It is a familiar scene.
Parents fill out forms on a clipboard as they sit in the waiting room of a full-service health and dental clinic. Teenagers, insured or not, can use the health center for a range of services, from physical exams and flu shots to dental extractions and root canals.
But there are surprises. The patients who trickle in and out are students. The 900-square-foot room is a retrofitted classroom that has been converted into a full-service health and dental clinic for the students of Kahuku High and Intermediate School. It is the first such health center in the state.
When Civil Beat visited the clinic on a recent school day, a dental assistant was taking X-rays of one boy’s mouth, while a dentist was doing a comprehensive dental exam on another. A third student checked in at the front desk for his doctor’s appointment.
The clinic spares these kids the hour-long drive into town that they would normally have to take for basic checkups and other health services, which often required missing a full school day. It also provides wellness counseling and other advice to help the students to live healthier lives. Ultimately, it aims to make Kahuku into a healthier community.
Preventable chronic diseases such as diabetes plague Hawaii — particularly low-income residents with limited access to medical care. Type II diabetes, whose prevalence is exacerbated by child obesity, is expected to affect one in every two children in Hawaii by 2050, according to the Healthcare Association of Hawaii’s 2013 Community Health Needs Assessment. Nationally, the forecast is one in every three children.
Experts say many of the health problems that afflict Hawaii’s most vulnerable communities could largely be prevented if children had access to comprehensive health services at the state’s public schools like students do at Kahuku. Access to those services, including mental health support, would in turn enhance the children’s ability to concentrate and learn, ultimately ensuring their long-term success.
“Children spend the majority of their waking hours in schools and one of the best chances for improving the health of the next generation is through school-based programs,” the Community Health Needs Assessment says.
But those school-based services are all but nonexistent in Hawaii, according to Linda Juszczak, president of the national School-Based Health Alliance.
That void, she said, is “conspicuous.”
Makaha resident Cedric Gates grew up eating “artery-clogging fast food” and staying indoors. He never played sports.
The dangers of such a lifestyle became clear when Gates’ 260-pound mother died of a heart attack at the age of 46. Gates was 12 years old at the time.
He dropped out of Waianae High School when he was 15. And he was becoming obese.
But it wasn’t until years later — when he was 17 years old, nearly 200 pounds and fresh out of trade school — that Gates woke up one morning and realized he needed to change things if he wanted to avoid the same fate as his parents.
His father, too, struggled with his health, suffering two strokes while battling heart disease and diabetes.
One day, Gates decided to go for a run. The next day he went to the park, where he saw some friends playing basketball.
Soon enough, Gates was playing the sport everyday. And instead of fast food he started cooking and eating fresh produce, he says, displaying a recent photo of his fridge, its shelves lined with rainbows of fruits and vegetables.
Gates and his brother even helped launch a nonprofit devoted to expanding the life expectancy of children and adolescents on the Waianae coast by promoting nutritional education, physical activity and community wellness. The Active Hawaii Organization is currently advocating for a market where residents can buy cheap produce instead of chop suey and fast food, among other initiatives.
But Gates, now 20, wonders where his life would be had he not had his epiphany. What if Waianae had a school-based health center?
Efforts are underway across the country to set up full-service health clinics at public schools where students have limited access to such care because of factors that include geography and income. There are as many as 2,500 of these school-based centers — what some call “one-stop shops” for healthcare — nationwide, more than 300 of which also offer full-service dental care, according to Juszczak.
At a typical school-based health center students can be treated for acute illnesses and chronic conditions; screened for dental, vision and hearing problems; and counseled on healthy habits and ways to prevent injury, violence and other threats.
Most of the centers rely on state funding or private donations, while a few are subsidized by the federal government through the Affordable Care Act. The federal legislation set aside about $200 million for construction and equipment at school-based health centers between 2010 and 2013.
It was this grant program, along with grassroots community advocacy, that facilitated the recent creation of the Kahuku school clinic. In 2011 Kahuku’s Koolauloa Community Health and Wellness Center got $500,000 through the Affordable Care Act.
“There was just such an obvious need” for the Kahuku school clinic, said Koolauloa Health Center CEO Ben Pettus, who helped secure the grant.
The center recently completed construction and just started serving students this year. Dozens of the school’s roughly 1,500 students visit the clinic every day for a wide array of services, according to Kahuku Principal Pauline Masaniai. Teachers can use the clinic, too.
Many of the students have limited access to health care; very few doctors and dentists’ office exist along the 30-mile stretch between Sharks Cove and Kualoa Ranch, meaning that students typically have to drive all the way into Kaneohe or Honolulu for an appointment — during the school day.
In fact, the clinic is expected to drastically reduce chronic absenteeism among students who would otherwise miss class due to illness or far-away appointments, a problem that the state school district has made a top priority in its strategic plan. A Civil Beat analysis last year found that chronic absenteeism — what Hawaii defines as 15 or more missed school days — is highest in poor, rural areas.
