Clinics in New Orleans schools provide Dr. Melissa Trozzi Nass '99 with a setting for spotting difficult problems.
By Eve Abrams ’93
Photography by Jackson Hill
One day this past winter in New Orleans, Melissa Trozzi Nass ’99 was seeing a patient at McDonogh 35 High School, in its School-Based Health Center. The center is a fully functional medical clinic set behind the school in a modular building that looks something like a trailer. Throughout the day, students come and go for appointments, as well as for new and pressing medical needs. On this particular day, Dr. Nass sat in a private examination room with her computer at her back, talking to her 17-year-old patient. The girl was there for a routine sports physical—a requirement for participating in any sports at McDonogh 35. The girl, African American, slightly overweight and with long hair, sat on the examination table, comfortably answering Nass’s questions. They had a relaxed, easy rapport.
Nass always starts with the basics—Where do you live? Who lives in your house with you?—to get a feel for the person’s social history. She gradually eases into questions regarding one of the most risky behaviors associated with this age group and population: sex. Taking a sexual history is not only part of the routine, it’s also of paramount importance.
Dr. Nass learned the girl had last had sex the week before and began to counsel her about safe sex practices and STD prevention. But the girl said she didn’t need counseling; she wasn’t going to be having sex any time soon.
“Really?” asked Nass. “You just told me you had sex last week. What about that partner? You’re not planning on having sex with him again?”
“Oh no,” the girl replied matter-of-factly. “He got shot. He died.”
Nass was taken aback. “I’m so sorry to hear that,” she said. “What happened?”
“He got shot on the way to my house last Thursday. So I’m not going to have sex with him again.”
“How are you doing?” asked Nass. “Are you okay?”
“Oh, yeah,” the girl responded. “I’m straight.”
Nass told her there was a social worker at the health center whom she could talk to, and that she could use the Health Center as a supportive place, but the girl shrugged her shoulders. “No, I’m straight,” she repeated calmly.
Nass was struck by how blasé she was, how un-noteworthy this violent incident seemed to be. Nass believed the girl when she said she felt fine, but she had a harder time shaking the impact of the girl’s story on herself.
Then came her next appointment—another sports physical—this time for a 15-year-old girl on the volleyball team. The girl was thin, African American, happy, enthusiastic. She was doing well in school, and had solid, supportive friends. “She was straight as an arrow,” says Nass. “She generally seemed like a low-risk kid.”
But when Nass asked a routine question—“Has anyone in your family dropped dead suddenly?”—to see if there was a history of cardiac issues in the family, the girl thought for a moment and then answered: “My 13-year-old brother was shot. Does that count?”
Nass finished the physical exam, and the girl went back to class. Perhaps because she’d been away on maternity leave—off in another world within the very same city where fatal violence is not a common component of life—Nass felt depressed by her patients’ stories, as well as by how accustomed to violence they appeared to be. She made her way down the hall of the Health Center to talk to the social worker, who grew up in New Orleans.
“I just can’t believe it today,” she told him. “Every patient has been affected by violent crime. It’s so depressing.”
After listening to Nass talk, the social worker asked, “Did I ever tell you that my brother was shot when I was in the 10th grade?”
“Oh, yeah, and my stepbrother when I was a senior.”
Nass has been back at work for several months now as the medical director for the Louisiana State University Health Sciences Center’s three School-Based Health Centers in New Orleans. She’s no longer overwhelmed by the ongoing presence of violence in her patients’ lives. For better or worse, once again, she’s used to it. Homicide ranks high among the leading causes of teen death (along with suicide, substance abuse, HIV, and unintentional injury from car crashes), and like all aspects of poverty, solving this particular problem is not easily done. But Nass believes that public health programming is key to creating social change and to having a positive impact on vulnerable populations. And Nass says her practice of considering her patients’ specific problems in a larger, social context is a direct result of her Wesleyan education.
