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Preventive Medicine

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In 1954, after processing its last immigrant, Ellis Island, the nation's chief immigration station, closed its doors for good. It reopened in 1990, but now only tourists pass through its imposing buildings.

At the other end of Manhattan, however, just north of Harlem, a different port of entry continues to thrive. The neighborhood of Washington Heights has long been an unofficial doorway to American dreams, both good and bad. There is no Statue of Liberty here. Instead, a large McDonald's on Broadway welcomes newcomers, the majority of whom these days arrive from the Dominican Republic.

Where Ellis Island was orderly and bureaucratic, this neighborhood is anything but. Police cars prowling near 168th Street and bullet-proof glass in the corner doughnut store speak of the crime readily associated with this pocket of Manhattan. All-purpose bodegas hug the street corners while fruit and vegetable stands clutter the sidewalks, giving this section of Broadway a slightly foreign flavor.

Out of the third-world bustle rise the brown-brick skyscrapers of Columbia Presbyterian Medical Center. Since its construction in 1928, this elite medical institution--a carefully constructed partnership between Columbia University and Presbyterian Hospital--has dominated the Washington Heights landscape.

Just opposite the medical center, tucked inside a high fence, Public School 128 quietly goes about educating and caring for the children of this community, many of them recent arrivals themselves.

To Blanca Battino, the school's principal, it has often seemed that miles, not yards, separate her elementary school from the medical giant on the other side of Broadway.

She has spent a good deal of her nine years at PS 128 puzzling over how to tap into her neighbor's vast medical resources. Many of her students need basic health care but don't have it because of financial, linguistic, or cultural barriers. To solve this dilemma, Battino reasoned that health professionals from the medical center could come to the school and treat students there. After several frustrating years of trying to communicate this idea, her logic is finally beginning to sink in, and Broadway doesn't seem quite as wide these days.

This morning, 1,440 elementary students and their 85 staff members squeeze into PS 128, a squat pink school that is also called the Audubon School. "This is a relief," sighs Battino. "Last year, we had more than 1,600 students." Washington Heights falls within Community School District 6, the most crowded of Manhattan's school districts.

Audubon is a common name in this neighborhood. More than a century ago, John James Audubon, the naturalist painter, lived on an estate that straddled Harlem and Washington Heights. His name lingers on streets and buildings, the most well-known being the Audubon Ballroom. It was there, at a rally in February 1965, that Malcolm X was fatally shot.

As Battino pores over an updated list of her students, a teacher pokes his head into her office and asks to use the school's one copier machine. "Darling, it doesn't work," she smiles.

Accustomed to tight budgets, Battino has learned to improvise, and regularly scours the neighborhood for resources to help her students learn and grow. "If I have a special need, I look around my community to see which organization can support my goals," she says. "I work with everyone I can get my hands on."

This year, she has 18 community projects based at her K-5 school. Members of the Actors' Guild read aloud to students, and the Washington Heights Coalition, a civic association, sponsors a homework club as well as a Parents as Partners in Education group, which offers workshops in parenting skills.

One of her most pressing needs, however, has been improving the health of her students and their families. The school's health personnel, two full-time nurses and a three-member support team, are overwhelmed by a complex of problems that include skin diseases, dental cavities, malnutrition, tuberculosis, lead poisoning, and emotional trauma, including "schoolphobia."

Schoolphobia occurs when children are afraid to leave home, Battino explains, either because they fear that their mother will disappear or be killed while they're in school or that they themselves will be hurt en route to school. To cope with the increasing numbers of children suffering from this condition, Battino has brought the Safe Havens program to PS 128, a pilot project that identifies neighborhood businesses willing to provide "safe havens" from the streets to students.

But the real answers to this complicated diagnosis, it seemed to her, lay across the street within the confines of Columbia Presbyterian Medical Center. For her first six years at the school, she tried a variety of tactics--writing letters to administrators, talking with nurses, and attending community meetings--but nothing seemed to work.

Then, about three years ago, things began to fall into place when staff members at Columbia University's school of nursing and from Presbyterian Hospital heard about Battino through a colleague. They approached the principal about running some health-research projects in PS 128.

Battino welcomed them into her school but still seems bewildered by the medical center's apparent myopia when it comes to understanding the community's needs. "I guess I've been talking to so many people, that someone heard about me," she says. "But wouldn't common sense tell you to come over yourself and find out?"

With an institution as large as Columbia Presbyterian, however, change comes slowly. Well into the 1970s, the medical center was able to maintain a professional distance from its neighbors. "Until 15 years ago, while the hospital always provided health care through clinics to the community, it did very little else," acknowledges Helen Morik, the director of government and community affairs for Presbyterian Hospital. "It didn't know community leaders or participate in community affairs."

