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The Doctor Is In

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It's a Wednesday morning in mid-October at Denver's Abraham Lincoln High School, and Isaac Acosta is feeling sick again. The 15-yearold freshman has come to Lincoln's comprehensive health clinic to discuss his ailment with Kay McCann, the school nurse. Acosta walks into McCann's tiny office clutching a notebook and an American Civics textbook; he doesn't look well.

"It's my stomach,'' he tells the nurse, a tall woman wearing a long white skirt, a red blouse, and rubber-soled shoes. McCann nods; Isaac has been in to see her several times since school began in September. McCann is concerned about the number of classes Isaac has been missing because of his stomach problems.

She asks him a few questions, then picks up the telephone and calls the boy's grandmother. "This is Kay McCann, the school nurse,'' she says. "I'm going to send Isaac home because he's still not feeling well, OK? All right. Thank you. Here he is.''

McCann hands the phone over to Isaac, who tells his grandmother that he'll be home soon.

There's a small problem, however. Isaac has to take the bus, and he's fresh out of tokens. He asks McCann if she has any. She doesn't, so she calls the front office to see if anyone there does. They don't.

"How much does it cost?'' she asks him.

"Fifty cents.''

"All I have is a dollar bill, so bring me the change.''

Isaac takes the money and says he will.

Seizing the opportunity, McCann hands the student a consent form that he and his parents must sign in order for him to take advantage of the clinic's full range of health-care providers, which, in addition to McCann, includes a doctor, a physician's assistant, and a team of mental-health counselors.

"Bring that clinic form back tomorrow morning,'' McCann implores him. "You've got to get your mom's signature, OK? Then we can get some things going for you around here. I don't want you missing any more school.'' Isaac nods in agreement and then goes on his way.

McCann has done her part; the rest is up to Isaac. But if he does bring back the consent form-- as 70 percent of Lincoln's students have--he'll have access to one of a growing number of comprehensive medical and mental-health clinics located in public schools. He'll be able to get a complete physical examination or, if he so desires, make an appointment with a social worker. And he won't have to pay a cent.

Most students at Lincoln High need little prodding to join the health clinic. Some, however, enroll only after getting into trouble. They are given an ultimatum: Go to the clinic for counseling or get suspended from school. Most students choose counseling.

Take Roger Fine, now 18. "When I was a freshman,'' he says, "I beat up a guy really bad out on the football field. The principal at the time told me that the only way I could stay in school was if I got into violence counseling. So I started that, and then I started going to a group called COA-- Children of Alcoholics.''

Once enrolled at the clinic for counseling, Fine began using it for medical reasons, as well: "broken bones, sprained ankles, cuts, you name it.'' He credits Tracey Brouk, the clinic's drug and alcohol counselor, with helping him quit drinking. And he credits the clinic in general with keeping him in school. Although he is no longer a student at Lincoln, Fine plans to earn his diploma through an alternative-education program offered by the Denver Public Schools. Then he's going to join the Army.

If it hadn't been for the clinic, he says, "I know I could have forgotten about the Army because I would have dropped out of school. I'd have probably ended up working at McDonald's for the rest of my life. The clinic kept me in school. I know it did.''

Depending on who's counting, there are anywhere from 300 to 600 schoolbased clinics now operating in the United States. Once seen as something of a novelty, they are increasingly being touted as an essential part of the nation's health-care delivery system. Most can be found in schools that serve low-income students, many of whom have no health insurance. Access, advocates say, is the key; teenagers are more likely to seek medical attention if the health clinic is located where the students spend much of their time--at school.

If President Clinton gets his way, school-based clinics will figure prominently in any healthreform package passed by Congress. Clinton's plan calls for approximately $450 million to be spent over a four-year period to increase the number of such clinics, which would operate as "essentialservice providers.'' School clinics would be linked to health-insurance networks, allowing the facilities to be reimbursed for the services they provide. The plan would completely change the way such clinics are financed. According to the Center for Population Options, school clinics currently receive 45 percent of their funding from state and local governments, 16 percent from the federal government, and 39 percent from foundations and other sources.

