Department Chair and Professor of Clinical Population and Family Health at Columbia University’s Mailman School of Public Health, New York, NY, September 2009

Dr. John S. Santelli is the Department Chair and a Professor at Columbia University’s Mailman School of Public Health. Previously, he was Chief of the Applied Sciences Branch in the Division of Reproductive Health at the U.S. Centers for Disease Control and Prevention (CDC). Dr. Santelli is a pediatrician and adolescent medicine specialist whose past research includes HIV/STD risk behaviors, programs to prevent STD/HIV infections among adolescents and women, school-based health centers, clinical preventive services, and research ethics. He has been a national leader in ensuring that adolescents are appropriately included in health research. He has written numerous articles on adolescents, including “Changing Behavioral Risk for Pregnancy Among High School Students in the United States, 1991–2007.”

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Youth Policy Toolkit: What interested you in youth RH? Could you please highlight some of the YRH-related projects that you have worked on? What particularly interested you about this/these project(s)?

Dr. Santelli: I became interested in adolescent reproduction in medical school. I did a summer research project in Buffalo on teen pregnancy, and following that, I was doing an adolescent medicine fellowship for pediatrics. My first job out of my training was running school-based health centers in Baltimore. It was a fabulous experience because it was a model for taking clinical care to another level in terms of turning it into a public health intervention. In essence, we took clinical care out of the hospital and into schools where adolescents were. As part of that, I worked for a health department and became involved in all sorts of youth policies, including how schools can be either health promoters or negative influences and compared how those different environments affect sexuality education or health education.

After about five years, I moved to the CDC and worked on HIV/STDs, adolescent school health, and finally reproductive health. At every stage, I received the chance to work with youth issues, including street youth, so called “high-risk youth,” youth coming into STD clinics, and youth in foster care or detention. In all those areas, I think the center of what I have been most interested in is adolescence, reproductive development, and how that [reproductive development] fits into the whole development of healthy individuals and successful adults.

Youth Policy Toolkit: How has some of the work that you have mentioned aided in developing policies for youth?

Dr. Santelli: I think that public health is intrinsically tied to health policy. I have been involved in a whole set of issues, and the most visible has been abstinence-only education. I was working at the CDC when the [second] Bush Administration began, and I saw this slow then more rapid shift in the emphasis on adolescent health programs in ways that I thought were pretty disturbing because the [policy changes] were not science-based. For four years I put up with it. There came a point, however, when I decided I needed to get out of government and moved to Columbia University. At this university, I felt I could be more public in my critiques, and I’ve been a major and visible opponent to abstinence-only education for the last five years. I think we’ve actually been enormously successful in ending this program that was poorly conceived, not science-based, and that violates people’s reproductive rights. Every day in public health whether you’re doing research or you’re a practitioner, you’re making decisions based on policy and hoping to advance policy.

Second, I’ve been involved in ensuring that adolescents are adequately involved in research because oftentimes adolescents are systematically excluded from research. This is because it’s been very difficult at various times to ask adolescents questions about their sexual health and also drug use, but if you don’t include them in research studies, then we don’t know how best to design programs and policies to improve their health. I’ve been a big advocate through the Society of Adolescent Medicine to try to improve adolescent inclusion in research.

Third, I was trying to improve the CDC’s efforts to improve teen pregnancy prevention through policies and also with HIV and STDs. In each of those areas, I’ve tried to take what I know as a scientist and researcher as well as this sort of “street smarts” I developed in Baltimore to see what you can implement and to see that we have programs and policies that make good sense.

Youth Policy Toolkit: In your opinion, why is it important to develop policies targeted specifically toward youth?

Dr. Santelli: Youth are different than children, and they’re different than adults. “Youth” is variously defined, but it begins somewhere in the early teen years and extends into the twenties. The evolving health needs, increased developmental capacity, the ability to make good choices, the transitions from dependency on family to making your own decisions both in health and other realms all emerge during that period of time. I think you need policies that are sensitive to that.