Nass helps her patients to the best of her abilities—with the tools available to her and the options available to them. “You can’t just give a patient an antibiotic to treat an infection when they lack the resources to get the prescription filled,” Nass says. “It’s not our job to put a Band-Aid on the problem, but to understand patients in a larger context and come up with plans that work for them in their lives.”
In her senior year of high school, after she’d been accepted to Wesleyan, Nass was a volunteer at Boston Medical Center. One day, she accompanied a group of pediatricians to the Massachusetts State Legislature to advocate for budgetary funding to be allocated to kids without insurance. During lunch with the lawmakers, the doctors asked for $1 million, laying out the case for why this money would make a difference in the lives of kids and adolescents. Two days later, the State House allocated $3 million, and for the young Melissa Trozzi, pediatricians became the most powerful people in the world. She wanted to be one of them.
Now, at age 34, Nass is not only one of the powerful (a pediatrician specializing in adolescent medicine), she also holds a degree in public health, and is an assistant professor of clinical pediatrics at LSU School of Medicine, New Orleans.
Medicine is a changing field, and back when Nass declared her intention to become a physician, doctors a generation or two older advised her to become a biology teacher instead. Medicine’s a mess, they told Nass. But she never saw it that way. “I think you can make it what you want it to be. It is hard, but I see the degree and the training in pediatrics as opening doors. I think that Wesleyan laid the foundation for my journey.”
Ironically, it was never a call to science or medicine that led Nass down this path. Rather, it was a desire to better the lives of young people. Nass sees physicians, and pediatricians especially, as critically positioned advocates of social change. “Because in our culture, physicians are given an enormous amount of power in lives of people as individuals,” she explains. “People still respect doctors.”
For Nass, this respect is reciprocal. Her one-on-one interactions with patients and their families are the most meaningful part of her job. “It’s what I look forward to every day.” These aren’t just polite words; rather, they’re an articulation of Nass’s central approach to her profession. “You have to let your patients inform you,” she explains. “I learn from them.” When Nass sees a range of patients coming in—over and over—with the same problems, she listens hard to what they have to say and what their issues are. Then, she says, “You have the opportunity to intervene and effect change.”
Nass sees patients every day at three primary care clinics. One is in downtown New Orleans, and two are on the campuses of different New Orleans high schools. The latter are School-Based Health Centers, and they’re part of a network of 2,000 such centers across the country that provide health care to kids by focusing on prevention, early intervention, and risk reduction. Each School-Based Health Center has a sponsoring organization (such as a community health organization, a nonprofit, a university, or a school system), and each creates a particular collaboration with its associate school. The idea is that by treating adolescents’ medical issues where they already are (in school), and educating them about healthy lifestyle choices, these centers create healthier, more health-conscious teens, and train them to become informed, proactive medical consumers. At the same time, the centers prevent costly future problems. Because School-Based Health Centers accomplish this without taking kids out of school or parents out of work, they also foster higher academic performance and increased graduation rates.
Statistics indicate the approach is working. Several studies show that children with access to School-Based Health Centers demonstrate a decrease in absenteeism and tardiness, and an increase in grade-point averages. African American males who use School-Based Health Centers for mental health care are three times more likely to stay in school than their peers who don’t use the School-Based Health Centers. On the financial side, students who regularly use School-Based Health Centers show a marked reduction of inappropriate emergency room use, fewer Medicaid expenditures, and fewer hospitalizations.
Like their organizational structures, the financing of School-Based Health Centers differs from center to center, but the majority bill public insurance programs such as Medicaid, as well as private insurance, for health center visits. Funding also comes from state governments, private foundations, sponsoring organizations, school districts, and the federal government. Given recent cash-flow problems at all levels of government across the country, one might expect that School-Based Health Centers would have taken a significant hit. Linda Juszczak, the executive director of the National Assembly on School-Based Health Care, says she thought she’d be hearing about centers being forced to close their doors completely. But, speaking with the caveat that budgets can change, Juszczak is cautiously optimistic: “The reality is that the clinics have been doing well. They’re valued—by the community, parents, students, and state governments. They are filling a niche that is not being filled in another space or form.”