To their supporters, school-based clinics are an idea whose time has come. But to their opponents, they are yet another example of the way public schools have strayed from their original mission: educating students. Such critics ask: Don't schools have enough problems already without having to be responsible for the physical and emotional health of their students? Besides, couldn't money set aside for health clinics be better spent on such things as books or computers? (In fact, most schoolbased clinics, including Denver's, receive only a small portion of their funding from the local school system.)

Conservative Christians are more pointed in their criticism. Health care, they argue, is the responsibility of the family, not of the schools. Many conservative religious organizations have vowed to fight the growth of school clinics, which they see as nothing more than state-run centers for birth control and abortion referrals. Phyllis Schlafly, of the conservative Eagle Forum, has said that the purpose of school-based clinics is to "make teenagers think that promiscuity is the norm.... It's trying to make little girls into whores. How can you describe it another way?''

As it turns out, many clinics, such as Lincoln's, don't dispense any birth control at all. And studies indicate that reproductive services account for only about 10 percent of the visits students make to school clinics. The largest number of visits (29 percent) are for treatment of acute illnesses and injuries, followed by mental-health counseling (18 percent) and physicals (15 percent).

Still, opposition to school-based clinics shows no sign of letting up. [See "Dead On Arrival,'' page 23.] In Maryland, which is one of 12 states recently awarded seed money from the Robert Wood Johnson Foundation to finance school clinics, a group known as the Coalition for Parental Rights and Family Integrity was formed specifically to fight school facilities that offer reproductive services and mental-health counseling. "It is obvious that these clinics are strategically being placed in schools to gain access to teenagers without parental involvement,'' Nancy Jacobs of Concerned Women for America said at a news conference last September in Annapolis, Md.

At Lincoln High School, such talk is moot. The clinic has now been around for more than five years, and it has become, by and large, an accepted part of the school's culture. Advocates of school-based clinics cite it as a model; many educators considering health clinics for their own districts visit Lincoln to see how it's done. "I just don't think there's much of a controversy now,'' says Bruce Guernsey, the clinic's director.

It wasn't always so. In 1986, when the clinic idea was first being discussed in Denver, opposition came quickly. "Abortion Foes Protest High School Health Clinics,'' proclaimed one headline in The Denver Post. The article reported that "anti-abortionists are passing out pamphlets in front of Manual and Lincoln high schools to protest school health clinics that they fear will offer birth control and abortion referrals.'' It didn't seem to matter that the Denver School Board had already decided that contraceptives and abortion counseling would not be allowed at the clinics. "Not for the first year,'' predicted Jeannie Hill, director of an organization called the Sidewalk Counselors for Life, "but I would bet that after that they will allow birth control counseling and abortion referral. They would not have the clinic if that were not their goal.''

Denver's Catholic leadership attacked the proposed clinics on the grounds that they would violate parents' rights. "I cannot in good conscience endorse the clinics nor counsel parents of Catholic teenagers to enroll their children in the clinics as they are now proposed,'' J. Francis Stafford, then archbishop of Denver, told the Post.

Dr. David Kaplan, chief of adolescent medicine at Children's Hospital in Denver and chair of the clinics' governing board, reflects on what happened: "Because some of the first school-based clinics had a family-planning focus, I think there was a concern, especially on the part of the Catholic Church, that these were going to turn into contraceptive mills.'' Kaplan was instrumental in securing the six-year, $600,000 grant from the Robert Wood Johnson Foundation that helped establish Denver's school-based clinics.

"I think people were worried that there was some kind of 'hidden agenda' that hadn't surfaced yet,'' Kaplan says. "There was a lot of uneasiness about how this was going to work. We were in the newspapers almost every week for a while, and that put pressure on the city council.''

When the council held a public hearing on the proposed clinics, hundreds of citizens, including former governor of Colorado Richard Lamm, showed up to voice their support. Shortly there- after, the council voted in favor of the clinics, with the condition that no contraceptives would be dispensed and no abortion counseling would take place. "And we've never gone against those recommendations,'' Kaplan says.

In April 1988, Denver's first school-based health clinics--one at Lincoln High School and the other at East High School--opened their doors. (In November, a third clinic opened at Manual High School.) As of last June, the clinics had served more than 6,000 students.