A confluence of factors--some economic, some philanthropic, some medical--forced the medical complex out of its insularity. By the early 1980s, the other five hospitals in Washington Heights had closed, leaving the medical center the community's sole health-care provider. Meanwhile, the population was swelling, its social and health needs escalating. Crime, fueled by the arrival of crack cocaine, was on the rise, deterring patients from seeking treatment there and potential faculty members from applying for jobs.

At the same time, the center wanted to expand its facilities, but it needed community support to win approval from city planners. So, the institution began to look beyond its hallowed walls and figure out how to connect with its neighbors. "The outreach," Morik admits, "was not entirely altruistic."

Many of the neighborhood's 33 elementary and high schools have benefited from the new outlook. This year, Columbia Presbyterian faculty members and graduate students are involved in seven projects at PS 128, including an after-school sports club for girls, a free immunization project, and a girls' literature club. Graduate nursing students also provide psychiatric nursing services, dental students teach about preventive tooth care, and medical students ACT as mentors for older students.

While the school clearly benefits from these services, the Columbia Presbyterian students and faculty also gain: They have access to a convenient and cooperative study population for their research projects; they acquire valuable, and publishable, field experience; and they are building goodwill within the community, a critical factor to the medical center's operations.

Although Battino wishes the connection had been made sooner, the relationship comes better late than never. "It's a good beginning," she concedes.

It's raining when Donna A. Gaffney, an assistant professor of clinical nursing, and her team of nursing students emerge from PS 128 later in the morning. They have just held the first meeting of the year for the girls' literature club.

"Let's go get some lunch and debrief," Gaffney tells her entourage. They troop across Broadway back to the nursing school, where they settle into a small conference room.

The literature club, called "Growing Heroines," developed from a grant Gaffney received two years ago from the American Association of University Women Educational Foundation to study how literature could be used as an intervention tool with preadolescent girls. The counseling process is known as bibliotherapy.

"As the year goes on, they will become comfortable and more trusting, and open up," Gaffney says of the 12 girls who attended the session. "They'll talk more about their families, which can be tricky. Let me know how it goes--we can always bring them here for treatment."

In its second year, the club is a big hit with the girls and their teachers. But the nursing students say they felt some resistance at first.

"Initially, I didn't feel the support of the teachers," says Mellen Lovrin, a graduate of the nursing school who coordinated the book groups last year. "They were suspicious. They said, `Of course, you can do a good job if you only have seven kids.' But once they saw we were sincere, the relationship became very exciting."

In a few short years, PS 128 has come to rely on the free services these health professionals provide. "Columbia Presbyterian is an integral part of our community. We'd be at a loss without them," says Laverne Nimmons, the school's assistant principal. She credits Battino for making this important connection. "It's up to the principal to bring the community into the school, but that's not something that happens naturally. It depends entirely on the principal's relationship with the community."

Among the health services now offered at PS 128 is the hospital's child-immunization project. Located in a small room down the hall from Battino's office, the project is a free, communitywide clinic that targets medically at-risk children under age 5, although older children are treated as necessary. "I like to think we're providing a good model that shows working in schools is a viable option for immunization and a good way to reach parents," says Alan Schulman, the project's coordinator.

Such services, however beneficial, are just a drop in the bucket, observes Rose Occino, the school's social worker. In her position on the front line of treating troubled children, Occino speaks freely about the inherent frustration of working with Columbia Presbyterian. "When someone comes to us and offers a free counseling program, we're thrilled, happy. Anyone who can take extraneous pressures off our teachers is very important to us," she says. "But we could use more Columbias. We have a hundred kids who need their services."

Both sides know that what the medical center can do is limited. Last year, for instance, there was more demand for the literature group than space available. "Girls were begging their teachers to let them come," Lovrin recalls. "I'd see girls in the hall looking in at us, wanting to belong. It was frustrating to serve such a tiny segment of the population."

But Occino and her team are used to limits and restrictions. In many ways, they operate their own emergency room at PS 128, surviving by a makeshift triage system. For them, Columbia Presbyterian is just one option for treating a few students. The trick is to determine which ones need help the most because the medical center can only treat a limited number of free patients.

As for the others, Occino wrangles with community agencies, argues with bureaucrats who won't accept Medicaid, and dodges red tape, doing a frantic tap dance to match her students and families with an ever-shrinking number of social services. "It's a multipronged approach--some kids need food, some families need housing, some need help signing up for welfare, others need psychotherapy. The middle-class 'Come to my office at 4, and we'll talk' just won't work here."

Washington Heights stopped being middle class in the 1960s, when blue-collar families started moving out to the suburbs and Latino immigrants began to move in. As the population grew, it became younger, poorer, and less well-educated.