There have been cuts—some relatively small; others, more substantial—but most states are holding steady, says Juszczak. In Oregon, for example, School-Based Health Centers were slated for substantial cuts, but advocates managed to keep their budgets stable. New York’s School-Based Health Centers also escaped budget cuts, as did Michigan’s. Other places, including Nass’s native Boston, aren’t so lucky; the city is currently planning to close its centers run by the Boston Public Health Commission. What is clear is that advocacy efforts on behalf of School-Based Health Centers have an impact. And these advocates aren’t medical professionals; they’re young people and their families who want this access to health care to continue.
New Orleans’ seven School-Based Health Centers are among the many clinics that came into the city post-Katrina in an effort to make primary and preventive care accessible to an indigent population. “The idea that patients with little to no insurance can access preventative medicine is really important,” says Nass. “I think it’s an invaluable resource in this city.” Nass had never heard of School-Based Health Centers before accepting her current job, but she says they make perfect sense. “They make medical and mental health care available to kids, meeting them where they are.” They also provide the ground for meaningful collaboration between the educational and healthcare systems.
Unlike younger children, who go to the doctor for yearly check-ups and shots, adolescents often fly under the medical-attention radar. By the time children turn 12, their medical points of contact diminish significantly, which makes adolescents, by definition, underserved. What’s more, adolescents’ issues are not typically the kinds of things for which they seek out care. Nass puts it this way:
“They don’t say, ‘Mom, I have to go to the doctor; I have a substance abuse problem. Mom, I have to go to the doctor; I feel depressed, or suicidal.’ And so by really providing comprehensive health services on campus, where the students have immediate and constant access to the health center, we are able to address those different needs for these kids. They come over [to the School-Based Health Centers] for colds, they come over for cramps, they come over for a variety of different things, and once we’ve got them, we address the issues that we know many of them face in their lives.”
Nass came to New Orleans in 2001 to begin four years of medical school and simultaneously pursue a public health degree. Tulane University’s dual program is one reason Nass was drawn to New Orleans; another is the city’s patient population. “I would say that the state of Louisiana and the city of New Orleans have one of the most economically disadvantaged patient populations in our nation,” she explains. “And if you want to advocate for social change, experience working with disadvantaged patient populations is crucial.”
These days, part of Nass’s job is teaching medical students and residents to feel comfortable with this very same population. Every day, pediatric residents follow her around, and she loves it. “One of the ways I see myself as being effectual is through exposing residents to a vulnerable and challenging patient population,” she says. Nass educates these future physicians by modeling culturally competent care. She demonstrates rapport building and connectedness to patients who have sometimes lived lives very different than her own. “I would say Wesleyan gave me tools to make connections with people who are quite unlike me. The Wesleyan community broadened my world view and nurtured a commitment to ‘give back.’ Hopefully, I give my residents a skill set they will take with them to other communities and pass on to others.” A belief in this sort of ripple effect is precisely what keeps Nass optimistic.
I ask her how specific the intertwining of her life’s threads—a desire to bring about social change, Wesleyan, and medicine—is to New Orleans. Could she be taking this journey elsewhere? “Possibly,” she answers with a sheepish grin, “and I would probably feel more effective, to be honest. The needs of this community are profound. And the infrastructure of New Orleans can be really frustrating. There’s a little complacency here. The boulder is harder to move.”
But then Nass shakes her head. “That’s so pessimistic, and I’m more than that.” She smiles. “I feel accomplished on a daily basis, and I feel fulfilled working with my patients and their families.”
Eve Abrams ’93 is a writer, radio producer, and educator living in New Orleans.[Editor’s note: some details regarding patients were altered to protect confidentiality.]