Lincoln High School, built in 1959, is a four-story behemoth that could easily be mistaken for a factory were it not for its well-manicured football field. Located in southwest Denver, in a working-class neighborhood of small clapboard houses, the school overlooks Federal Boulevard, one of Denver's uglier strips. Compared with the Kmart across the street, or the self-storage company next door, Lincoln looks pretty good. Inside, the school is a typical example of its period, with endless corridors, polished tile floors, and beige brick walls. Solid as a rock, Lincoln High School was built to last.

At one time, more than 3,000 students attended the school. Now, Lincoln serves slightly more than half that number. About two-thirds of the students are Hispanic; Asians, whites, and a handful of African Americans make up the remainder. Half qualify for free or reduced lunches. Carol Bubes, one of the clinic's social workers, describes the student body this way: "Lower middle class and poor. There aren't any wealthy kids at this school.''

Halfway down the first floor hallway, beyond the glass display cases that hold the school's athletic trophies, is a door with a small hand-lettered sign that says simply, "Health Office open during school hours, 7:15 a.m.-2:45 p.m.'' Behind the door is a waiting area with three small couches and a reception counter, where Theresa Saiz greets a steady stream of incoming students. Fluorescent lights buzz overhead. Occasionally, the sound of a booming car stereo can be heard through the windows, which face the student parking lot.

Although the clinic was carved out of two homeeconomics classrooms, it looks pretty much like any other medical center, with offices and examination rooms. Space, however, is tight. Several infirmary cots are in odd places; one is tucked into a small hallway, while another is in the staff's lunchroom. A tiny closet, with barely enough room for one person, has been transformed into a lab.

Typically, anywhere from 50 to 75 students will visit the clinic each school day. If it's for something minor, like a headache or a scraped elbow, Kay McCann will usually do the honors. For more serious medical problems, Connie Boyle, a physician's assistant, is available. If she thinks a patient should see a doctor, she may ask him or her to make an appointment to see Dr. Mike Rudnick, who spends every Thursday at the clinic. (Rudnick's primary job is director of the teen clinic at the Westside Neighborhood Health Center, a nearby public facility operated by the Denver Department of Health and Hospitals.)

For mental-health needs, students have a variety of options. Carol Bubes is responsible for shortterm counseling, while Susan Addison, also a social worker, is available for ongoing treatment. Tracey Brouk handles drug and alcohol counseling; Dan Santos does gang and violence counseling. All of the counselors hold weekly grouptherapy sessions. Brouk, for example, leads several groups, including the one for children of alcoholics.

Everything that goes on at the clinic is strictly confidential. "That is the A-number-one concern of the students,'' says director Guernsey. "If you don't provide that, then you won't really see the scope of their problems. It took us awhile to really convince the student body here that the clinic was confidential. They were afraid we would tell their parents.''

When the clinic first opened, Lincoln's student population was about 8 percent Asian. Yet none of the Asian students would go to the clinic. The reasons turned out to be cultural. "We learned that if Asian kids walked into the clinic,'' Guernsey says, "they were basically admitting that they were pregnant or had a sexually transmitted disease. Because that was part of the services we offered.''

After Lincoln hired a former Vietnamese political refugee by the name of Quang Nguyen to become the school's Asian community-affairs specialist, things started to change. Nguyen, a strong supporter of the clinic, meets with every incoming Asian student and urges him or her to join the clinic. About 75 percent of them now do so. He's even translated the consent form into Vietnamese, the first language for most of the school's growing Asian population, which now numbers 220 students. "Our enrollment at the clinic has gone up a lot with Mr. Nguyen's presence,'' Guernsey says.

Teachers, too, had their own reasons to be skeptical of the clinic at first. "There were some who felt that this wasn't the role of the school,'' Guernsey says. "There were some who felt that it disrupted what they were trying to do in the classroom.''

"And there still are a few,'' McCann interjects.

