How School-Based Health Centers Can Help Save Our Kids

Thanks to my elementary school nurse, I finished school on time. That’s right: In the 5th grade, I strained during a school vision test to read the little letters I saw projected on a screen 10 feet away. Asking in bewilderment if I wanted to try again, the screener asked, “How have you even been seeing the chalkboard?” Off to the nurse I went to get my prescription recorded for her records, and glasses were ordered that day.

In the context of today’s school health services, my experience seems paradisal. That’s because today, public school health services are conspicuously absent. As a youngster, I never gave much thought to how the presence of that nurse or vision screener and her assessment impacted my uninterrupted performance in school. Given that we know academic success and wellbeing are inextricably linked, the low number of school-based health centers and staff is particularly troubling. Increasing the number of centers with fully staffed health professionals—nurses and school psychologists in particular—can greatly improve child health as well as academic performance.

The Affordable Care Act appropriated $200 million for the explicit purpose of building and expanding school health centers, a number that still seems low considering that only 45 percent of public schools have a full-time nurse, and 30 percent can only count on a nurse part time. A quarter of public schools have no nurse at all. A mere 12 states have met the Department of Health and Human Service’s desired ratio of one nurse for every 750 students.

The cost of a school nurse—the average salary hovers around $43,000 a year—and of equipping a center with supplies varies from state to state, and even county to county. If the ACA money were used solely on nurses, it would only allow 4,651 nurses to enter the field. After covering the staffing of public schools in New York City, Los Angeles, and Chicago we would be left with funding for a little over 1,000 full salaries—without even beginning to consider the cost of dedicating and maintaining a physical space in a school and procuring supplies.

Historically, school-based health centers have done everything from dispensing Band-Aids and cleaning cuts to providing immunizations, dispensing medications, and coming to the aid of children suffering from seizures. These centers have also offered preventive care and treatment for children who may not otherwise have access to health insurance. They can have a significant impact on what is known as the “achievement gap,” the major race and socioeconomic disparities in academic success that begin to emerge as early as elementary school, by working to address the health issues that have the greatest impact on a child’s performance in school.

An emerging body of research points to the ways in which these disparities could be drastically reduced, and preventive care restored, with the return of robust care being offered in house at our public schools.

The Journal of School Health devoted an entire issue to research by Charles Basch, Ph.D., of Teachers College, Columbia University, that highlights health issues with historically high socioeconomic, racial, and urban health disparities, how they contribute to poorer academic outcomes for minority youth, and how school-based health care can mitigate them. Children of color currently make up 85 percent of New York City’s public school system, one of the most racially segregated in the nation, and Basch’s research outlines seven health problems that can be easily addressed by a school nurse within these segregated environments and help reduce the disparities.

The least contentious health issues addressed are asthma, vision and nutrition. The prevalence of asthma among black children in the United States is 12.8 percent versus 8.8 percent for white children, and the annual estimate of asthma attacks among black children is 8.4 percent compared to 5.8 percent among white youth. Poorly controlled asthma can impact cognition and plays a significant role in absenteeism; the overuse of emergency departments and underuse of effective medications among minority youth are a good measure of how the affliction is having greater negative consequences for children of color.

As someone who needed glasses fairly young, it’s unsurprising that more than a fifth of youth have vision problems. A national sample of nearly 50,000 children showed those from low-income families were less likely to have vision diagnoses than high-income children. Once diagnosed, black children have less intensive and sparser care than whites. And everyone knows that breakfast is the most important meal of the day, but one study showed that among 9-year-old girls over a three-day period, 77 percent of white children had breakfast every day while only 57 percent of black children did. Of children qualifying for reduced or free lunch in their public schools, less than half participated in schools’ free breakfast programs for which they were eligible. Nutrition influences brain activity, which results in significant impacts on children’s learning and cognition.

There are uncomplicated solutions to these problems. Asthma screenings are quick, and medicines are immediately effective. Dealing with symptoms and management of asthma at school can decrease both absences and severe attacks. Vision screening is widespread in schools, but the coordination of follow-up care by a school health professional is essential for children in need of eye-care interventions and is the biggest culprit behind current disparities. Participation in universal school-breakfast programs has shown reductions in absences, and allowing children to eat breakfast in their classrooms as opposed to the cafeteria has resulted in increases in the programs. School-based health centers can oversee the distribution of healthy meals for children in need of these programs, with the added perk of highlighting which students may benefit from other school-health services.

Attention deficit and attention deficit hyperactivity disorders (ADD and ADHD) have received much attention in recent years. ADD/HD affects sensory perception, absenteeism, cognition, and even organizational and planning skills. Urban youth of color are more likely to be affected by and less likely to receive a correct diagnosis and effective medication. Screenings by school psychologists and learning specialists can aid in the diagnosis of ADD and ADHD and the accessing of medications, as well as help students with effective behavioral modifications. School nurses are in a position to manage the medications by dispensing them to students at school if necessary, and ensuring that the timing and dosage are accurate.