And the clinic, like most other school-based health centers, targets poor, minority children, and never turns away a student over inadequate or non-existent insurance. In rural areas in Hawaii, slightly more than 11 percent of residents lack health insurance, compared to fewer than 7 percent of people in urban areas, according to recent American Community Survey data. And roughly twice as many children lack health insurance on the neighbor islands compared with Oahu, the data shows: an average of 5.3 percent of children in Hawaii, Kauai and Maui counties, versus 2.5 percent of kids on Oahu.
Reduced fees are offered to the uninsured and under-insured based on their ability to pay, while students on Medicaid or another public insurance plan do not pay any out-of-pocket expenses. According to Pettus, the center’s CEO, as much as 90 percent of the school’s students are on Medicaid — the federal health care assistance program for low-income families.
The center is designed to sustain itself financially using the insurance revenue it does receive, according to Pettus. It employs four staff in addition to the school’s health aide: a physician’s assistant, a medical assistant, a dentist and a dental assistant.
But the center is an anomaly in Hawaii. Public schools in other parts of the state, including Waianae and Kau on the Big Island, are looking toward duplicating what Kahuku has done, but they have minimal funding and little guidance for their initiatives. The result, according to Mary Boland, dean of the University of Hawaii at Manoa’s School of Nursing and Dental Hygiene, is a paltry “mishmash” of services.
Boland, who is also involved in efforts to build a system of school-based health services, says the state desperately needs to establish clear laws and administrative policies on school-based health. The Hawaii Department of Education is only responsible for selecting health aides who can provide basic care under the supervision of a few Department of Health nurses. And unlike many states, Hawaii doesn’t require vision and hearing screening, Boland said.
“Health has never been on their (the DOE’s) radar screen,” Boland said. “There are so many things we can’t fix, but this is one of the few things we can.”
Boland helped develop a proposed $2 million school-based health care program in which medical professionals would screen students for treatable health conditions, provide them referrals to outside health care, prevent and control communicable diseases and other problems, while also providing emergency care for illness or injury.
The school-based health centers “will exist at the intersection of education and health and will be the caulk that prevents children and adolescents from falling through the cracks,” the proposal says.
Right now, the Kahuku center is under scrutiny as officials from the DOE and state health department assess the success and feasibility of expanding the concept.
Public health experts and educators say the connection between wellness and learning is clear.
“Our objective is to have healthy children,” said Lea Albert, superintendent of schools in the Windward district, including Kahuku. “If you aren’t healthy, you can’t learn.”
A 2009 study published in the Journal of School Nursing found that states that oversee health education and health services have higher test scores and lower dropout rates.
The center at Kahuku High and Intermediate focuses primarily on the reduction and prevention of diseases such as diabetes and injuries such as suicide by promoting healthy living and providing comprehensive health and counseling services. The staff can also write prescriptions that students fill at nearby pharmacies.
“This will be their health home,” says Oreta Tupola, the center’s chief operations officer, as she ushers students in and out of the clinic. The center, which is open after school every day until 4:30 p.m., is planning on offering services during school breaks, too, according to Tupola, a trained social worker who graduated from Kahuku herself.
Advocates also stress that the center provides full-service dental care in an area that has the lowest possible score on the U.S. Department of Health and Human Services’ Health Professional Shortage Area dental listings. Experts say school-based dental services could make a big difference in Hawaii, where the rate of tooth decay among children is twice as high as that among children on the mainland and access to dental care is limited, according to Healthy Smiles Hawaii.
Meanwhile, the clinic provides internship opportunities to students in the school’s Health Academy while ensuring access to critical sports medicine and nutritional planning services in a school where 80 percent of the students participate in one or more of its 50 interscholastic teams. The clinic is also trying to raise enough money for a mobile health and dental van that would visit the five elementary schools in the area.
Gates wonders whether his own battles with weight and poor health — and possibly even his mother’s death — could’ve been prevented had his school offered comprehensive, relevant health services and wellness counseling. Perhaps he wouldn’t have ended up dropping out of school in search of something more fulfilling, he said.
Perhaps more people on the Leeward Coast would eat and live healthily if their schools had invested in encouraging those habits.
What Kahuku is striving to do is “take health education out of the textbook and make it a real-life, real-world activity,” Albert said.
The end goal of the school-based health centers, Albert says, is to make Kahuku — and its rural, poor counterparts in other parts of the state — a better place to live.
“Where you live can determine your mortality,” Albert said, citing a recent documentary, Ola: Health is Everything, which explores the widespread social factors that have contributed to Hawaii’s health care crisis. “I want the zip code in Koolauloa to be a zip code where folks are healthy, have a long, healthy life.”
“I don’t want the location to determine our longevity.”