"The approach that we've taken has been to really listen to what the teachers say,'' Guernsey continues. "When they say it disrupts the classroom, they're probably right. And that's something we need to look at. In the early days, we'd have a number of meetings with teachers to talk about how to minimize the disruptions. One of the options teachers have is to not release a student from class to come to the clinic, and there are some who do that.''

Students are required to come to the clinic with a pass from a teacher; they must show the pass to the receptionist before entering their names in a logbook. Every now and then, a teacher will drop by between classes to make sure a student actually reported to the clinic.

Even some teachers who grumble about the clinic are willing to concede that it serves an important function at the school. "I think a lot of kids hide out in the clinic,'' says one teacher, eating pizza with two of his colleagues in the teachers' lunchroom. "Have you guys noticed that? They're always in the clinic. Maybe it's legitimate, and maybe it's not. But they're there all the time. A few kids abuse it. But I'm sure it is the major health program for a lot of kids.

"I'm not trying to sound too negative about it,'' he adds, "because I think it's a good deal for the students. But they need to get their class time in, as well.''

Another teacher, a longtime veteran, says he was against the clinic when it was first proposed. "It just seemed like a lot of problems at the time,'' he explains. "It had never been done before. We didn't know what it was going to do. There were questions about the sex education part.'' Now, he says: "I think everyone supports it. Most of the families don't have medical insurance. So for this neighborhood, it's probably a good thing.''

On the wall of Connie Boyle's combination office/examination room is a poster of a teenage boy with a pleading look in his eyes. The text, in bright red letters, says: "Trust me. I won't get you pregnant.''

Statistically, only about 10 percent of Boyle's work at the clinic is related to teen pregnancies. Acute illnesses, such as ear infections or bronchitis, are much more common. But it's the pregnant girls that stand out in Boyle's mind. "And I'd say that 40 to 60 percent [of those girls] want to be pregnant. Some of them will come in every three to six weeks to get tested. That's the discouraging thing.''

Boyle tries to explain the phenomenon. "It's a way for them to take on an adult role. Sometimes it comes in their senior year, when they feel that it's the next step. I think a lot of them are afraid to get out and work. They don't know what they want to do. Some of them think they'll get out of the home, which they rarely do because they need the support, both emotionally and financially, from the parents.''

All 9th grade students at Lincoln are required to take a course called "Community of Caring,'' which includes a section on teen pregnancy and sexually transmitted diseases. Clinic staff members take part in the curriculum. Despite such efforts, the teen pregnancy rate at Lincoln, Boyle says, remains "fairly high.''

"I don't feel that we've really made the number go down,'' she says. "I think we delay it in some kids. A student who may be thinking about getting pregnant at 16 might do it at 17. And maybe that's helpful.''

Some critics of school-based clinics believe that they actually encourage teen pregnancies, but Boyle disagrees. "We haven't seen that. And I'd say it if we had.''

For several years, a small but vocal group of students at Lincoln has urged the administration to allow birth control to be dispensed at the clinic. Some staff members, however, are reluctant to press the matter. "I would not want to get into it if it didn't have a lot of support,'' says Bruce Guernsey. "We just don't need that. We don't need the controversy. We're already providing a very good service.''

Besides, says Dr. Mike Rudnick, "The reason kids are getting pregnant is not because birth control methods are not available to them but because they basically want to become pregnant. If we had condoms here in the clinic, if we handed them out, if we had them in the bathrooms, if we went window to window in the parking lot, I don't think we would change the overall rate of teen pregnancy. That's not where the problem is.''

Rudnick, 48, is a friendly, soft-spoken man with a round, gentle-looking face. He's dressed casually, in a blue plaid shirt, skinny tie, and white sneakers. A well-used appointment book sticks out of his shirt pocket. Originally from New York, Rudnick taught anatomy in medical school before deciding to become a pediatrician.

"You'd think that the longest appointment in a doctor's office would be for a full physical,'' he says, "but actually in my office the longest appointment is for a negative pregnancy test. Whenever I see a girl come in for a pregnancy test, I see am- bivalence. This is a girl who knows, at least in her head, that birth control is available to her, and for free. If she was concerned about getting pregnant, she would have protected herself from it. For the most part. And the reason is this ambivalence.

