This ankle is most assuredly broken,” Dr. Barbara Staggers says, sounding almost gleeful.
Staggers is tall, 39 years old, African American, a physician. She smiles broadly and turns. Her 16-year-old Latino patient, laid out on a few chairs, narrows his eyes, perhaps startled by the pleasure he can hear in her voice. Staggers pats the boy’s hand, surveys his pale face. Her eyes follow his long, muscled leg, stopping to study the spot where his foot draws down to the south. There, the bone takes a sharp detour east, its trajectory sketched by a plum-colored bruise, the fruit of basketball played too hard.
Staggers raises her arms in a V of triumph and grins. “Yep. Broken. Yes!”
After following Staggers on rounds here in a clinic at Fremont High School and at the Teen Clinic of Children’s Hospital in north Oakland, Calif. even a casual observer might understand her glee. This is the first clean break of the day. The patient, suffering from the kind of injury doctors are trained to handle, will be treated and sent on his way. Within a few months, he will be playing ball too aggressively again.
Many of Staggers’ other patients suffer far murkier ailments. So far today she has seen teenagers who are suicidal and homicidal; victims of sexual abuse; sufferers of serious diseases, from asthma to AIDS; and kids who are addicts to everything from alcohol to crack and junk. She has also seen teenagers who are pregnant or love starved and too many who have given up all hope.
The crisis among patients like Staggers’ has been widely reported as a tale of inner-city poverty and youth crime, but her weekly schedule is a rebuke to that simple notion. Many of her patients are poor, minority teenagers, but she also draws patients from more privileged neighborhoods. One kind of patient comes to her after taking a bullet in the belly during a downtown shootout. Another kind arrives bruised and broken, having drunk himself sick before wrecking his parents’ luxury car in a high-speed crash.
“As a physician, I’m dealing with people who are incredibly resilient physically,” Staggers says in her cramped office at the school clinic, just before the injured athlete arrives. “Yet they still see their most positive option as being dead.” In conversation, Staggers rolls her shoulders forward for emphasis and explains things in well-crafted bursts. “Guns and cars are different kinds of weapons. But they can be weapons all the same. Different presenting symptoms. The same disease.”
What are the different presenting symptoms Staggers confronts? While black teen-agers are far more likely to be shot to death, white teens are more likely to be injured or killed in an automobile crash or to kill themselves. But both groups share this underlying condition: Three-quarters of the deaths of young people from ages 10 to 24 a total of 30,000 each year occur not from disease but from preventable causes.
For most other age groups in the country, the risk of a violent death or injury from these causes has leveled off or declined. Not so for adolescents or for young people in their 20s, whose escalating risk of violent injury and death begins in their teens. Among youths from 15 to 19 years of age, the risk of being shot to death more than doubled in the last decade.
Consider this toll: 5,749 teens were killed and tens of thousands injured in automobile crashes in 1991. Among youths 10 to 19,3,398 were murdered, and 2,237 killed themselves in 1990. During the 1980s, 68,997 teen-agers died in car crashes, 19,346 were murdered, and 18,365 killed themselves. That added up to 106,718 for the decade. Today’s teen-ager runs roughly twice the risk of being murdered or becoming a victim of suicide compared with teens during most years of the turbulent 1960s. (The risk of death from car crashes has declined, perhaps as a result of safety laws, public education and lower speed limits.) As if the old dangers were not threatening enough, HIV infection has begun to cut a wider swath.
Across lines of race and class among teen-agers, the number of preventable deaths is rising at an alarming rate. Adolescence has become a high-risk activity.
As the athlete with the broken ankle hobbles off to have his bone set, Staggers tugs at the MD credentials hanging from a chain around her neck and surveys a waiting room full of difficult cases. Few of Staggers’ patients readily reveal the underlying reasons for their visits. The receptionist’s signin sheet contains a litany of mundane complaints aching ears, persistent coughs, upset stomachs. Inside the examining room, the more serious business will tumble out if Staggers can find a way to dredge it up. On this morning, it turns out that the earache was caused by a beating, the cough by parental neglect and the stomachache by a suicide attempt.
