August 2012

Young San Franciscans not Immune to Health Problems

Melissa Mutiara Pandika

The ages between 16 and 24 represent a critical period during which individuals evolve from being children to young adults responsible for their own well-being and care. According to data gathered by the Transitional Age Youth Task Force in 2007, although the majority of San Francisco’s 80,000 16 to 24 year olds, or transitional age youths, are on track to successfully mature into young adults, an estimated five to eight thousand—up to 10 percent—are at high risk for unemployment, homelessness, involvement with the criminal justice system, and poverty. These challenges, in turn, can create health issues, and trigger mental health problems, substance abuse, unplanned pregnancy, and obesity. Yet this age group has the highest percentage of uninsured of all age groups, said Dr. Tonya Chaffee, MD, MPH, San Francisco General Hospital’s (SFGH) director of teen services, and a national advocate for adolescents. 

 Uninsured youth and young adults have access to a limited number of medical services through Healthy San Francisco (HSF). Founded in 2007, HSF is open to San Franciscans between the ages of 18 and 64 who have a combined family income at or below 500 percent of the federal poverty level, have been uninsured for at least 90 days, and are ineligible for other public insurance programs, like Medi-Cal. HSF is available to all eligible individuals regardless of immigration, employment, or health status, but offers limited services, such as preventive and routine care, laboratory tests, and mental health services, which must be provided within the City and County of San Francisco. HSF doesn’t provide vision or dental care. Participants choose a Medical Home—San Francisco Department of Public Health (DPH) clinics, such as SFGH, San Francisco Community Clinic Consortium clinics, and private providers—which assigns them to a physician. Program participants pay a quarterly fee for coverage and services, based on a sliding income scale.

Transitional age youth in underserved communities, like those enrolled in HSF, face unique health risks. “They are past the frailty of infancy and childhood…and they’re not even close to adulthood and beyond when the body starts breaking down, so you’re dealing with a robust, healthy group of people,” said Dr. Pierre Marie-Rose, MD, an SFGH pediatrician who mostly sees HSF participants, and who serves as medical director of tattoo removal clinics at SFGH and the Second Chance Tattoo Removal Program. With the exception of rare, chronic or congenital diseases, such as asthma or juvenile diabetes, their health conditions tend to stem from environmental causes, he explained. 

Drs. Chaffee and Marie-Rose frequently encounter mental health issues that stem from instability in their patients’ lives, many of whom have experienced or been exposed to violence, physical abuse, poor foster care, and/or unstable homes. The economic downturn has led to an increase in poverty and lack of employment opportunities, especially for youth. “I’d say a good 56 to 60 percent [of my patients] have mental health problems,” said Dr. Chaffee. As a provider for primarily underserved youth, as well as medical director of the Child and Adolescent Support Advocacy and Resource Center (CASARC), which serves youth who have been abused or witnessed severe violence, Dr. Chaffee sees many patients with post- traumatic stress disorder, depression, and anxiety, which often manifest as physical symptoms, including headaches and abdominal pain. 

In her discussions with patients dealing with the trauma or stress of abusive or dysfunctional intimate relationships, Dr. Chaffee often uncovers a need for reproductive care. In addition to serving patients at SFGH and CASARC, she works at New Generations Health Center (NGHC) located at 625 Potrero Avenue, a reproductive health clinic that provides full clinical services, including pregnancy, sexually transmitted disease (STD), and HIV testing. With volunteers from UCSF and SFGH, and funded by the State of California’s Family Planning, Access, Care, and Treatment (PACT) Program, as well as start-up grants from the Gold and Goldman foundations, NGHC caters to high-risk youth aged 12 to 24. Most patients are low-income, and live in the Mission or Bayview-Hunters Point, neighborhoods that report the highest teen pregnancy and STD rates, according to the NGHC website. Many NGHC patients who seek reproductive care become HSF participants, said Dr. Chaffee, which ensures they have access to mental health services. 

 Poverty and substance abuse often go hand-in-hand. “Every time we’re dealing with poverty, there’s going to be a certain percentage who wants to escape reality, and drugs are a relatively cheap, accessible means of doing that,” said Dr. Marie-Rose. Dr. Chaffee added that HSF participants with substance abuse issues tend to have moved beyond recreational drug use into the addiction stage, especially if they started abusing drugs as teenagers. According to the Centers for Disease Control (CDC), substance abuse can increase the risk for injuries, violence, HIV infection, and other diseases.

Violence is another significant health issue among youth in underserved communities, of which minorities make up a disproportionate part. According to a 2010 CDC report, among 10 to 24 year-olds, homicide is the leading cause of death for African-Americans; the second leading cause of death for Latinos; and the third leading cause of death for Asian/Pacific Islanders and Native Americans. Besides causing premature death, youth violence can lead to physical and emotional trauma. Since violence tends to occur in a cycle, those who experience it play each role—victim or perpetrator—at some point. If they or someone close to them is a victim, they may feel motivated to retaliate against the perpetrator, Dr. Marie-Rose explained. 