"When I see a flat affect on a patient, when they come in and don't seem to give a damn whether they are pregnant or not, or which direction their lives go or not, or whether they're going to be alive at 25 or not, then I see a girl who's been abused. About 25 to 30 percent of my female patients have been abused, usually sexually, usually in an incestuous way, when they were young. Those things get suppressed, and they get denied, and they get at least forgotten on the surface. So when they come to their teen years, and they start to come out of their sociological shells and reach out to other people and get into relationships, they find that they get into very dysfunctional situations. This is where the problems come from. Where a girl will get involved with a guy who abuses her, for example. Where she will have sex with him not because she likes to have sex necessarily but because it's expected of her.''

For girls raised in such an environment, having a baby can be life-affirming. "Making love is lifeaffirming,'' Rudnick says. "It sounds pretty good, doesn't it? And it feels good. And it feels like love, even if it isn't.''

Still, Rudnick would like to be able to dispense birth control and offer abortion referrals at the school clinic, "if that's what the students want.'' But, he adds, "We're a guest here; we abide by what the school community thinks the overall community's mores are.''

As director of the teen clinic at the Westside Neighborhood Health Center, about four miles from Lincoln, Rudnick is the primary health-care provider for many of the school's students.

"I'm their link for when school's out,'' he says. "School is open 180 days a year. That leaves 185 days where students need coverage elsewhere. A fair number of them have private doctors or HMOs. But sometimes they perceive that the services bought and paid for by their parents have more of an allegiance to the one who's paying for it. That may be a false perception, but in many cases they feel that they can't get the confidentiality that they need.

"Teenagers should be the healthiest segment of the population, medically. But, in fact, they are the unhealthiest. They are the segment where we've made the least strides in changing their morbidity rates. And the reasons are social. Basically, they shoot themselves in the foot all the time. So they'll have the usual maladies that anyone else will have, and they'll have the serious maladies that anyone else will have, but by and large they get into trouble because of risk-taking behavior and psychological problems.''

Among those risk-taking behaviors are taking drugs and drinking alcohol. And the number-one substance of choice at Lincoln is marijuana, followed by alcohol. Especially popular are the 40ounce bottles of malt liquor, known as "40s.''

"They love those,'' says drug and alcohol counselor Tracey Brouk, who keeps an empty bottle of Olde English "800'' on her desk as a constant reminder of what she's up against.

Brouk is confident, however, that she's making an impact on the students at Lincoln. "We've had a lot of success,'' she says. "I haven't had to make too many referrals to residential treatment programs. We can pretty much take care of the problems here. And, for the most part, we're seeing reduced use among students and a greater motivation to stay in school.''

Before the clinic opened at Lincoln, students who were caught on campus with drugs or alcohol were automatically suspended from school, sometimes for two or three weeks. "If you're keeping students who are using drugs out of school,'' Brouk asks, "what do you think they're doing? They're at home, unsupervised, or out on the streets, using drugs.''

Now, students caught with drugs or alcohol are given the option of staying in school--on the condition that they attend weekly therapy sessions with Brouk, for a predetermined length of time. The program has helped reduce the school's suspension rate.

Brouk says working full time in a school setting "is almost like working in a day treatment program. You have access to the kids at any time. So you're really on top of things. It's not like an outpatient program, where you see people only once a week, and that's it, and you wonder, 'How did they get through the week?' Here, you can actually go out into the hallway and see how they're interacting with friends or how they're doing in class. You get more of a global picture.''

Four Lincoln students are gathered around a table in the clinic's kitchen/ lunchroom. Richman Lieu, 16, is wearing a Denver Nuggets T-shirt. Rick Alire, also 16, has a friendly smile and pitchblack hair pulled back into a small ponytail. Sharleen Reyes, 18, is a shy Hispanic with dark brown eyes and a small gold cross around her neck. Student council president Aussy Rabih, 18, is wearing blue jeans and a Harvard University sweat shirt.

Richman first came to the clinic as a freshman. Because he wanted to try out for the school's tennis team, he needed to get a physical examination. He could have gone to see a doctor at his family's HMO, which is in Aurora, clear on the other side of town. But the clinic was much more convenient. (Every August, the clinic opens several weeks before school begins in order to provide physicals for those students who wish to participate in school sports.)