Staggers sees several patients, including one young man, who are exploring their sexuality. “This school has a fair number of kids who openly identify [themselves] as gay or bisexual,” she says. Staggers has double-barreled concerns about the boy: Does he know everything he needs to know about safer sex? Are the older men he has been staying with overnight perhaps trading sex for shelter taking advantage of his youth and naivete?
The boy is handsome, soft-spoken, painfully shy. He has had several near-fatal bouts of asthma, but his family is scattered, and nobody seems to be in charge of his care. Treating teens like this boy seems to require a kind of double vision: Staggers is treating the asthma but also trying to anticipate an underlying danger, counseling him to avoid exploitation, drug abuse, AIDS.
Next door, three young women have arrived a few days after their junior prom for pregnancy tests. As she reads their names, Staggers raises her eyebrows in disappointment. There’s a faint, nearly inaudible growl in her throat. These three girls know better. They’ve been taught how to protect themselves from sexually transmitted diseases and pregnancy.
Like these young women, teen-agers all over the country, most of whom are sexually active, increasingly risk serious illness and death through sex. A recent report by the Centers for Disease Control found that among teens, new infections with HIV are occurring at a startlingly high rate.
Preparing to meet with the girls individually, Staggers suppresses an exasperated scowl and replaces it with a stoic, neutral expression. This part of her practice inspiring teens to make use of what they already know is by far her biggest challenge. It demands the ability to hector and persuade without seeming to nag or lecture.
“It’s hard when you’re angry, but you have to take time with these kids if you expect to make a difference,” Staggers says outside the examining room. “To make an impact, you have to push past the facts. You have to press the girls for more information and look for the underlying causes. I ask them, ‘Is an orgasm worth dying for?’ and, ‘Why do you want to be pregnant?’ They’ll tell you they want to get an education first. But then they’ll go and have unprotected sex. Many of them don’t think they have any control. The boys tell them they don’t like the feel of a condom. The boys say, ‘Trust me.’ And the girls desperately want to trust somebody.”
Staggers is a vicious mimic, and she pauses to take on the role of a teen-age boy, wheedling: “I just don’t like how it feels. Please, baby. Trust me.” She rolls her eyes and whirls. “Please, girls. Let’s trust ourselves.”
Staggers believes there’s an “influential connection” between the 1 million teen-agers who get pregnant each year and the violence that pervades their lives. “Even though, in many ways, they don’t want to get pregnant, they do it to replace some of the people they’ve lost,” she says. At first blush, this sweeping statement seems hyperbolic, a shade New Age. To blame teen-age pregnancies on violence in the streets seems a bit of a stretch. But during her examination, one of the three prom revelers, a striking and articulate high-school senior, proves a spot-on example. This young woman can rattle off safe-sex guidelines so expertly that she could work for the CDC. Still, here she is waiting for the results of her pregnancy test, having picked up a bad case of herpes after the big dance.
I ask if there’s anything else bothering her. At that, the forthright teen-ager becomes querulous. She hems and dodges. Finally, her hands flapping back and forth, she admits to having a hard time keeping a clear head ever since the recent murder of her 25-year-old cousin. The killing has left her feeling betrayed. Her cousin was called out of his home by his friends among them people she knows from the neighborhood. Clearly, the young man was set up. She puffs big clouds of air through her cheeks. You learn not to trust anybody, she says.
Perhaps Staggers can chart the perils of adolescence so well because she grew up in an upwardly mobile home that was thoroughly guarded against teen dangers. Her greatest influence was her father, one of the first African American doctors in a surgical subspecialty (urology) in the Navy. When Dr. Frank Staggers Sr. left military service, he moved the family to Castro Valley, an archetypal California suburb. The Staggers family settled above a sleepy commercial strip in one of the Eichler homes dotting the hills. Eichler’s design, distinguished by expansive panes of glass and open redwood beams, was the architectural corollary to the family’s upward arc.
Barbara Staggers’ great-grandmother was born to a slave woman and an Irish slaveholder. On her father’s side, there was a railroad switchman and his wife, who never went to high school. Among her parents’ generation, there were great social strides; all of her father’s siblings and many of his 35 cousins have advanced degrees.