Most contentious of the issues tackled by Basch in his call to arms is teen pregnancy. Among 15- to 17-year old girls, the pregnancy rate among blacks is more than three times higher than whites, and the rate among Hispanic teens is more than four times as high. Teen mothers on average have two fewer years of schooling. They are 10-12 percent less likely to finish high school, and have 14-29 percent lower odds of attending college. The implementation of evidence-based, comprehensive sex education is the best way to reduce the teen pregnancy disparity. This requires the overhaul of the popular abstinence-only education programs, which have been shown to leave students ill-equipped to make the healthiest decisions. Given the fraught political environment, comprehensive sex education is not widespread, and school nurses can be an essential resource for students beginning to engage in sexual activity. From dispensing condoms to connecting students to community resources for treatment who may disclose concerns about both pregnancy and sexually transmitted infections, and being the person on campus who can answer questions privately about reproductive health, nurses can address issues that are not part of classroom learning.

There are signs of hope, as Basch was asked by Secretary of Education Arne Duncan to outline national health strategies in schools, but the now well-known public funding cuts to both healthcare and education continue to threaten the health status and educational attainment of youth in America’s public schools.

The disparities can be shocking. But these specific health issues are fairly straightforward, do not require specialists, and can be tackled easily within a school environment by nurses, resulting in the improvement of both kids’ public health and academic achievement—as long as they are given the finances and support to do so. As a front line of defense against immediate health emergencies and the prevention and maintenance of chronic diseases that develop in elementary school years, ensuring the presence of fully staffed, funded, and stable school-based health centers is essential—most especially for our children already victim to a shameful lack of resources.

 

Originally published at The 2×2 Project

Maternal Health and the Status of Women

Both globally and domestically, maternal health and the standing of women are inextricably linked. If women do not have the means and access to give birth safely, with trained and educated midwives, physicians and nurses, with appropriate prenatal education and care, it is often indicative of the standing of women in their communities and countries overall. Women’s inequality is also linked to the soaring population growth in developing countries, which will pose a range of new challenges for the next few generations.

Some may point to the United States as an anomaly, citing women’s increasing economic and financial independence, education, and leadership roles in America, while in terms of maternal health rankings, we remain pathetically far down the line for our resources (49 other countries are safer places to give birth than the U.S. – despite us spending more money on healthcare than anywhere else). Of course, the recent and incessant attacks on allowing women to access credible, accurate, up-to-date and comprehensive sexual and reproductive health education and services makes this statistic not entirely…surprising, shall we say.

So, I found the incredibly detailed and visually impressive infographic by the National Post, pulled from spectacular data and research done by Save the Children to be particularly fascinating. What they did was combine information on the health, economic, and education status of women to create overall rankings of the best and worst countries for women, splitting the countries into categories of more developed, less developed, and least developed, and the countries were ranked in relation to the other countries in their category (the divisions were based on the 2008 United Nations Population Division’s World Population Prospects, which most recently no longer classified based on development standing). While these divisions and the rankings can certainly be contentious and may incite some disagreement (nothing unusual there, these kind of rankings usually are), I thought the results were interesting. Some highlights – Norway is first, Somalia is last. The United States was 19th, and Canada was 17th (Estonia fell in between us and the Great White North) in the most developed. Israel is first in the less developed category, and Bhutan is first in the least developed category. The full report with data from Save the Children is also available, if you want to learn more about the information combined to make this image. Take a look:

A Woman’s Place – Courtesy of the National Post

One thing that I thought was particularly great was that the researchers combined women’s health and children’s heath data to create rankings specific to being a mother, when that category is sometimes only assessed based on access to reproductive care.The specific rankings of maternal health highlights largely mimics the overall standing of women, as seen here – Norway is number one, again, and Niger falls into last place:

Mother’s Index, Courtesy of Save the Children

I think these images and graphs are particularly moving given one of the top health stories coming out of the New York Times today, which showed that a recent Johns Hopkins study indicated meeting the contraception needs of women in developing countries could reduce maternal mortality (and thereby increase the standing of women in many of the nations doing poorly in the above ranking) globally by a third. When looking at the countries in the infographic that have low rates of using modern contraception and the correlation between that and their ranking in terms of status of women, it’s not surprising what the JH researchers found. Many of the countries farther down in the rankings have rates below 50%, and for those countries filling the bottom 25 slots, none of them even reach a rate that is a third of the population in terms of contraceptive use – which of course in most cases has to do with availability, not choice. Wonderfully, the Gates Foundation yesterday announced that they would be donating $1 billion to increase the access to contraceptives in developing countries.