"It's easy,'' he says. "You can come in, get an appointment, and walk out. You don't have to drive 20 miles to see your doctor.'' So far this year, Richman has been to the clinic four times. "I think every school should have this.''

Rick, too, first came to the clinic for a physical exam. Now, he's become something of a regular. As one of the school's "peer group counselors,'' he often urges other students to seek help at the clinic. Last year, he even worked part time at the clinic, assisting Theresa Saiz at the front desk for an hour each morning.

Because his father is a Vietnam veteran, Rick can get medical treatment at Fitzsimons Army Medical Center, which is nearly as far away from Lincoln as Richman's HMO. "It's a hassle getting there,'' Rick says, "because I have to take time off from school. I'd rather come here. If there's something the clinic can't do, I'll go to Fitzsimons, but otherwise I'll come here.''

Sharleen has used the clinic for a variety of reasons. "When I was a freshman,'' she says, "my sister ran away from home. So I came here to talk about it with Tracey Brouk. She counseled me for a while, then I was in a Children of Alcoholics group-therapy program. And the nurse took care of me when I was sick. If it hadn't been for the clinic, I don't know where I would be.

"Most of the teachers here, you can't talk to them because they'll push you aside. But you can come to the clinic, and there's always someone to talk to. A lot of kids are real scared to talk to their parents. When they come here, they know that they don't have to be scared of anything. The kids aren't going to get screamed at. They don't treat you like a baby. They don't keep secrets from you.''

For Aussy, the most important thing about the clinic is its guaranteed confidentiality. "My parents like the clinic because it's here,'' she says, "but actually they don't know what I come here for. If I need someone to talk to, they don't have to know. Because I'm doing it on my own time. I don't think parents understand how important the confidentiality is. They want to know everything.''

When Bruce Guernsey first heard that school-based clinics were going to be established in Denver, he was so excited that he approached Dr. David Kaplan about getting involved. A few months later, he was hired as director of the clinics, a job he has held ever since. With a background in adolescent mental health, Guernsey, 46, was well-suited for the position. "I knew these kids,'' he says. "The faces and names were different, but the problems were very, very similar.

"Teenagers have unique barriers to seeking health care that have to do with the transition between childhood and adulthood. They're beginning to experience a lot of problems that they may or may not feel comfortable sharing with their parents or significant others, such as sexuality, or drugs, or alcohol.''

Guernsey knew how difficult it was to try to persuade teenagers to seek out any kind of mental-health counseling. "They're not going to get on the bus and go over there and go through all the rigmarole that it takes when there's a sign over the door saying 'Mental Health,' '' he says. "So the school seemed like an ideal place to set up a clinic.''

From a cubbyhole of an office at Lincoln, Guernsey spends much of his time raising money to keep the Denver clinics running. Because the initial $600,000 grant from the Robert Wood Johnson Foundation ran out last July, Guernsey has had to look elsewhere for longterm financing. "We've had funding from many, many different foundations,'' Guernsey says.

But grant money is only part of the puzzle. Five separate agencies help pay for the clinics: the Denver Public Schools; the Denver Department of Health and Hospitals; the University of Colorado Health Sciences Center; Human Services Inc., which operates four mental-health clinics in Denver; and Arapahoe House, a substance-abuse treatment program. Salaries for staff members are paid for by the different agencies. Guernsey, for example, works for the University of Colorado.

To an outsider, Lincoln's clinic seems firmly in place--but looks can be deceiving. Kay McCann believes that, despite support from most of the school's teachers, the clinic will always have to defend its existence. "If there were a choice as to what had to move out of the building and what could stay,'' she says, "the clinic would go. It's just a turf issue, I think.''

Still, as long as James Trevino is principal of Lincoln--and as long as the money is there--the clinic will stay. "It's an essential part of our total school program,'' says Trevino, a former school psychologist. "We've demonstrated that it works. For someone to try to take it away would tell me that they don't really understand the importance of having these services on-site. I would be very angry, and I would fight it.''

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