Under the watchful eye of two attentive parents, Staggers’ younger brother became an ordained minister and teacher and her elder brother a doctor specializing in the treatment of addiction. Staggers wobbled between her desire to dance, her wish to pursue veterinary medicine and her ambition to become a doctor like her dad. At 18, she worked in a summer camp for inner-city Oakland teen-agers. There, she got hooked on the idea of doctoring teens. “Black physicians are social engineers,” her father says. “I told her it was pretty hard to pursue a doctor’s career as a dancer. But it would be possible to keep dancing if she trained to be a doctor.”
For Barbara Staggers, being an upwardly mobile black in the ‘burbs was a sometimes mixed experience. Her junior-high-school counselor told her she would “never be able to achieve anything higher than a job washing dishes,” she remembers, and she was tracked out of the class of high achievers she’d studied with until then. Her father intervened forcefully with school officials.
“What if my parents hadn’t been watching out for me? I think about that a lot,” she muses. “Lots of kids just fall through the cracks because nobody is paying attention when they need it the most. It’s in that moment when the crack is opening up for a kid that it’s most important to intervene.”
Boy! oh, my! no! don’t tell me!” Staggers hunches over the telephone, as if the sheer weight of her concern can be brought to bear on her umpteenth case of life or death.
At the Teen Clinic of Children’s Hospital in Oakland, she’s packed into her chair, surrounded by papers and correspondence and piles of telephone messages. Boxes of research files, speech materials and papers spill out of pink milk crates.
This is the first time I’ve heard Staggers stopped cold. She scuffs her Reeboks beneath her chair and nestles the receiver against her cheek. A patient is nearing physical collapse from starving herself.
“Uh, oh! Anorexia and psychosis, too. She’s hearing voices. Ah, man,” Staggers says, frowning. “Do we know how much she weighs? “Excuse me. She weighs how much? Boy, oh, boy. Is she pale and blue-looking? When anorectics need hospital care, we’re talking cardiovascular trouble. And so we’re talking risk of instant death.”
Staggers quickly refers the doctor to Lucile Salter Packard Children’s Hospital at Stanford, across the bay. Packard has a specialized eating-disorders clinic and in-patient psychiatric care. It’s the appropriate place for this particular teen-ager. Swiveling in her chair, Staggers looks glum. “That was a tough one. You know, among anorectics, the odds aren’t terrific. One-third of those who get treated get better, one-third or more stay the same — and up to a fifth die.”
She’s up and out before finishing the sentence, clearly discomfited by the notion that there are cases even she can’t get traction on. We’ve been talking about some of the others troubling her sleep. There’s a 14-year-old female patient who lives with a 28-year-old pimp and drug dealer. So far, he’s not sexually involved with the girl, and he doesn’t show any signs of trying to pressure her into prostitution. ”I’ve been watching to see if he would try to pimp her out,” Staggers says. “He seems to genuinely care for and protect her.”
Staggers could turn the girl over to Child Protective Services. But that public agency is overwhelmed with urgent cases, and the best they could offer is foster care. Staggers still remembers, with a shiver of disgust, an 11-year-old girl with chronic illness turned over to the agency a few years ago. The girl’s parents were homeless, and CPS officials believed she could not be adequately cared for on the street. So they separated the girl from her parents.
“She ended up getting hospitalized as a psychiatric case,” Staggers remembers. “Her parents were good to her, and she missed them. What we did initially, by referring the case, was take a tragedy and make it worse. In the end, we got the parents jobs and a house. The kid is doing wonderfully now.” With that experience as a backdrop, Staggers calculates that her current 14-year-old patient may be better off staying with the one person who has cared for her, even if he’s a pimp.
Staggers hurries off to meet with a middle-class teen-age girl, a runaway from her suburban home. “I can’t tell you how many middle-class girls I have who get involved with the gangs at this age,” she says. ”This girl was an A student. Now she’s failing.” Staggers sends two peer counselors, young women who have graduated from gang-involvement and drug-treatment programs themselves, in for some straight talk with the teen. Then the doctor follows up, both with the girl and with her parents getting her to agree to go to family therapy and advising them to lighten up once they get their daughter home.