Although community outreach has long been a part of the nursing school's history, coping with these drastic changes has been a big challenge, admits Mary O. Mundinger, the dean of the school.

"Becoming attuned to the cultural and health needs of this population has been a quick study for us," she says. "But we believe the community is important to our social contract. You don't just set up shop in a geographic region and go about doing your business in isolation."

Columbia's other health-sciences schools--public health, dentistry, and physicians and surgeons--have also responded and sponsor many community-health projects, many of which are targeted at schools and children. In general, individuals at the Medical Center seem proud of how the institution has grown outward to collaborate with local residents and organizations.

"Now, we are a good neighbor," says Morik, the community-affairs director. "We interact on a daily basis with various community organizations. It has become a natural part of how we operate. The hospital would never now say the community is not valuable to us--it is tremendously valuable."

Nevertheless, the past decade has not completely erased the barriers between the two. Tension and resentment still arise, especially when salt is rubbed in the proverbial wound.

"It's a town-and-gown thing--it's class," says Susan Pope, the children's librarian at the nearby Inwood Library and a resident since 1979. "Columbia Presbyterian really runs things in the neighborhood. People often see them as taking the best housing and real estate."

In 1989, Columbia Presbyterian built a 300-bed community hospital, the Allen Pavilion, at 220th Street. It has just opened the last of four Ambulatory Care Network Corp. clinics. These new facilities are designed to relieve pressure on the medical center's emergency room and to connect patients with primary-care physicians, ultimately providing better quality care to the community.

But that's not necessarily how residents are interpreting Columbia Presbyterian's new comprehensive-health system.

"Some people are saying it creates a two-tiered system--one for the wealthy and one for the people," says Moises Perez, the executive director of Alianza Dominicana, a nonprofit community-services organization that serves Dominicans in the neighborhood. "The bottom line is the medical center is a business like any other. It has to reconcile credits and debits, and a lot of decisions are made on that basis rather than on what's best for the community."

More controversial has been the construction of the five buildings comprising the Audubon Biomedical Science and Technology Park, the first of which now stands on the site of the original Audubon Ballroom. The ballroom's ornate facade was preserved, but many residents and preservationists were angry that the building was destroyed. When completed early in the next century, the complex should create about 2,500 jobs, and there will be incentives to encourage neighborhood residents to apply for them.

"Although we've always realized the importance of a strong neighborhood, if we can't make this community economically viable, how are we going to recruit the best students, doctors, and nurses?" asks Ivy Fairchild, the director of community affairs for the health-sciences division of Columbia University. "No matter how much we do, the community will always ask us to do more. That's OK--it keeps us on our toes."

At the end of this rainy afternoon, Battino plays air-traffic controller in the cafeteria, keeping her students in a holding pattern until a parent or sibling arrives with an umbrella to escort them safely home.

As children and adults swarm around her, she greets each one with a smile, some with a hug, gliding effortlessly between English and Spanish.

It is easy to see why Donna Gaffney describes her friend as "Glenda the Good Witch surrounded by all of her munchkins."

But unlike The Wizard of Oz character, Battino cannot find the answers to her problems in a magic crystal ball. Her school's partnership with Columbia Presbyterian Medical Center offers some relief, but it is tenuous. Its health and survival depends to a large extent on the availability of resources, whether grant monies for pilot projects, graduate student time, or space within PS 128. Good intentions can only go so far.

"Sometimes, there are weeks when I am so upset," Battino says, as she gives a child a goodbye hug. "I am frustrated by the increasing needs of families and the diminishing resources in the community and by the insensitivity shown to immigrants."

Meanwhile, hundreds of miles away in Washington members of Congress are feuding over the future of welfare. Proposed changes to Medicaid could have profound implications for her students and their families and for the way Columbia Presbyterian is able to care for local residents. Medicaid pays for roughly 70 percent to 80 percent of outpatient care at Columbia Presbyterian.

"We're trying not to think about it--it would be an absolute crime," Morik says. "Somehow, we can't imagine not being able to treat our community, especially after we've worked so hard to set up these systems."

Battino could say the same.

After the last child has been claimed from the cafeteria, she sits down at a lunch table and reflects on her own childhood in a neighborhood on the Lower West Side.

Hers was the only Latino family in a predominantly Irish community. It was not an easy place to grow up. Battino still remembers the teacher who squelched her desire to become a writer by accusing her of plagiarism. "She didn't think a Latino girl could have written so well in English," she recalls.

But from that community, Battino took away a faith that good things can come out of adversity. "I still love Irish music," she smiles. "I dance the jig every March 17th for the whole school, and they love it."

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