Also of note, and in relation to maternal and newborn health, is a new study recently published by Mailman researchers that showed PEPFAR funded programs in sub-Saharan Africa increased access to healthcare facilities for women (particularly important for this region, as 50% of maternal deaths occur there), thereby increasing the number of births occurring in these facilities – reducing the avoidable (and sometimes inevitable) complications from labor and delivery, decreasing the chance of infection and increasing treatment if contracted. This has clear implications for children as well (and why I think this study relates to the National Post infographic and the NY Times article), since newborns are also able to be assessed by trained healthcare workers and potentially life-threatening conditions averted – including HIV, if the newborns have HIV+ mothers and need early anti-retroviral treatment and a relationship with a healthcare worker and system. And it goes without saying that if a new mother is struggling with post-delivery healthcare issues, including abscesses and fistulas, or was dealing with a high-risk pre-labor condition like preeclampsia, the child will have an increasingly difficult early life, perhaps even a motherless one.

Child Mortality – What Are the True Biggest Causes?

A great image from Population Services International‘s most recent issue of their magazine, Impact, from the cover article written by Desmond Chavasse, Ph.D, Vice President, Malaria Control & Child Survival, PSI, about causes of child mortality globally.

Causes of Child Mortality – Image courtesy of Population Services International

One of the purposes of the image, of course, is to show the stark contrast between directed funding for treatment and eradication of certain diseases and the number of children afflicted with these illnesses. How does this impact our understanding of global health and of the marketing around certain hot topic health issues and ways in which donors feel as though they are contributing to a decline in preventable deaths?

When I worked in development for HIV/AIDS organizations, it was fascinating to speak with donors about their reasons for giving and their understanding of the prevalence and incidence (and the general audience grasp of the word incidence, which is the measure of risk of contracting a certain illness or disease within a specified time frame) of HIV. Contrast this with the understanding of malaria, TB, diarrhea, deaths due to childbirth complications (for the mother and the infant), and the gap between perception and reality was startling. In no way do I want to deny the importance of consistent development support for all diseases on a global scale, but I do think there is something lacking in terms of the education around these issues for donors and even some advocates.

Solutions? Come chat with me on Twitter.

Abortion Isn’t That Simple, Mr. Douthat

Ross Douthat, one of the NY Times conservative columnists whose pieces I occasionally force myself to read, wrote an article yesterday about sex-selective abortion. In short, he claimed that the reason 160 million women were “missing” (that is, the reason they were so outnumbered in many countries like India and China, as well as other nations in the Balkans and Central Asia) was because they were “killed” via sex-selective abortion. In his words, the women weren’t “missing,” they were “dead.” (He also claims that the author of the book he cites, Mara Hvistendahl of the book “Unnatural Selection: Choosing Boys Over Girls, and the Consequences of a World Full of Men,” appropriates the issue to one of patriarchy, of greater social issues and inequities – which I agree with. He then says that “the sense of outrage that pervades her story seems to have been inspired by the missing girls themselves, not the consequences of their absence,” saying that she is more upset by the idea of abortion itself than she is about the issues surrounding abortion. Don’t you think that’s for her to decide? And doesn’t it seem she’s already decided what she thinks based on her book?)

Douthat, however, manages to contradict the crux of his argument near the start of his column.

He begins by saying “female empowerment often seems to have led to more sex selection, not less.” He then quotes Hvistendahl as saying “women use their increased autonomy to select for sons,” because male offspring bring higher social status. In countries like India, sex selection began in “the urban, well-educated stratum of society,” before spreading down the income ladder.

If this were the case – if in fact women had become truly empowered in their respective lands – culturally, politically, economically – then why would they be aborting based on the opposite – that men in their communities are still holding the cards? Are they imagining that men still hold positions of power and wealth in their countries, or are they living the ramifications of that painful reality everyday? Women do have some increased autonomy in many of these regions. But guess what? This autonomy has likely served to highlight the still very real inequities and disparities that exist in their communities, which contributes to the rates of sex-selective abortion. If women see which sex has the higher status, and one of the few autonomous decisions they can make is to choose the sex of their baby – they are likely going to choose the one with more status. This upsetting power dynamic shows just how far away true empowerment is for many of these women and their communities. If they felt their children would have the same opportunities if they were female than if they were male, the sex selection abortion Douthat decries would actually decrease. It is not the responsibility of the female fetus to ensure she is treated with the same respect and equality as the male fetus. Douthat seems to really care about female fetuses – but seems less interested in addressing the massive social, political, and economic issues that create so many difficulties for them once born. (His colleagues Paul Krugman and Nick Kristof seem to have handles on that. Too bad they were off yesterday.)