As the parents and daughter file out, reunited, Staggers allows herself a moment of relief. Her eyebrows bobble, and she grins. About her advice to the parents, she explains, “We don’t get very far by just telling teen-agers not to take risks because it scares us. When we demand to know why they’ve screwed up, the kid says, I had to. Everybody else was doing it.’ The adult replies, ‘If everybody else jumped off the cliff, would you, too?’
“The honest answer to that question,” continues Staggers, “is yes. It’s really, really important that we understand this. For the teen at that moment, being down at the bottom together feels better than being on the edge of a cliff alone. What we need to engage our teens in discussing is this question: What else can you do to be part of a group and still survive, while taking reasonable risks? If you’ve got to jump off the cliff, can’t you choose one that’s not 50-feet high? Can you jump off the cliff that’s 2-feet high instead?”
Staggers’ approach to treating teen-agers involves more engaged listening than most doctors or parents ever muster. Her method uncovers underlying symptoms. She mentions a 16-year-old white boy who came into the clinic for treatment of his swollen knees. By probing further, she learned that he’d jumped from the second story of a building while high on PCP and needed help with his drug habit. Another boy was in the hospital recovering from injuries suffered in an automobile accident. Since his breath smelled as if he’d been drinking at the time of the accident, alcohol treatment was recommended. But nobody asked him why he’d crashed into the wall in the first place. Staggers did ask. “He told me, ‘I’ve done this before. Several times,’ ” Staggers recalls. “And so we knew he needed suicide-prevention counseling, too. The experience left me wondering: How many suicides are really homicides? And how many homicides are really suicides?”
From experiences like these, Staggers first developed her theory about the common problems of teen-agers. She believes a festering generational grievance cuts across differences of income, ethnic background or particular trauma.
But if adolescence itself has become a high-risk activity a disease to be treated with preventive therapy, as Staggers believes what is the most effective treatment? Collecting her belongings at the end of a day, Staggers considers this question carefully and answers a bit haltingly. “With all the kids I know who make it, there’s one thing in common: an individual contact with an adult who cared and who kept hanging in with the teen through his hardest moments,” Staggers says. “People talk programs, and that’s important. But when it comes down to it, individual, person-to-person connections make the difference…. Every kid I know who made it through the teen-age years had at least one adult in his life who made that effort.”
When Staggers leaves work in downtown Oakland, she beats a retreat to the suburbs where she was brought up and where she presently lives with her second husband, 8-year-old son and 9-year-old stepson. Zipping along in her new Acura Integra at 75 mph, it’s a short drive but a world away. The freeway slices around inner-city Oakland like a melon spoon, cutting southeast past a string of suburban villages, to Castro Valley.
“Notice anything?” Staggers laughs as we emerge from the car outside Castro Valley High School. At Fremont High, most of the school gates were chained shut, and security guards roamed the hallways, two-way radios at the ready. The average grade-point average is 1.7, and only a small fraction of the students will go on to college. At Castro Valley High, students wander freely. Most students come from two-parent families, and incomes are high. Almost all of them will go on to college.
“You’re about to find out the problems for teens are similar even in very different settings,” Staggers insists, bustling down the hallway to the school’s counseling office. “Sure, it looks better out here. It is better. But there are plenty of scary things happening here, too.”
Just last spring, one Castro Valley teen-ager was killed with a baseball bat in a brawl after a Little League game. Although not reported at the time, tensions at the school had been fierce in the weeks before the brawl. The school’s wrestling coach had been charged with making sexual advances to a boy on his team. That had led to gay-baiting teasing aimed at the wrestlers, some of whom were also baseball players. Then, ongoing racial skirmishes between Anglo and Latino students resulted in a series of confrontations.
Natalie Van Tassel, an ebullient white woman who has worked in Castro Valley schools for 25 years, was Staggers’ counselor during high school. She still treats Castro Valley’s troubled teens. Within a minute of hitting the door of Van Tassel’s office, the two are deep into cases.