Additionally, adolescent legal status intersects with health status so at age 18 you can make a decision in this country whether you want to be hospitalized or have surgery or see a doctor or not. At age 17, you may be developmentally similar but you lack many of the same rights, and so we have to develop a whole series of laws, including minor consent laws, that allow adolescents to make decisions about those things. Understanding what the difference is between a 12 year old, a 15 year old, and a 22 year old is intrinsic to what adolescent medicine and adolescent public health thinks about, but not something everybody sees. A question we continually ask ourselves is, “How do you craft policies that work for most if not all adolescents at a particular stage?”

Youth Policy Toolkit: Can you give us an example of a successful policy that you have helped to develop and some real examples of how this policy has affected the lives of youth?

Dr. Santelli: Almost 20 years ago there were guidelines that we at the Society for Adolescent Medicine developed on adolescent health research. [They were] designed to provide some ethical guides to institutional review boards and adolescent researchers. To do this, we had a conference in 1994 where we brought a whole group of adolescent medicine specialists including researchers, IRB members, and chairmen to say, “These are the ambiguities in federal policy. How can we craft a better solution?” We were seeing teens that weren’t being included in all sorts of studies. There would be an STD study and everybody would realize adolescents get STDs or STIs, but that they are excluded from the actual study. This conference fundamentally made the climate for doing adolescent research better.

The other area where I’ve been successful is spearheading the efforts against adolescent medicine and abstinence-only education. I think most people in this society thought it was a crazy idea, but most people couldn’t figure out how to deal with it. Knowing what was driving it from inside government in terms of social forces, we put together a team that drafted some very strong statements that have been widely used by advocates as well as policymakers, and I think we’ve been successful in ending that program. We’ve seen many states that have rejected funding because their health departments are saying this is not science; this is not good policy. We’ve seen the Obama Administration zero out the funding in the 2010 budget.

Youth Policy Toolkit: What are some of the RH challenges facing youth at this moment in time? And how do these challenges affect the development of policies that could help in creating a more enabling environment for them? 

Dr. Santelli: What we see globally are kids who are not able to reach their full potential because of sexual orientation, abuse, or lack of education. Every human being in their adolescence matures sexually, and it’s a challenge for society to have to deal with it. In this country, for example, there are many people who do not accept individuals who have same-sex orientation or who are not traditional in their orientation. We have many people who are not accepting of adolescent sexual behavior outside of marriage. The vast majority of Americans initiate sex before marriage, but we have a vocal minority in the country that believes that that is wrong and that government policy should try to suppress that. Every society has various issues that they have to deal with.

The U.S. is somewhat unique in the sense that it has some of the worst public health indices on adolescent sexual and reproductive health in the world at least vis à vis other developed countries. We have much higher rates of teen pregnancy and STDs. It’s pretty clear it reflects not only social mores in this country but also an inadequacy in public health programs to help young people. Everyone needs help in making the successful transition to adult sexuality, but I don’t think we’re doing such a great job of being supportive. In the last few years, we’ve seen higher rates of STDs and teen pregnancy. Most of that reflects a failure of public programs including sex education and access to healthcare.

Youth Policy Toolkit: In your most recent paper, “Changing Behavioral Risk for Pregnancy among High School Students in the United States, 1991–2007,” you asserted that the increasing rate of teen pregnancy in the U.S. is associated with weaker HIV prevention efforts. What kinds of policies would revitalize HIV prevention efforts? How can these policies target youth?   

Dr. Santelli: In the 1980s, we also had some great public policy leadership, particularly in the office of the Surgeon General Koop during the time of the HIV epidemic in the U.S. He told us we had a big issue, had to take it seriously, and this is what we can all do to prevent people, including young people, from being infected with HIV. As a result, we had widespread implementation after 1987 of HIV education and prevention programs of all sorts. Not only did he help create programs but also raised public awareness. Both of those are important. You have to have political leadership saying, “This is important,” so people pay attention. I think we were very successful. Rates of condom usage rose dramatically between the 80s and 90s and into the current decade. We saw a reduction in sexual partners, and we saw a delay in sex among young people. We saw all the demographic trends that would reflect the message we were sending out. I still credit Surgeon General Koop and the public health service for accomplishing that. Surgeon General Koop’s leadership was essential.

