school health is a place, not a discipline

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School Health is a Place, not a Discipline Philip adam President, Dean Hopp, ladies and gentle- M men, members of the American School Health Association, I wish to thank you for the honor you have bestowed upon me. I am very proud to receive the Howe Award and very grateful to those who nominated me. William A. Howe was a prominent physician who was deeply interested in the health of schoolchildren. He was appointed state medical inspector for the New York State Dept. of Education in 1915 and also served his community as physician, health officer and School Board member. In 1926, while attending an American Public Health Association meeting in Buffalo, N.Y ., he chaired an ad hoc committee of like-minded physicians who decided that a national organization of school physicians was needed to promote better health instruc- tion and improved school health services. The following year, the American Association of School Physicians was formed with 325 members. William Howe was elected as the Association’s first president. 1936 was a watershed year in the history of this organization. It had been clear for sometime that many disciplines were making significant contributions to the well being of schoolchildren and in recognition of this, membership was made available to all those involved in school health programs. This was also the year when the name of the organization was changed to the American School Health Association. Dr. Howe died on his 78th birthday in 1940. In 1941, the Howe Award was created and in 1942 the first recipients were named. Between then and now, dis- tinguished men and women who have worked to improve the health of schoolchildren have been recipients of the Howe Award. I am honored to be among them. I would like, as many have done before me, to anticipate the future by looking to the past for clues. It is always easier to describe where we have been than to predict where we will be at the end of this century. I hope you will forgive me for my pediatric approach. It is not the only one but I would like to touch briefly upon the history of school health as seen through the eyes of a pediatrician. School health services are almost 100 years old. They first emerged in the 1890s on the Eastern seaboard. In Cambridge, Mass., where I work- ed, school health services began in 1899. All programs in this era had a single purpose and that was to keep contagion out of the schools. The approach was direct - the nurse made daily inspections for fever, rashes and lice. As the 20th century began, improvement occurred in housing conditions, public health practices were J. Porter widely disseminated, vaccines were developed and antibiotics were discovered. All these events made a contagion watch less necessary and less important. As a consequence, school health programs began to evolve as these secular changes and medical advances occurred. School health gradually evolved into a screen- ing and health education mode. The disciplines of edu- cation, psychology, nutrition and social service became vital. This evolution was slow as I read the history and the pace varied from community to community. The reasons for this are at least twofold. First, financing of school health services was and continues to be a difficult issue. Second, there has been a continuing debate as to what the proper role is for the school in the area of health. Some educators believe that basic education is what schools are about and all avail- able effort should be concentrated on reading, writing and arithmetic. Others, probably a minority, do not relish the broadening of services offered in school but see untreated medical, developmental and psychosocial problems and feel that the school is the last place where these issues can be addressed. These individuals feel that healthy children learn better and though they don’t seek the responsibility, they believe they must assume it. This debate within the educational community is not new and has raged for at least a half century. What can we learn from this period of screening, referral and health education? A report entitled Physical Defects: The Pathway to Correction was published in 1934. It was an inquiry into the success and failure in the detection and correction of physical defects as reflected in the medical examination pro- cedures in New York City schools. This study pointed out that defects that were detected went uncorrected. I am sorry to report that I found this to be true 30 years later in my city. A subsequent analysis of school health services was published in book form in 1942 entitled Solving School Health Problems. The shorthand for this report is the Astoria Study. It is a seminal study and I would like to quote from it, remembering that it was written 45 years ago. “The big problem was that there were two health service programs for school children. One was car- ried on by the physicians, nurses and dentists of the Department of Health; the other by the teach- ing staff of the Board of Education. Originally intended to supplement each other, the two pro- grams had become almost totally independent. Philip J. Porter, MD, Director, Healthy Children, Division of Health Policy Research and Education, Harvard University, Cambridge, MA 02138. Philip J. Porter, MD, was the 52nd recipient of the American School Health Association’s William A. Howe A ward, the Associa- tion’s highest honor. During the award ceremony at the 1987 conven- tion, Oct. 7-10, at Indianapolis, Dr. Porter made the following comments. “If the child had had his tonsils removed, proto- col required that the school physician should inspect the child’s throat before the defect could be considered corrected on the record. Sometimes all the children in a class who had been examined a month or two previously would be called down to journal of School Health December 7987, Vol. 57, No. 70 477

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Page 1: School Health is a Place, not a Discipline

School Health is a Place, not a Discipline Philip

adam President, Dean Hopp, ladies and gentle- M men, members of the American School Health Association, I wish to thank you for the honor you have bestowed upon me. I am very proud to receive the Howe Award and very grateful to those who nominated me.

William A. Howe was a prominent physician who was deeply interested in the health of schoolchildren. He was appointed state medical inspector for the New York State Dept. of Education in 1915 and also served his community as physician, health officer and School Board member. In 1926, while attending an American Public Health Association meeting in Buffalo, N.Y ., he chaired an ad hoc committee of like-minded physicians who decided that a national organization of school physicians was needed to promote better health instruc- tion and improved school health services. The following year, the American Association of School Physicians was formed with 325 members. William Howe was elected as the Association’s first president.

1936 was a watershed year in the history of this organization. It had been clear for sometime that many disciplines were making significant contributions to the well being of schoolchildren and in recognition of this, membership was made available to all those involved in school health programs. This was also the year when the name of the organization was changed to the American School Health Association.

Dr. Howe died on his 78th birthday in 1940. In 1941, the Howe Award was created and in 1942 the first recipients were named. Between then and now, dis- tinguished men and women who have worked to improve the health of schoolchildren have been recipients of the Howe Award. I am honored to be among them.

I would like, as many have done before me, to anticipate the future by looking to the past for clues. It is always easier to describe where we have been than to predict where we will be at the end of this century.

