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An Ounce of Prevention

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It's 8:24 A.M., four days until winter break, and it seems as if at least half the student body at Istrouma High School in Baton Rouge, La., is flooding into the school's health clinic for a checkup.

Two oversized 11th graders amble into the clinic--a converted classroom off the main hallway--to weigh themselves for the wrestling meet later today. They step on and off the scale, then shuffle out into the crowded hallway to class. Another student, extending a bloody thumb to the nurse, pops in to request a Band-Aid.

The waiting room is cluttered with plastic chairs, scales, and an assortment of pamphlets on AIDS, drunken driving, syphilis. A table along one wall overflows with equipment: a centrifuge, a microscope, a strep-throat kit.

Sitting under the clinic's fluorescent lights, a 15-year-old, his arm in a sling, waits for the doctor to check how his broken bones are healing, while another student quietly confesses to the nurse that she has come in this morning for a pregnancy test.

"Everybody stops in here; this is a stopping station,'' says Geraldine Brewer, the ebullient clinic coordinator, who oversees the bustling waiting room at Louisiana's oldest school health clinic. Brewer, whom many students call "Mama,'' says she already has 11 appointments scheduled before noon. She can also count on a number of walk-ins, which average 25 a day.

The crowd this Tuesday morning is here mostly because the doctor from the local charity hospital is making his weekly visit. Some may be here because the school recently showed a film on sexually transmitted diseases that featured pictures of diseased genitalia along with an appeal to use condoms.

School board guidelines prohibit the clinic from distributing contraceptives, but the nurses are permitted to talk about condoms in the context of S.T.D.'s.

"It's sort of a pre-holiday warning for them to be good during break,'' says Brewer, smiling. "After a long break, kids tend to come in with more S.T.D.'s,'' she explains.

This clinic, which opened in 1987, may very well represent the future of school-based health care: a full-service operation with community support funded by the federal government in cooperation with state and local governments and private sources.

The notion of a network of school-based health clinics supported by grants from foundations and state governments has been simmering around the country for more than a decade. Currently, more than 574 school-based clinics operate in 33 states, according to the Center for Population Options, a family-planning research group. Yet, those clinics vary widely in the services they offer and the ways in which they are financed.

Now, President Clinton has made school clinics a cornerstone of his plan to reform the nation's health-care system.

In the Administration's plan, now being scrutinized by Congress, the President is requesting $400 million for a four-year program to establish school-based clinics in medically underserved areas. School-based clinics received approximately $17 million in federal funding in 1992.

Even if Congress approves only a small fraction of the funding requested, clinics in impoverished areas with limited access to health care, like Istrouma's, stand to benefit enormously.

Istrouma's long, brick school building is sandwiched between rows of low-income houses and a commercial shopping strip on one of the more dangerous streets in North Baton Rouge. Six people were injured near the school in a spate of drive-by shootings in the past year. Two of the victims were Istrouma students.

One of the boys, who'd been shot in the stomach last spring and now wears a colostomy bag, strides into the clinic for his doctor's appointment. Beverly C. Buchmann, the clinic's nurse practitioner, once had to intervene when the boy's teacher, who was unaware of his condition, refused to allow his repeated trips to the bathroom.

A petite woman with a maternal manner who has been Istrouma High's nurse since the clinic opened, Buchmann says her job is only partly student advocacy. It's also too often about averting disaster.

Just the day before, a diabetic student came into the clinic on the verge of a coma. He had not taken his insulin because he said he had no way to get to the doctor to pick up a new prescription, recounts Buchmann, who promptly put him in a car to the hospital.

"Had we not intervened, he would've gone into a coma and could've died,'' Buchmann says.

By all standards, Istrouma's nearly 900 students can be categorized as "at risk.'' Seventy-five percent of them are eligible for free or reduced-price meals under the federal school-lunch program, a key indicator of poverty. Most students at this inner-city school have received less than adequate health care, and some haven't seen a doctor since infancy.

East Baton Rouge Parish, which includes the city of Baton Rouge and its environs, has one of the highest teenage-pregnancy rates in Louisiana; the state itself has the third-highest rate in the nation. Nearly 20 percent of all babies in Louisiana are born to adolescents.

