A Clinical Debate : School Proposal’s Foes Continue to Focus on Birth Control Role

In 1970, after much controversy, the United States’ first health clinic on a public high school campus opened--an attempt to reduce teen-age pregnancies by offering students reproductive counseling and contraception.

Now, almost two decades later, with more than 120 school-based clinics nationwide, the general focus of the facilities has changed significantly to center on prevention and treatment of acute and chronic illness, counseling for drug abuse and other behavior-related problems, physicals and immunizations, with less emphasis on sexual matters.

But, as supporters of the first such clinic in San Diego prepare to make their proposal Tuesday to the city Board of Education, they face a vocal opposition that has zeroed in on the original issue of teen pregnancy, even though clinic directors reported in a 1986 national survey that no more than 15% of student visits involve family planning problems.

Variety of Services

A Hoover High School committee of parents, teachers and community health providers has proposed a student health and social service center on the East San Diego campus that could offer a variety of services to students with parental permission. Among them: medical care for illness and injuries; physical exams, immunizations and medications; counseling for police-related and drug and alcohol problems, and referrals for specialized medical and dental care.

The center also could offer counseling for family problems, provide information and referrals on pregnancy and sexual issues, handle prenatal care and perhaps dispense contraceptives, based on favorable responses to a proposed list of services from 17% of 8,000 parents who returned a survey sent them by Hoover last month.

The initial proposal up for consideration Tuesday would direct Hoover administrators to design a specific operating plan, seek a contract provider and obtain funding from private national foundations that support such clinics. There would be no direct financial support from the school district.

Proponents cite surveys among Hoover students last year that show that half the school-age population has no regular health care, as well as new county data showing that 54% of all children in Hoover neighborhoods--kindergarten through 12th grade--are from families on welfare. The proposed clinic is intended to serve any student at Hoover, Wilson Middle School or the seven elementary schools in the area.

Unless the students--a rainbow mix of Indochinese, Latino, black and white teen-agers--receive regular health care, the Hoover committee argues, they cannot and will not learn to their potential. Members note the overwhelming caseload of 1,000 students a month seen by Hoover’s school nurse, who can diagnose and refer students but cannot treat illnesses or prescribe medications. Many students cannot afford to visit doctors even when referred, the committee says.

Letter From Bishop

Those arguments have made no headway with opponents led by Bishop Leo T. Maher of the San Diego Catholic Diocese. He has decried the proposal on philosophical grounds in a pastoral letter to county Catholics, writing that a school-based health clinic is but “a disguise for a sex clinic.”

Maher alleges that clinic backers seek to encourage sexual promiscuity among students in a conspiracy with Planned Parenthood, the family planning agency whose mission is opposed by the Catholic Church because it offers counseling on abortion.

Maher successfully led the opposition to a July, 1986, proposal from San Diego schools Supt. Tom Payzant to establish school-based clinics, and he is even more vociferously opposed this time, even though the impetus for a clinic now comes from an individual school community.

Father Douglas Regin, the diocesan “respect life” director, has said that health clinics undermine the moral value of society by offering “safe sex” to students, and that schools should instead stress that pregnancy can be avoided through a moral life style of abstinence until marriage.

Opponents also argue that any requirement for parental permission prior to reproductive services would be subverted by clinic directors in their zeal to push contraception and abortion. They further question the sincerity of Hoover administrators who say that area students’ health and social service needs are unmet or that only private funding would be used.

At both the local and national levels, the primary fight against clinics revolves around the political issue of providing adolescent family planning services. There is no disagreement on the basic facts surrounding that issue.

No Agreement on Solution

About half of all American teen-agers are sexually active by the time they leave high school, and more than four in 10 women become pregnant before they reach age 20. Data from the Hoover Institution at Stanford University shows that 23% of all women will be single mothers by age 25. Of those, 53% are black.

Beyond those figures, however, there is no agreement on how to address the problem.

UC San Diego pediatrician Jeffrey Black, a consultant to the San Diego Unified School District, said clinic experiences in St. Paul, Minn., and Baltimore indicate a possible reduction in teen pregnancy resulting from a combination of contraceptive services and counseling, in addition to classroom sex education.

In a March article on school-based clinics for the journal Contemporary Pediatrics, Black said that at the St. Paul clinics, where both pregnancy counseling and contraceptives are offered, the birth rate declined from 59 per 1,000 to 37 per 1,000 over eight years, and the percentage of sexually active women using birth control services increased to 35% from 7%.

Black added, however, that other clinics have not shown similar gains, and other programs with only sex education and/or an emphasis on abstinence produced measurable results. But, in the same March issue, Dr. Morris Green, a pediatric professor at the James Whitcomb Riley Children’s Hospital in Indianapolis, said that “there is no evidence that sexual activity is increased among students who participate in clinic family planning counseling,” a conclusion that Los Angeles school district clinic administrators have also reached after almost two years of operation.