Many of Drs. Chaffee and Marie-Rose’s patients are obese. “Obesity… transcends socioeconomic status, but there are inherent factors present in the communities we’re serving at SFGH that lead to obesity in these communities,” said Dr. Marie-Rose. Low-income communities tend to have a greater abundance of fast and other unhealthy food options, he explained. Because these neighborhoods often have high crime rates, leaving one’s home to access parks and recreation centers can be dangerous, resulting in a sedentary lifestyle. Obesity, in turn, places individuals at higher risk for a host of diseases. Dr. Marie-Rose said that many of his obese patients are on their way to developing or already have type 2, or adult onset, diabetes, which occurs when the body develops resistance to insulin, the hormone that allows the body to metabolize and use sugar, resulting in elevated blood sugar levels. Long-term complications of high blood sugar can include heart and kidney disease, and retinal damage leading to blindness. According to the Alliance to Reduce Disparities in Diabetes, type 2 diabetes disproportionately affects ethnic minorities, who also make up a larger share of the poor and uninsured. Obesity can also result in low self-esteem, especially among youth, Dr. Marie-Rose pointed-out. “We encourage self-loathing in our children because we have these standards for beauty that are so rigid, especially now with…dangerous diet pills, steroids, and plastic surgeries,” he said. 

Eighteen to 24 year olds represent the age group with the lowest participation in HSF, at just nine percent, or about 4,891 of HSF’s 54,348 participants, according to the 2011 HSF Annual Report. “For individuals between18 to 64… healthcare is generally not a big concern,” said HSF director Tangerine Brigham. “Those in youthful age groups tend to feel somewhat invincible.” She recalled how she often observes young people riding their bicycles through the City’s busy streets without helmets, despite there being substantial information on the high risks of such behavior. “I talked to students at City College who would be eligible (for HSF). They said, ‘Well I’ll enroll if I need to enroll’…. Young people generally don’t think about health programs until they need them.” Dr. Marie-Rose agreed that older people are more motivated to seek healthcare, while young people, perceiving themselves as healthy, don’t embrace preventive health. Moreover, they no longer have the convenience of relying on parents to make health appointments, and are no longer obligated to meet school-related health requirements, such as immunizations or sports physicals. 

Dr. Chaffee pointed to the lack of services designed specifically for transitional age youth, especially those in underserved communities. “There are no guidelines for the care of this population,” she said. “People] say, ‘Oh they’re adults, which they’re not.’ They haven’t gotten all the chronic health problems like heart disease…. But they’re not adolescents because they’re kind of on their own… They’re dealing with childhood issues, but they’re still in that identity time, developing careers and long-term relationships. Although mental health issues are prevalent among underserved youth, most mental health clinics are tailored to older adults. “Imagine throwing a 25-year-old schizophrenic with a 50-year-old man,” she said. “[Transitional age youth] don’t really click with those clinics.” If a young adult is fortunate enough to attend college, they’re often serviced through a campus health center. However, most of Dr. Chaffee’s patients don’t attend college. For them, there are a handful of health centers, most of them affiliated with SFGH and DPH, which cater specifically to their age group, such as NGHC, the Third Street Clinic, and the Hip Hop Clinic. 

Dr. Marie-Rose, who runs SFGH’s tattoo removal clinic from the hospital’s Children’s Health Center, which only recently began seeing 18-24 year olds, agreed. “The biggest problem is that it’s the Children’s Health Center,” he said. “We’re trying to shoehorn young adults into an environment meant to treat infants and children…. Adolescent health is a lot easier when you’re working in an environment designed for adolescents and young adults.” The waiting area setup, the structure of appointments, and the nature of staff members’ interactions with patients at the center create barriers to 18 to 24 year-olds. Dr. Marie-Rose recalled how some of his older HSF patients almost left because they thought they were in the wrong place. 

Dr. Marie-Rose also pointed-out that age may not be the best basis for effectively addressing the needs of underserved youth. Adolescent development occurs as a continuum, happening at different rates for different people. “You could have a 16-year-old functioning at a 22-year-old level and vice-versa,” said Dr. Marie-Rose. “Many of the young people who define themselves in [an age group] have nothing in common with each other… so the system is not going to meet the needs of that group.” He hopes to see a more flexible healthcare system that accounts for the possibility that some young adults may not have the social, emotional, and/or mental skills necessary to navigate complex institutions—including having the patience and maturity needed to schedule an appointment by phone—and might need individual screening. “But it goes beyond that. Sometimes the instructions are given, and the way they’re given might transcend a patient’s ability to process,” said Dr. Marie-Rose. “They don’t file the right paperwork and, boom, they fall through the cracks again.” The stigma associated with admitting a lack of understanding creates an added challenge. When given medical instructions, sometimes “less mature” patients “will simply nod and act like they get it,” even when they don’t, he said, potentially leading providers to make erroneous assumptions about transitional age youth. 

Though health care providers have been working to meet the needs of these youth, “there was a disconnect at some level. We need to do a better job at recruiting and retaining these patients,” said Dr. Marie-Rose. “It’s something we need to think about when we move toward the Affordable Care Act,” added Brigham. “We need to make sure those in this age group enroll in the programs available to them.” 

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