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Going Beyond the Health Room

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Many people still think of a school health program as a health room, a few hours of instruction on health issues, and a part-time school nurse who dispenses aspirin and Band-Aids. While this image was probably never accurate, the health needs of students of the 1990's go far beyond it. The epidemic of H.I.V./AIDS, concern about teenage pregnancy, and the poor health of too many of this country's young people are causing educators and health-care professionals alike to take a fresh look.

What they are seeing is mounting evidence on need and benefits that argues powerfully for greater coordination in this area. A word that recurs frequently in their conversations is "comprehensive.''

Put simply, a comprehensive school health program provides both health-related instruction and health services within the context of a healthy school environment. Instruction, or health education, gives students the information they need to make informed choices. Services--or the access to them--may range from routine first-aid and hearing-and-vision screenings, to primary medical care, whether through a school-based health clinic or referrals and partnerships with local health providers. And a healthy school environment encompasses both safe physical surroundings and a psychological climate that facilitates learning. This includes an emotional environment that fosters high achievement by all students and respects their diversity by race, sex, sexual orientation, and ethnicity.

Every school system already addresses these three basics in some way. Developing a comprehensive health program often means expanding what already exists and, perhaps more importantly, integrating the separate pieces into a coherent whole that complements the school's fundamental educational mission.

A healthy child is a teachable child. And the same child who is at risk of school failure is frequently also at risk of poor health. A student who is hungry, in physical or emotional pain, or impaired by drugs or alcohol cannot benefit fully from schooling. A child or adolescent who is frequently sick is also one who is repeatedly absent from school.

More than two-thirds of teachers report poor health among students as a problem in their schools. While good health does not guarantee good academic performance, early sexual activity and childbearing, smoking and alcohol use, heavy drug use, and delinquency set the stage for low academic achievement, school misbehavior, and dropping out. Consider these findings from research and observation:

  • More than 40 percent of all girls who drop out of school give pregnancy or marriage as their reason.
  • Students with untreated vision and hearing problems perform poorly when they cannot read the blackboard or hear the teacher.
  • Malnourished children are less physically active, less attentive, and less curious than those who are well nourished.
  • Children who are abused or neglected frequently suffer psychological as well as physical damage that hinders learning: They may be overly aggressive and disruptive or, at the other extreme, withdrawn and depressed.
  • Children and youths who get regular exercise have better concentration--and consequently better mathematical, reading, and writing scores--than those who do not exercise regularly.

The relationship between health and learning is so compelling that any serious discussion of educational excellence or school reform must address the health needs of children. Yet statistics paint a bleak picture, particularly for children from low-income families:

  • More than 30 percent of poor children (and 9 percent of children from families with incomes above the poverty line) do not have any kind of health insurance, public or private.
  • Nearly half of all high-school seniors report illicit drug use at some time in their lives. And 57 percent report drinking alcohol during the previous month.
  • Violence is a fact of life for many children. In a study of 8th and 10th graders, half of the boys and more than a quarter of the girls had at least one physical fight during the past year.
  • An estimated 1.9 million children are reported neglected or abused each year.
  • More than half of U.S. teenagers report having sexual intercourse by age 17. And some 2.5 million teens contract a sexually transmitted disease each year.
  • Only 40 percent of students ages 11 through 17 regularly participate in year-round appropriate physical activity.
  • Hundreds of adolescents have been diagnosed with AIDS. Thousands more are already infected with the human immunodeficiency virus and, given the incubation period of 10 years or more, will develop AIDS in their 20's.

Because they are, quite literally, matters of life or death, AIDS and H.I.V. infection have taken center stage in discussions of school health. They have also prompted educators and communities to look at issues (such as adolescent sexuality and homosexuality) that are as important as they are politically loaded.

AIDS has made it imperative for educators to talk about adolescent homosexuality. This is a difficult political issue, especially for administrators and school-board members who may fear facing irate parents in the check-out line of the local grocery store. Nonetheless, we must find new paths through the political quagmire in order to provide gay and lesbian young people with the information, support, and services they need to be healthy and to avoid H.I.V. infection.

Magic Johnson has made the general public aware that heterosexual transmission of the H.I.V. virus is increasing. But females have a much higher risk than males of contracting H.I.V. from their sexual partners--a fact that has especially serious implications for young girls who trade sex for drugs or who have sexual intercourse with (generally older) H.I.V.-infected men. Among teenagers, the H.I.V. infection rate for girls is consistently higher--sometimes several times higher--than the rate for boys. This is the opposite of the pattern for adults, where nine times more men than women are diagnosed with AIDS

The critical relationship between health and learning--and the unparalleled access that schools have to young people--make schools a major (albeit sometimes reluctant) player in child and adolescent health issues. This does not mean that every school should operate a full-fledged health clinic or that schools should neglect their primary educational mission. But it does mean that schools can--and should--be the catalyst or conduit to provide the ounce of prevention today that makes a pound of cure unnecessary tomorrow.

In addition to formal instruction about health, teachers who themselves understand health issues can incorporate health messages into almost any subject--biology (growth and development), home economics (nutrition and safety), history (disease control), and social studies (foods and health practices in other lands). Coaches and trainers can exploit teachable moments on the playing field and in the locker room. Even a school that offers few direct health services can play an important health role by providing school space for health consultations or on-site screening, arranging for transportation to health facilities, and coordinating scheduling so that students are not penalized for getting needed care.

Good health for children and young people concerns every facet of a community, not just educators. co quote possPutting a comprehensive school health program in place can be a long-term solution to problems--such as teenage pregnancy, alcohol and drug abuse, and skyrocketing health costs--that have already reached crisis proportions in many communities. In the long run, taxpayers benefit when health-care costs drop. Employers benefit when employees do not miss work to care for sick children. And future public-health-care dollars will stretch farther as children carry patterns of preventive health care into adulthood--wearing seat belts, not drinking and driving, and getting medical help before a trip to the emergency room seems the only alternative.

The key to strong support for school health programs is broad agreement that these programs are a wise investment in the future. If policymakers and community members believe this, then resources will be found--whether by adjusting the education budget, by using health-department funds to reach young people through the schools, by creating new funding mechanisms, by redefining old ones, or by tapping into insurance and other reimbursement systems.

States are already finding creative ways to use Medicaid to fund school-provided health services for low-income children. For example, states from Alabama to Washington use E.P.S.D.T. (the initials for Early Periodic Screening, Diagnosis, and Treatment, the child-specific section of Medicaid) to fund school-provided health services.

Many states are experimenting with new funding mechanisms that cross departmental lines. For example, to deal with the large number of children without health insurance, Florida is testing a plan to use the school as a grouping mechanism for negotiating health-insurance coverage. The legislature created the Florida Healthy Kids Corporation in 1990, which is using a mix of state (departments of education, health and rehabilitative services, and insurance, as well as a special state appropriation for the corporation), federal (Health Care Financing Administration and Maternal and Child Health), and foundation (Robert Wood Johnson Foundation) resources to subsidize insurance premiums for schoolchildren from low-income families.

Structures such as these--organized according to who is served (children and youths) rather than who is doing the serving (agencies and departments)--are key to addressing the health needs of young people. An effective school health program in the 1990's must reflect this and go far beyond the outdated image of a health room, an occasional visit by a school nurse, and a one-time health-education course.

Margaret C. Dunkle is a senior fellow with the American Council on Education. She was senior author of Beyond the Health Room, published last year by the Council of Chief State School Officers.

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