School Health

The core issues of health and learning have been around for a long time. In Greek mythology, the close relationship between healing and health was represented by the sisters Panacea and Hygeia. Hippocrates espoused an approach that paid attention to the social, behavioral and environmental influences on patients. The reciprocal relationship between health and learning was recognized by Socrates. It is notable that the word "doctor" means "teacher", from the early Greek. It is not surprising therefore that one can find traces of these themes attempting to intertwine themselves throughout history.

The figure below, Medicine and Health Timeline, is modified from the monograph, "Medicine and Public Health, the Power of Collaboration" (R. Lasker, New York Academy of Medicine, 1997, Comprehensive School Health: Our Nation's Investment) to include the major historical events relevant to school health between 1847 and 1997. She characterized the historical relationship between medicine and public health as having proceeded in three phases: an early supportive relationship prior to the early 20th Century, a period of professionalization and practice transformation spurred by the emergence of bacteriology, and finally, an acceleration of functional separation in the post-World War II era. She suggested four underlying causes: the progressive loss of a perceived need to work together; lack of incentives or structures to support cross-sectoral relationships; recurring tensions deriving from overlapping interests; and, development of striking cultural differences.

Figure 1
Medicine and Public Health Timeline (1840-1998)
School Health Timeline

*Bold = School Health

The major epochs from the 1850's Civil War period, through World War 1, the Great Depression, World War U, the Great Society of the 1960s and 70s, to the present, document the progression of health problems from infectious disease to chronic disease, to modern challenges of relationships of health outcomes to health behaviors. Key health care strategies began with quarantine and sanitary reform, followed by maternal and child health programs, antibiotics, and finally, screening and treatment progressing to managed care. Focus of health activities started with water systems and pasteurization, personal hygiene, the hospital as a center of care, to categorical health programs, to modem conceptualizations of healthy communities.

The historical relationship context for school health, of course, shares the same major societal events and issues, and pressing health needs. However, from the health perspective, schools have always been viewed with varying degrees of being embraced by the schools as sites to access populations, to deal with pestilence, control disease, and promote health through nutrition, lifestyle, and direct education. The evolution of education as entitlement was attractive to the health sector since such a similar entitlement to health care did not and has not developed to this time.

Prior to the founding in 1847 of the American Medical Association, Rhode Island made education compulsory in 1840, followed by many states. In 1850, the Shattuck Report of the Sanitary Commission of Massachusetts emphasized school programs as a major focus for public health and disease prevention. In the 1860s, the New York Board of Health asked the Board of Education to screen for smallpox in an effort to combat a smallpox epidemic. By 1870, smallpox was a requirement for school attendance. In the late 1800s and beginning 1900s, nutrition services and health inspections of schools and students were instituted. By 1915, the impact of health programs in schools was marked in that tuberculosis control involved a national campaign of school children's Easter Seal Crusaders, with financial goals and personal commitment to daily health chores, and holding "open air" classrooms, even in the dead of winter. The Cardinal Principles of Education in 1918 recognized one principle of lifelong learning to promote the health of the individual and the community as fundamental to education.

A powerful coalition between the AMA and the NEA was started in 1911, with the formation of a joint committee on health problems. By the 1920s all states had laws regulating health and education interfaces in schools, including safety, nutrition, and health screenings. This same AMA/NEA coalition actively discouraged the direct provision of health services in schools. However, a variety of medical and dental services were set up in schools during this period of 1920s to 1970s, especially for indigent children. There was one instance of 83 tonsillectomy and adenoidectomy operations done in a public school in New York City for children who could not afford them. A riot ensued, spurred by a rumor that Jewish children's throats were being slit. The origin of the rumor was said to be from a group of "snip doctors" who performed T&As for a fee, and feared that this movement would interfere with their business. In the 1920s, 30s, and 40s, professional child health associations began to notice the "huge variation" in quantity and quality of school health programs across the nation, and a separation between school nurses and providers of health care in the community. Even within schools, the health education components and health services components were often completely separated administratively. This situation continues today in many schools.

This separation was reinforced by the independent development of nutrition education and services, physical education curricula, formal classroom health education (the classic School Health Education Study - 1960s), and health services. Early attempts at integration of school programs was attempted by the U.S. Office of Education's Health and Nutrition Projects of the early 1970s, a part of the War on Poverty and Great Society programs. The Robert Wood Johnson Foundation funded a few early demonstration projects that focused on linking families to primary care services via school health programs. Some of these emphasized expanded roles for school nurses; outreach lay health workers to connect families to sources of ongoing care in the community; and health promotion programs. In the 1970s and 1980s, this Foundation continued to support the development of more direct care, school-based services, especially for families with difficult access to community services. This experience also highlighted the recognition of the impact of the newer "social" morbidities. The parallel development of school- based health services, as opposed to a comprehensive program with linkages to existing sources of care in the community, spawned the debate of "Health Services in the School vs. School Health," and further strengthened the need for integrated services for families.

More recent developments at the national level coincide with the modem challenges of societally-determined health problems, more recognition of the impact of health behaviors on morbidity and mortality, and the trends of managed care impact on health care. In 1988, the CDC created the Division of Adolescent and School Health, about the same time as Healthy People 2000 was launched. In 1994, National Education Goals were announced in which health was notably in the background. However, reference was made to the need for students to start school with healthy minds, bodies, and mental alertness necessary for learning. At the same time, the Federal Interagency Committee on School Health was established, as was a large group of National Associations belonging to a National Coordinating Committee on School Health. These groups are rumored to be gaining momentum again. In 1997, the prestigious Institute of Medicine published a report on Comprehensive School Health: Our Nation's Investment. It is not yet clear whether some of the recommendations of that report and some of the innovative efforts reported will take hold, but the mere existence of such a report from the IOM signals a sea change in the way school health is viewed by policymakers. Finally, I note in 1998 the GWU Comprehensive School Health Initiative, as we all hope to make it an initiative with national and long-lasting impact.

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