It seems that Douthat wants to push for the feelings of regret and remorse about abortion itself, separate from the issues surrounding it. Does sex-selection abortion sadden me? Yes. Does aborting a fetus that indicates it will have Down Syndrome sadden me? Yes. You know what else makes me sad? That a woman cannot afford a baby because she is single and has no familial or community support; because she has an abusive partner (homicide is the number one cause of death for pregnant women); because she has a low-wage hourly job that offers no maternity leave which could help her stay well while carrying the baby if needed; because she has no health insurance meaning she can’t access quality pre-natal care to make sure her baby would be healthy since we are systematically closing down those facilities that offer services for women who are uninsured (and also help provide birth control to prevent pregnancy!); because she has no way to pay for day care and she may have to quit her low-wage job to care for her baby; because she would then have no money for all the supplies, food, and developmental tools her baby would need to thrive which can lead to malnutrition, behavioral problems, child depression; because she could then become part of the 29.9% of families in poverty that are headed by single women, and her child could become part of the 35% of those in poverty who are under 18 years of age – the poverty rate for households headed by single women is significantly higher than the overall poverty rate.

We’ve cut child welfare services that aid women by the tens of millions in the past few years. Georgia alone cut over $10 million in Child Welfare Services. We’ve also cut subsidies that support adoption agencies – the organizations that help women find families that may be able to care for her baby were she to carry it to term – and who make sure these families are actually fit to do so! TANF (Temporary Assistance for Needy Families) provides women and families with aid so that children can be raised in their own homes or with relatives, instead of being placed in foster care and becoming wards of the state. How much have we cut from TANF? 17 of the poorest states, with some of the highest poverty rates in the nation, have already stopped receiving funds.

Birth control, one might say? Sure – birth control is expensive, so if she doesn’t have health insurance, she isn’t likely to be able to afford birth control (hey, Planned Parenthood can help with that, too! Seeing a pattern?) And if her partner refuses to wear a condom? If she is in an abusive relationship, if she fears leaving her partner, if she relies on her partner for added economic security – she’s much less likely to argue with him about the condom use. Or even feel that she has the agency to begin a negotiation discussion at all.

These facts make me sad. And all of these facts might lead a woman to decide she can’t have a baby. And many things not listed here may lead a woman to decide that she will not have a baby. And that she will have an abortion. Is it my decision? No. It’s not. It’s not yours or Ross Douthat’s, either. Again, Douthat represents the contingent of pro-lifers who want to make it seem like pro-choicers are cheering the performing of abortions right and left. What we are cheering is the right for women and respect of women to make their own decision based on their very specific personal circumstances. And given the fact that the medical establishment has not agreed with the pro-life camp in claiming that fetuses before a month into the third trimester can feel pain (reacting to stimuli does not equal pain, to reiterate, and pain without a cerebral cortex is seen by physicians as not possible), which has most recently become the pro-life camp’s wildly off-base rationale for preventing a woman’s right to choose, and given the fetus’ place of residence in the woman’s uterus as a part of her body, not as a human, these issues that Douthat sees as “sideline” are actually very much at the center of the argument. Bottom line – it’s the woman’s body. It’s the woman’s choice. She will be the one carrying it, she will be the one birthing it. No one else. So why should anyone else decide?

Additionally, it is not a crime for a woman to not want children. Since she is able to give birth, it is her decision as to when and how that will happen. Everything about her life and future will change once she has a baby. So she needs to be sure she is ready for that. How can one disagree with that? Douthat may not like it, but “the sense of outrage that pervades his story” (see what I did there? 😉 ) seems to me more rooted in his anger and frustration with his opinion not being considered by women in these decisions and not being able to control what a woman decides to do about what is going on in her body.

All of the things I listed – the job issues, the healthcare issues, the family and community issues, the issues that arise when a child doesn’t have access to food, clothing, and developmentally appropriate stimulation – are the causes. So why don’t we start figuring out how we can mitigate those facts and issues instead of attacking the effect – the abortion – which is a decision women come to after weighing all of those facts and issues just discussed. Douthat’s fear tactics of talking about female fetuses strewn across Indian hospitals is scary imagery. So is this:

Photo thanks to ehow.com

And this:

Photo via Captain Hope's Kids Blog

And this:

Photo property of streetkidnews.blogsome.com

Want less abortions? How about providing health insurance, that covers both birth control and pre-post natal care? How about equal pay for equal work, so women are more financially and economically secure, providing them with the resources to stay out of poverty and keep their children out of it, too? How about child care in work environments, helping women who cannot afford day care can stay in their jobs and remain a part of the economy? While we’re at it, how about great public schools and clean community centers, so women know their children are being intellectually fed and socially stimulated in safe environments that help keep them out of more dangerous and potentially life-threatening social circles? How about comprehensive sex education so men and women know how to protect themselves not only from pregnancies but from diseases that can endanger a fetus and create complications during birth and cause health issues for them and their children – creating more expense, particularly if one has no health insurance.

Let’s talk then. And how about you follow me on Twitter?