Last school year, at Istrouma High alone, 50 students became pregnant; most of them decided to keep their babies. The school clinic prides itself on offering services tailored to each student's needs, Buchmann explains, so it provides comprehensive prenatal care. Pregnant students are offered a range of services, including nutrition counseling, hospital X-rays, and even midwifery, if they choose.

The clinic also offers immunizations, athletic physicals, hearing and vision screening, blood-pressure checks, drug- and alcohol-abuse referrals, and treatment of minor injuries.

But aside from dispensing medication and patching wounds, the clinic also serves as a safe haven for students.

Child-abuse and -neglect cases are not uncommon here, says social worker Shannon Cerise, who spends 2 days a week at Istrouma and admits it is the hardest work she's ever done. The school's teachers routinely send problem students to Cerise.

"A lot of what I do is crisis counseling,'' she says, fingering the thick case files on her desk. "One of my kids got robbed at gunpoint near his house, and he came into the clinic so shaken up.''

"He is an 11th grader, a special-education student, and his mom is an alcoholic and kicked him out of the house for the fifth time,'' says Cerise, visibly distressed as she recounts the case. "His brother died when he was little, and he's trying to do the best he can.''

Lonnie Hilgerson, the student's special-education teacher, cannot contain his enthusiasm for the clinic, which sits one floor below his classroom. He has sent other students to the clinic who have been beaten. And he recently learned that one of his students has been prostituting herself.

"She was put on Plank Road to make whiskey money for her mom,'' he says, referring to an infamous street nearby.

"Our students are disturbed when they come through that door,'' says Hilgerson. And although it takes tremendous energy to come to their aid, he says, "I'll fight to the death for these kids, and so will the clinic staff.''

To hear the widespread acclaim for the clinic from educators, teachers, and parents today, you would never know that the clinic once faced vigorous opposition.

School officials and the medical director of the Earl K. Long Medical Center, a local charity hospital, had been discussing the possibility of opening a school clinic for more than a year. The hospital was willing to donate supplies and medical help if the school would put up construction and other personnel costs.

When the Robert Wood Johnson Foundation announced a grant program to fund school-based health centers, they joined forces to apply for a six-year, $600,000 grant to set up two clinics, one at Istrouma High and the other at a nearby middle school.

Dr. Gary Peck, a pediatrician at the Long Medical Center who spearheaded the effort, presented the clinic proposal to the East Baton Rouge Parish school board in the fall of 1986. Opening school clinics was a novel idea, and the 12-member board debated the issue for several months.

Istrouma High School is located 15 miles down a whitewashed highway from the headquarters of the evangelist Jimmy Swaggart. In the late 1980's, before a sex scandal crippled and nearly destroyed his ministries--which included a syndicated television show and a 1,500-student Bible college--Swaggart was a significant force in the parish. He led the opposition to the proposed clinics, denouncing them as "sex clinics'' that would dispense contraceptives and offer abortions.

Swaggart was joined by other conservative Christian groups and some school board members in charging that the clinics would promote promiscuity and encourage teenage pregnancy.

An assistant principal, who supported the concept of a clinic but not the availability of contraceptives, reportedly said of the plan: "I like soup, but I don't like cyanide in it.''

Fearing the proposal would not win board approval, a community group called the School-Based Adolescent Health Care Advisory Committee was formed to support the clinic effort.

The committee cited the high teenage-pregnancy rates, and argued that family-planning services were simply a matter of good health practice.

The committee held packed public meetings where community members gathered to air their grievances. Doctors from the Long Medical Center defended the need for on-site primary-care services for adolescents.

Opponents, however, continued to decry the proposal as potentially "dangerous.'' They charged that the Robert Wood Johnson Foundation had a "hidden agenda.''

They distributed leaflets accusing school officials of letting themselves be "duped'' and claiming that the foundation would "force'' the clinics to provide contraceptives, which would ultimately undermine parental authority.

Maudine Ault, who led the opposition on the school board, issued an even more explosive charge. Ault alleged that the clinic plan was merely "a cover-up'' for a plan to is sue contraceptives to control the growth of the minority population. The plan, she said, deliberately placed the clinics in the somewhat racially divided city in schools with large minority enrollments.