“The other assets of using schools as sites for health care delivery are more clear-cut,” Black said. Although detailed studies are not widespread, Black cited a school clinic in Dallas where students showed a lower rate of hospitalization than those in schools without a clinic.

Little Effect Seen

Michael Bernstam, a Hoover Institution senior researcher specializing in teen pregnancy issues, said his studies show that the rates of illegitimate pregnancy or abortion among teen-agers are little affected one way or the other by family planning services at school-based clinics.

“I can understand why schools would like such services because they see real girls--not just statistics--who are pregnant or sexually active, and maybe in some cases they can help by talking them out of pregnancy,” Bernstam said.

“But I believe the real benefit in this area for a clinic comes from helping the health of future babies, because these girls who get pregnant usually have less access to prenatal care, are less likely to stay in school and have a higher birth mortality rate and have more babies with low birth weights, which we know brings problems down the line.”

Bernstam suggested that a wide range of social services to stem dropout rates and to boost self-esteem, if offered at a health clinic, might have more of an effect in lowering pregnancy rates than sexual counseling alone.

“If you can show a girl that there are greater opportunities ahead, that completing school and going to college is realistic, then you don’t have to worry as much about pregnancy,” he said.

Bernstam said he understands the philosophical position of the Catholic Church, recalling a 1976 audience he had with Pope Paul VI. “I told him that if the church had enough time and money to persuade the world of its position, fine, and that he could preach as long as he wanted to, but it would not change the practical facts of life one iota.”

Bernstam’s colleague at the Hoover Institution, sociologist Kingsley Davis, is quoted in Bishop Maher’s pastoral letter as decrying contraceptives as a “technological device” to try and solve a social control/social discipline problem.

But Davis said in an interview that while he does believe contraception alone is no solution, he would have no problems with behavioral counseling and contraceptives within the context of a comprehensive clinic. “I see nothing wrong if (a proposal) is for a general clinic with pregnancy issues as one component,” he said.

Hoover and school district administrators say too many teen-agers have a lack of knowledge about human sexuality, about pregnancy and about where to get help either for prevention or pregnancy care. At present, district nurses can provide no family planning counseling, and can only suggest that worried students seek help from agencies such as Planned Parenthood or Door of Hope.

The three small programs in the district to help teen-agers who are pregnant or have a child continue their schooling have waiting lists.

But proponents insist that their overwhelming reason for the clinic proposal is to provide basic, free medical and counseling services to students who otherwise, both for reasons of transportation and economics, are unable to get them elsewhere. The student survey showed that 32% acknowledged having occasional depression and 16% had thought of suicide at one time or another, in addition to not having ready access to affordable basic medical care.

Because the Hoover clinic would serve all public schools in the area, health education--such as dental care for children--could easily be combined with clinic treatments, supporters say.

Father Francis Penko, pastor of Our Lady of the Sacred Heart parish near Hoover, said that “there is no question” that many students in the East San Diego area need better health care. He believes that opposition would be much less if a school-based health clinic banned all reproductive-related services, but added that he doubts proponents would be interested in such a limitation.

Penko said he thinks there is a desire for what he called “social engineering. If their concern is genuinely for health, then why not get private funding to hire another nurse or two more nurses and let the nurses refer to outside clinics and tell the students how to get there?” Penko said his own parish school refers children with health problems to a low-cost clinic several blocks from the church.

He and other opponents also label as a sham the need for parental consent, as proposed by the Hoover committee, because of a California law permitting minors to have access to reproductive services without the approval of parents.

But Los Angeles clinic officials and San Diego city schools attorney Tina Dyer say the law allows a minor to receive such treatment only if the provider--whether a doctor or clinic--has a policy of consenting to offer those services to any minor requesting them.

The law does not prohibit a clinic from setting up its own regulations not to allow any reproductive services for minors, to allow them only if parents have given permission for them or to allow them with or without parent approval, Dyer said.

“I don’t believe we would be mandated with a clinic into giving such services unless we chose to do so,” she said. “And my understanding of the proposal is that we would require parent permission for the service before it would be offered, and I believe that requirement would not go against state law.”

As for funding, another member of the organized opposition, Joan Patton--a board member of the San Diego County Right to Life Council--argues that clinic funding is unstable because private foundations provide money only for the first two or three years.

Supporters concede that foundations will not back clinics indefinitely, although the Robert Wood Johnson Foundation has provided $16.1 million for 23 clinics nationwide and has recently committed itself to additional funding for Los Angeles for another four years.

“For the present, clinics must rely on a creative combination of private and public funding,” Black wrote in his March study.

The Legislature has measures pending to provide some state money, but their success is questionable given the state’s present budget crunch in the health and welfare areas.

Tuesday: How three school clinics in Los Angeles operate.