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In November 2004, a 15-year-old girl visited Eastern Senior High School’s school-based health center, an on-site medical facility for students. She had started having sex three weeks earlier and complained of an abnormal vaginal discharge. Dr. Jessica Osborn told the girl she needed to be seriously evaluated, but instead of performing a pelvic exam herself, Osborn referred her patient to an off-site clinic.
The girl waited four weeks before visiting East of the River Health Center, and by that time, she was suffering from unbearable abdominal pain. Her sexually transmitted infection had progressed into pelvic inflammatory disease, a complication that can leave women infertile. The girl’s story is one that Osborn recalls with frustration. “I [could] do what needed to be done under normal circumstances,” says Osborn. But inside a D.C. public school, she could do nothing.
Starting on May 5, 2003, when Assistant Superintendent Ralph Neal sent Eastern’s school-based health center a letter calling a halt to all gynecological exams, Osborn had been forced to make hundreds of similar referrals, turning away, by her estimation, four girls a week. “I [could] do a testicular exam,” she says. But to her frustration, she couldn’t perform gonorrhea and chlamydia screenings on girls. “Separate and unequal,” she deems the policy.
The letter was also sent to H.D. Woodson High School’s Adolescent Wellness Center. Coleen DeFlorimonte, a nurse practitioner and the clinic coordinator for the center, says she “felt like our hands were tied” when it came to giving the exams. “As a health-care provider, it is never a good feeling if you can’t provide the health care that’s needed,” she says.
Thanks to Neal’s letter, for nearly two years, D.C.’s two high-school-based health centers appeared to be the only ones nationwide where doctors were forbidden to perform pelvic exams in the course of offering routine health care. John Schlitt, director of the National Assembly on School Based Health Care, says he wasn’t “aware of any other policy” as restrictive as the District’s. And on April 19, D.C. Public Schools (DCPS) Superintendent Clifford Janey reversed Neal’s order, following a recommendation to do so from the D.C. Department of Health.
In recent months, Osborn, along with children’s-advocacy organizations such as D.C. Action for Children and Childworks, had stepped up their fight to end the pelvic-exam moratorium. On Feb. 16, Osborn testified in front of the Board of Education that the exams were part of routine physical care and that the ban was discriminatory. She was particularly concerned that by preventing the exams, Neal was undermining the purpose of school-based health centers. Their mission, says Osborn, is to provide “access for those who generally don’t have access. We [were] being restricted in a community that needs it the most.” She adds, “There aren’t many pediatricians in Wards 7 and 8.”
School-based health centers began over 20 years ago in Cambridge, Mass. They are different from a nurse’s office because they can track immunizations, provide physicals, and perform sickness and wellness check-ups. To date, there are four school-based health centers in D.C., including ones at Marie Reed Learning Center and Brightwood Elementary. A memorandum of understanding between Eastern and Unity Health Inc., the D.C. health-care provider that runs Eastern’s health center, states only that “routine physical exams will be conducted” and “a general supply of prescription” medications will be kept. But because there is nothing in the D.C. Code that defines who regulates school-based health centers, legal issues have plagued them.
In addition to pelvic exams, the centers stopped dispensing prescription medications on the basis of orders given in the same 2003 letter from Neal. Although Neal had no formal regulatory authority over the centers, Osborn followed his directives because she feared that her center would be booted from school grounds if she disregarded them. But she also worried that when she referred her young patients elsewhere they wouldn’t go for “financial reasons, transportation issues, insurance issues, and parental-consent” obstacles.
The restrictions that affected Eastern didn’t apply to the city’s two mobile health-care units that visit schools. Dr. Matt Levy works in the Georgetown Kids Mobile Medical Clinic, which services Spingarn Senior High School and Anacostia Senior High School. Thanks to off-campus parking, which “allows us to be more flexible,” he could give students pelvic exams and dispense medications. Levy, who supported ending the restrictions, says that the care in school-based health centers should “be the same care you get going anywhere else.”
DCPS officials have been tight-lipped about explaining their actions in preventing the exams. Neal refuses to comment on the original letter, and Jennifer Ragins, the director of school health programs, says she’s “under instruction not to talk about the issue.” Janey declines to comment, but Carolyn Graham, a school-board member, says, “What has changed is a better understanding in a superintendent who is willing to look at the decision objectively.” Of past superintendents, she says, “I’m not sure children’s health was a priority for them.”
Even if Janey had chosen to support the ban, the Board of Education, which was slated to vote on the issue later this year, would have likely decided to end it. According to board member Tommy Wells, the vote would have been unanimous. “I think the emotions were more like, ‘This is ridiculous,’” he says. “The general feeling was that this was a no-brainer.”
Wells says that he is pleased by Janey’s decision. “It is in the interest of the health and safety of our young women, and I’m sorry it took so long,” he says.
On April 21, two days after the ban was rescinded, Osborn gave her first on-site pelvic exam at Eastern in almost two years. A freshman came in with lower-abdominal pain. “I felt much more useful, but I still wasn’t able to treat her,” says Osborn, who wanted to give the girl a shot of the antibiotic cestriaxone. The prohibition against dispensing medication is still in effect, so Osborn had to write a prescription and hope that the girl would get it filled; she asked the girl to bring the empty prescription bottles “for proof.” Osborn is frustrated that she can’t medicate on-site, “but that’s another battle,” she says. CP