Supporters responded that the clinics were targeted to serve those most in need of medical services, regardless of color. Besides, they said, participation would be voluntary and students would need their parents' written approval to receive services of any kind.

Willie F. Hawkins, then an associate administrator at the Long Medical Center, lobbied school board members and promoted the benefits of the clinics at local gatherings. "It was quite a struggle, because the wrong idea had gotten out in the community and created a problem for us,'' he says. "It got totally out of context, and we had to overcome all this controversy.''

The clinics were primarily meant to reduce absenteeism, Hawkins says. Too many students would leave school to go home for a minor problem like a sore throat and not come back.

"This was about routine things,'' Hawkins says. "The clinic is not an emergency room.''

With the deadline for the grant application just weeks away, the debate was deadlocked.

The clinics' champions knew they would never win approval for a program that offered all the services they hoped to provide. So, Dr. Peck and school officials compromised by agreeing not to offer family-planning services, contraceptives, or abortion referrals on site.

Once they struck the controversial wording about family planning, the school board swiftly approved the plan by a vote of 11 to 1.

The Istrouma clinic opened in fall of 1987, and the middle school clinic followed two months later.

Robert J. Meador, the president of the East Baton Rouge Parish school board, originally objected to the clinics but now proudly touts their accomplishments.

"Students [who are sick] are better off in school than at home ill and alone with no one to look after them,'' he says.

Since the clinic opened at Istrouma High, the absentee rate has been cut in half, according to Principal Elisha Jackson.

The benefits can be most clearly measured in health-care savings. For every dollar spent on clinic services, the taxpayers save $10 in emergency-room costs, according to Dr. Holly Galland, a family-practice physician at the Long Medical Center, who now supervises the city's school clinics.

The hospital donates lab and X-ray costs, and designates poor students as "no pays'' who get medical care for free. The hospital is usually reimbursed for these services by Medicaid, but sometimes the treatment is not covered and the hospital absorbs the cost. Hospital officials still believe the clinic is worth the investment.

Galland says some of the benefits are difficult to document numerically: the students who don't turn to drugs when they are depressed, the potentially violent fights that are resolved in the anger-management classes, the colds that don't turn into pneumonia, the heightened sense of security students feel because they have a place to go to when sick, depressed, or frightened.

In addition, although students are still getting pregnant, they are having healthier babies. Before the clinic opened, nearly all the babies born to Istrouma students weighed less than 5 pounds. Last year, there were no low-birthweight babies at all, Buchmann, the clinic nurse, reports.

For her part, Dr. Galland never expected that her part-time work in the school clinics would become so consuming.

"It's an obsession,'' admits Dr. Galland, who once taught 7th-grade social studies. The clinic work, she says, satisfies both the doctor and the educator in her.

Looking at the results of the first six years, Meador says he wouldn't mind having clinics in every school in the parish.

Earlier this school year, however, the future of even Istrouma High's resilient clinic looked momentarily precarious. Its foundation money was exhausted, and officials were not sure how to keep the clinic open. But, in a sign of the growing commitment to school health in Louisiana, the state decided to pick up the slack.

For the first time this school year, the clinic is operating under a $100,000 grant from the state office of public health.

And the prognosis for school clinics in the state looks promising. The public-health office agreed to fund two new clinics, both at middle schools in East Baton Rouge Parish. The clinics opened for business last fall, bringing to four the number of school-based clinics in the city. One other has opened in rural St. Martin's Parish and two in New Orleans.

Louisiana's school-health chief says state leaders finally subscribed to the idea of school-based health care because of the sobering statistics they face.

For example, the state ranks 48th in the nation in mathematics achievement for 8th graders, according to the National Assessment of Educational Progress. And the state's 4th graders have consistently ranked 46th or below in reading proficiency.

One out of every three children in the state lives in poverty. Adolescents are more likely to die a violent death in Louisiana than in most other states: In 1992, the rate of teenage death due to accidents, homicides, or suicides was 96.4 per 100,000, compared with 70.9 per 100,000 nationally.

"We are at the bottom of the list in everything,'' says Sylvia Sterne, the state's school-health coordinator.