What we’ve seen in the last 10 years is a shift from HIV prevention to this talk about abstinence. Abstinence can be a very healthy behavior, but abstinence is a “one size fits all” solution for everybody. So to talk about condoms in abstinence-only education, you had to tell people that they didn’t work. That’s not likely to engender a lot of confidence. The biggest change in contraceptive use we’ve seen recently since 2003 is a downturn in condom use in this country as well as increases in STD rates and pregnancy. At the same time, there has been very little change in sexual activity. I think we need to talk to young people honestly and straight forwardly about the importance of condom and contraceptive use. I think young people are no longer hearing that message.

Youth Policy Toolkit: What are the greatest gaps in youth RH programming and policies? 

Dr. Santelli: Again, I don’t think we’re taking young people seriously enough. I think we still think of them as children and not as something else. Society has to recognize that adolescents are unique and valuable human beings. We need to recognize adolescents’ reproductive rights as well as their human rights. They have rights to privacy and a right to participate in the political process even if they are underage. They show an emerging capacity to make their own decisions. They need to be supported and not suppressed. We need policies like that. That’s the broadest change I would like to see. I would also like to see a change in the dialogue around human rights and reproductive rights in this country.

In terms of specific policies, we need to improve access to healthcare for young people, including reproductive healthcare. Care gets worse as you enter the young adult years. Health insurance, access to care, and use of healthcare drops dramatically as you enter the mid-twenties, particularly for young men; and it’s because they don’t have jobs that have health insurance and we don’t have systems of care that are friendly to them. Even younger teens oftentimes don’t know where to go to get healthcare. We have great pilot programs, great adolescent health centers, and school-based health centers that serve adolescents, but those only reach a minority of youth. We really need to be serious about providing health insurance and health access for all young people.

Secondly, we need to rejuvenate health and sex education in this country. We need to have health education that provides all the facts they need to improve their health and supports them on healthy goals, such as using contraception and avoiding drinking in certain situations when you know it’s highly risky. We need a much stronger and better set of health education policies.

Youth Policy Toolkit: How has the field of adolescent health changed over the years?  What new priorities have emerged in policymaking related to youth health?

Dr. Santelli: There have been multiple changes. What’s emerged in this country is a strong, vocal well-trained scientifically based group of professionals who take care of adolescents. The number of people in public health who are trained to deal with adolescents has also increased. I don’t think we have enough people working in the field, but we clearly have some terrific professional standards we can look to. We’ve done a great job of professionalizing health education and moving it to a more scientific basis. We’ve learned a lot about what adolescents are and we’ve got a good body of research on effective programs such as sex education and contraceptive programs, health promotion programs, and counseling programs.

I still think the biggest priorities to address are these social and cultural barriers; the ability for adults to deal with and accept adolescent sexuality [and] for adults to recognize that adolescents are unique. We are clearly in an upswing, however, and that’s really exciting.

Youth Policy Toolkit: Based on your experience, what are the key areas for policy action?

Dr. Santelli: We have to move from ideology back to science in terms of development of public policies. Key areas include women’s health and the development of drug policies by the FDA. If we can get policymakers, congressmen, and other types of influential people all supporting an agenda based on health and science, I think we’ll be at a much stronger stance to face the future. From that will follow human rights. We need to recognize that healthcare and access to healthcare is a right. If we continue to treat it as a commodity, I think we will see the failure of healthcare reform. I think we need to utilize both a human rights and science-based perspective.

Youth Policy Toolkit: As you know, a policy is only as good as its implementation strategy. Could you please give us some examples of an YRH policy that has been implemented successfully? And, what do you think are the key components to implementing the policy?   

Dr. Santelli: To successfully implement a policy, one needs to have cultural and professional buy-in on basic policies. We have a set of legal rights that young people have to reproductive healthcare. If practitioners are not knowledgeable about those, if they don’t support them because of their own religious or cultural beliefs, then we see a failure of those policies. In theory, young people are supposed to access care independently until they’re ready to talk to their parents about reproductive issues, and in many places, they can’t get that kind of care.

We now have laws in the 50 states that allow a young person to access healthcare independently—in many cases for emergency and mental health and STD diagnosis and treatment. In general, I think it’s well-accepted by the professional community and by the public that when they [youth] are engaged in adult behaviors, they should be able to take care of themselves. That’s a big success. There are now 2,000 school-based health centers serving a considerable fraction of youth in urban and rural areas, and that’s a tremendous accomplishment. We’re seeing the recognition of this idea of taking healthcare to people where they are.