The women compare notes about sexual activity among their patients. “I don’t think I’m misrepresenting the past,” Van Tassel says. “I mean, I came from a small Midwestern town where most of the girls got married the day after graduation because they were all pregnant. But what has happened is that the explosion of sexual activity moved down in the age groups 12, 13, 14 “
Staggers interrupts. “Among mine: 10, 11, 12 “
“And the big difference,” Van Tassel continues, “is, if you wanted to be sexually active in your high-school years, you could do it without running the risk of dying because of it.”
The risk of HIV infection is an increasing danger for all teen-agers. Among the thorniest issues in prevention work is the ambiguous sexuality of many teen-agers and the disdainful disapproval or loaded silence from adults concerning same-sex exploration. In this more privileged setting, oddly enough, there seems to be even less acceptance of gay teen-agers than at Fremont High. Only one young man is open about his homosexuality here.
Van Tassel finds it toughest of all to deal with teen-agers who have no meaningful relationship with any adult. Suburban teen-agers are set loose to fend for themselves far too early, Van Tassel tells Staggers. “The parents here have a great capacity to give their kids things. Giving them so many material things masks what they’re failing to give time. What I see are kids without real parents.”
Staggers is pounding the table. “See, it’s the same disease, different symptoms. Here the kids have economic opportunity, but no real family life.” She’s worked up now. ”I’m tired of hearing people say, ‘I’m too busy.’ If you have kids or you’re related to kids and they don’t have adults in their lives, it’s your job to either take care of them yourself or find some other grown-up who can do it for you. Either do it or find someone who can. But just throwing up your hands and saying, ‘Time, time, there’s no time’ that just doesn’t cut it with me. How can we get that message through to the adults?”
Staggers doesn’t wear a watch. Sometimes her schedule seems chaotic, full of what appears — to some of her superiors, at any rate — to be overly generous amounts of time for her patients. She has a way of locking on to whoever is in her presence and letting all the others wait. There have been rumblings about her supposed failings as an administrator and turf fights with the hospital administration. Staggers’ department has been hit with a series of cutbacks in staff and resources in a hospital-wide restructuring.
In the midst of the cutbacks, even Staggers’ clinic at Fremont High may be in jeopardy. “That’s where services should be in the schools, in the community,” Staggers says firmly. “Can you imagine those kids turning up at a hospital clinic? With no insurance, no parent support, no information? Yet they’re the kids who need treatment most.”
But Staggers knows that her real beef is not with the budget-cutting administrators at her hospital. She’s at odds, fundamentally, with the way medicine is currently organized. Staggers is trying to practice public-health medicine in a fee-for-service world. No matter which proposal is eventually adopted to reform the nation’s health-care system, the underlying problem for doctors like Staggers will remain. Her focus on prevention, no matter how socially important, simply does not generate the fees that would fund such a practice.
Preventive medicine is not rewarded under the current system. Consider one example: While researching this story, I watched in the emergency room of Oakland’s Children’s Hospital one Friday afternoon as a 13-year-old gang member was treated for a gunshot wound suffered in a drive-by shooting. A 9mm slug was lodged in his thigh, and like dozens of other teen-age shooting victims treated over the summer, his case generated a hefty bill. These kinds of bills are paid off either by a private insurance company or by the state.
By contrast, if Staggers succeeds as Doctor to the Teens — talking an angry young man out of a gang, in one instance — her efforts often don’t generate a bill. Since her time isn’t billable, she and her institution are left holding the bag. Her model of health care makes sense, particularly in treating teen-agers, but Staggers’ efforts at prevention are never rewarded as well as the standard program of stitch-then-release.
When she gets agitated on this subject, Staggers sets her jaw and waves her arms. Teen-agers are less likely to receive medical care than any other age group in the country, she insists, and rarely do they get the kind of care they need, even when they are treated. For all the hazy rhetoric floating around in Washington about the domestic agenda, Staggers can’t understand how anyone expects to make headway without taking into account the special problems of teens.
Staggers often gives speeches around the country. She’s a doctor of publicity, too, turning out between appointments on one day, for example, to support the efforts of community groups in Oakland trying to shut down alcohol outlets. (“You put alcohol and firearms together, and you account for 50 to 75 percent of all adolescent deaths,” she says.) She’s also a regular fixture in testimony before state legislative committees.