Yet, there has been little money in the state in recent years to address any of these public-health or school concerns. The oil-industry bust of the early 1980's drastically reduced oil-industry revenue and left the state virtually broke.

"Everything the government had done was supported by oil money, and it all disappeared, so budgets for the last 10 years have been excruciatingly low,'' Sterne says.

By the late 80's, state health officials began to see school health centers as essential to raising academic-achievement levels. You can't educate a child who isn't healthy, they say, sounding the slogan of school-health-program advocates around the country.

But first, health officials had to have a mandate to establish the clinics, so they launched the state's first school-health initiative and began to build a coalition.

At the time, Louisiana had no school-health policy to speak of, and sex-education guidelines even today are determined by individual parish school boards.

The health department's contact with schools at the time was minimal, basically confined to processing immunization records. The state education department was also wary of the plan.

"They saw it as an infringement on their territory,'' Sterne says of the education department. "They taught kids, and they didn't want us messing in schools.'' Nevertheless, health officials continued to campaign and made allies among education leaders and other department heads.

But they knew the effort would also require political clout.

They appealed to State Rep. Irma Dickson, a longtime supporter of school clinics. And in 1990, Dickson won approval for a resolution to study the need for such clinics.

A report on that study, issued in 1991, outlined a litany of problems from literacy to child abuse to violence and explained how school clinics could address them.

The report was presented at the 1991 legislative session, where Dickson was busy drafting an adolescent school-health initiative. In the fall of that year, health department officials testified before the House health committee.

The main flash points of discussion were the familiar ones of contraceptives and abortion.

After considerable debate, legislators heavily amended the bill to preclude the distribution of contraceptives. Abortion counseling was specifically prohibited. With those caveats, it passed 98 to 0.

Yet, legislators did not fund the program, because, critics say, they were just testing the waters and lacked the political will to finance the clinics.

Then in 1992, Louisiana was awarded a $6 million federal maternal-child-health block grant, which states receive based on the number of children living in poverty. And state health officials saw an opportunity to use a portion of that money to fund school clinics.

The Baton Rouge clinics were already serving as an example of school health practice in action. And, later that year, the legislature approved the use of $500,000 from the federal block grant to fund the clinics initiative. The Istrouma clinic received the $100,000 that saved its operations.

Now heading into its second year, the adolescent school-health initiative is offering workshops at which local officials can learn how to smooth the way for school clinics.

Representatives from half of the state's parishes attended the last meeting. They learned how to use resources to counter opponents who rely on inaccurate information. They got a crash course in media relations and learned ways to publicize their town meetings.

They developed ways to do damage control on the hot topics of abortion and parental consent. Every strategy must take into account the fact that, even if they require parental consent, clinics are the antithesis of parental control, says Leslie Gerwin, a consultant to the state public-health office: "They're about teens taking control of their lives and understanding the consequences.''

But the biggest barrier to establishing clinics, Gerwin says, is usually financial. The Robert Wood Johnson Foundation estimates that one clinic costs about $150,000 to establish and slightly less each year to maintain. Equipment and supplies can run up to $60,000 the first year alone. And because state money is often not adequate to sustain even a handful of clinics for long, most clinics must put together a patchwork of funding from a variety of sources.

The funding problem makes President Clinton's $400 million proposal especially attractive, and school-health advocates are gearing up for the Congressional debate ahead, which could result in a new era for their profession. (See related story, page 13.)

Clinic supporters have a passionate spokeswoman in U.S. Surgeon General Joycelyn Elders, who is spearheading the Administration's campaign to set up a clinic in every school that needs one. During her tenure as chief health officer of neighboring Arkansas, Elders fought hard for school-based clinics, eventually winning state funding for 26 clinics, three of which offer reproductive services.

In virtually every public speech since her confirmation, Dr. Elders has boosted school-based clinics as the best way to educate the country's neediest children in how to live healthy lives.

Not surprisingly, however, the kind of opposition that has confounded efforts at the local level has attached itself to the President's proposal. Already, antiabortion groups have targeted the clinics section of the plan for defeat, and some national education groups, though generally supportive, have expressed concern about liability issues and the potential for increased costs to schools.

But at Louisiana's newest clinic, which opened in October, the only complaints to be heard seem to be from the students. They want the clinic's hours extended.

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