant learning disabilities that have not been detected; they've just been passed along until, all of a sudden, they're 18. Some are distracted by other kids or by family problems. Many kids have relatively low expectations that are reinforced by families who are not doing well. So it's often a self-fulfilling prophesy."

While reversing such defeatist attitudes among children is a difficult task at best, the clinic staffs are well on their way to doing so, and to achieving other patient goals like good health, and a diploma. n

A professional journalist and freelance writer, Mary Jane Fine has covered health and human services for the Philadelphia Inquirer, where she also wrote about the 25th anniversary of the Cuban Revolution and was nominated with a colleague for a Pulitzer Prize for a series on mental illness.