The uphill nature of her cause was evident at an afternoon hearing last May in Sacramento, the state capital. With teens and their advocates from all over the state waiting and ready to testify about their problems, a special hearing about teen-age health was abruptly canceled because legislators were busy downstairs grappling with a state budget that was $9 billion from balancing. In times of such stark shortage, it’s harder than ever to get teen-agers the attention they desperately need.
When Staggers was honored with the Lewis Hine Award in New York this year for her service to young people, Hillary Rodham Clinton, a fellow honoree, asked for her advice. The first lady got an impassioned briefing about adolescent medicine.
“She listened carefully, and I hope it made a difference in her thinking,” Staggers says. “If only the federal government could restructure health care so there’s community-based operations and more school-based clinics, we might get a grip on some of these problems.”
ON MY LAST DAY WITH STAGGERS AT the school clinic, a tall, lively African American teen-ager stops by to share the good news: She has been accepted at San Jose State University, and she’ll be starting college in the fall. Dressed in a red blouse and stretch pants, Ebony Hawthorne acknowledges that her prospects seemed rather bleak not so long ago. She had gotten pregnant at 15, and she nearly decided to carry the baby to term. It was a dicey conflict. On the one hand, she would not have been likely to have gone on to college if she had had the baby. But her family was dead set against an abortion, and she felt a powerful need to “have somebody to call my own.”
At home, it was difficult to find support. Ebony’s father, estranged from her mother, is a drug dealer who has been in and out of prison. Her mother is an addict. At the school clinic, she had opened up about her problems at home, her hopes and fears, and she ultimately decided to have an abortion.
As it turned out, her unwanted pregnancy was the prelude to a period of raw travail, which hit during last year’s holiday season. First, her stepfather died of a heart attack. Then, last November, Ebony and her mother were evicted from their home on Thanksgiving Day. Ebony was distracted, to say the least, from her schoolwork. She worried that notices from the colleges she’d applied to would never catch up with her.
On their way to a homeless shelter, mother and daughter stopped for fuel. There, at the gas station, they bumped into Ebony’s father, out of prison and back into business. He allowed them to stay for a week in an apartment he had rented nearby. Then he tossed them out, because he needed the apartment back “for work.”
Ebony sets her chin, speaking crisply, as if she’s desperately trying to distance herself from the bitterness she feels. “Does this make any sense to you? He told me he was throwing us out for my own good. For my own good! Why? Because he needed the apartment to sell his drugs from. And if he didn’t make any money, he wouldn’t be able to give me any Christmas money. Tell me, would you rather have a roof over your head or Christmas money? That’s when I decided: As far as I’m concerned, I have no father.”
Luckily, Ebony salvaged a relationship with her mother, who is now in a drug treatment program in San Francisco. She has been clean for eight months. “She’s trying to get my respect back,” Ebony says, frowning. “I don’t feel I lost my respect for her. Not at all. But she feels I have. She went through a hard task to get sober. And I’m proud of her.”
Hawthorne betrays a hint of pride in herself as well. She has managed to finish high school in an environment of homelessness, drug addiction, violence and neglect. Most of her classmates are headed for the streets, while she is going off to college. From a deep reservoir of will and hope, Ebony Hawthorne has mustered a quality in scant supply among today’s teen-agers. She has ambition.
“The difference between me and some of the others is that I push myself, because I’ve seen how my mother ended up,” Hawthorne says. “And I have people here at the clinic who push me, too.
“I want to be a psychiatrist,” she adds tentatively, as if ready to be challenged. “Because I want to really understand it all better. I want to understand myself what happened to me and all the anger I have much better. And then I want to be in a position to help people. I want to help the kind of people … who have problems like mine.”
Outside the door, another set of patients is waiting. In one room, peer counselors are giving a lecture about safer sex, practicing rolling condoms onto rubber phalluses with their mouths. A couple of students need prescriptions. Another doctor is on the line. But Staggers has already moved on to the next examining room, her face upturned and open, anxious to dig out the essence of her next case.