I hope you will forgive me for my pediatric approach. It is not the only one but I would like to touch briefly upon the history of school health as seen through the eyes of a pediatrician. School health services are almost 100 years old. They first emerged in the 1890s on the Eastern seaboard. In Cambridge, Mass., where I work- ed, school health services began in 1899. All programs in this era had a single purpose and that was to keep contagion out of the schools. The approach was direct - the nurse made daily inspections for fever, rashes and lice. As the 20th century began, improvement occurred in housing conditions, public health practices were

J. Porter

widely disseminated, vaccines were developed and antibiotics were discovered. All these events made a contagion watch less necessary and less important.

As a consequence, school health programs began to evolve as these secular changes and medical advances occurred. School health gradually evolved into a screen- ing and health education mode. The disciplines of edu- cation, psychology, nutrition and social service became vital. This evolution was slow as I read the history and the pace varied from community to community. The reasons for this are at least twofold.

First, financing of school health services was and continues to be a difficult issue. Second, there has been a continuing debate as to what the proper role is for the school in the area of health. Some educators believe that basic education is what schools are about and all avail- able effort should be concentrated on reading, writing and arithmetic. Others, probably a minority, do not relish the broadening of services offered in school but see untreated medical, developmental and psychosocial problems and feel that the school is the last place where these issues can be addressed. These individuals feel that healthy children learn better and though they don’t seek the responsibility, they believe they must assume it. This debate within the educational community is not new and has raged for at least a half century.

What can we learn from this period of screening, referral and health education? A report entitled Physical Defects: The Pathway to Correction was published in 1934. It was an inquiry into the success and failure in the detection and correction of physical defects as reflected in the medical examination pro- cedures in New York City schools. This study pointed out that defects that were detected went uncorrected. I am sorry to report that I found this to be true 30 years later in my city.

A subsequent analysis of school health services was published in book form in 1942 entitled Solving School Health Problems. The shorthand for this report is the Astoria Study. It is a seminal study and I would like to quote from it, remembering that it was written 45 years ago.

“The big problem was that there were two health service programs for school children. One was car- ried on by the physicians, nurses and dentists of the Department of Health; the other by the teach- ing staff of the Board of Education. Originally intended to supplement each other, the two pro- grams had become almost totally independent. ”

Philip J. Porter, MD, Director, Healthy Children, Division of Health Policy Research and Education, Harvard University, Cambridge, MA 02138. Philip J. Porter, MD, was the 52nd recipient of the American School Health Association’s William A. Howe A ward, the Associa- tion’s highest honor. During the award ceremony at the 1987 conven- tion, Oct. 7-10, at Indianapolis, Dr. Porter made the following comments.

“If the child had had his tonsils removed, proto- col required that the school physician should inspect the child’s throat before the defect could be considered corrected on the record. Sometimes all the children in a class who had been examined a month or two previously would be called down to

journal of School Health December 7987, Vol. 57, No. 70 477

Page 2: School Health is a Place, not a Discipline

be examined by the physician as to their progress in securing medical or dental attention. Some physicians thought this to be a good use of their time others seriously questioned it. ” I can comment that in 1964 hypertrophied tonsils

was the number one condition noted in the Cambridge school health program.

Moving ahead in time, Yankauer and others publish- ed an article in the American Journal of Public Health in 1955, entitled “A Study of Periodic School Medical Examinations.” In this article, the authors seriously questioned the need for repeated school health examina- tions. In summary, they noted that children who had an adverse condition on examination were known to have this condition and that the child was under care. I quote one of the article’s conclusions: “School medical examination of the first-grade children who had been previously examined in kindergarten was valueless from a case-finding standpoint.”

The next step in the evolution of school health services occurred in Cambridge, Mass., in 1965. The Dept. of Pediatrics at the Cambridge City Hospital realized that 60% of Cambridge’s children were without a medical home. These children and their families used the emergency ward of the city hospital for all their medical care. To make a long story short, a compre- hensive school-based program was developed for this population. Children from birth through adolescence were offered school-based comprehensive health care. The primary caretaker was the clinically trained nurse who was supported by the pediatricians in the Dept. of Pediatrics. This program was successful in improving health status, increasing access to care and reducing the cost of care both to the city and to society.

This program continued to screen, to refer, and to educate but it added a new dimension which was to treat on-site certain common medical problems.

Ten years later in St. Paul, Minn., a comprehensive school-based program was developed for adolescents. This program has gained national attention as it has had a positive impact on the critical problem of adolescent pregnancy. Comprehensive services are now present in five of the city’s six high schools and a clinic is to be opened in the remaining high school this fall.

During the last ten years, interest in comprehensive school-based services particularly for adolescents has been escalating at a rapid pace. School health is no longer a quiet harbor but rather a dynamic and often controversial area of medical care. The pace of the past 20 years far exceeds the pace of the previous 80 years. I do not know the exact number of school-based clinics as it is constantly changing. It would not be much in error to say that there are more than 100 school-based clinics in more than 75 communities. The importance of this innovative approach to the delivery of adolescent health care was underscored early this year when The Robert Wood Johnson Foundation awarded grants to 18 com- munities for the development of high school-based clinics.

This is the history of school health as I read it. I would like now to give one person’s definition of school health. School health is a place rather than a discipline. It is a place where multiple disciplines come together to

educate, to counsel, to prevent and to care for problems that otherwise might not be addressed at all or at least not on a timely basis. School health offers the student not only the opportunity for improved health status, but also the opportunity to achieve a life-style that will lead to a satisfying and productive life. Nursing and educa- tion have been, are and will be central to this effort. The nursing role will be different but then needs are differ- ent. Contagion has been replaced by the not so new “new morbidity.” The scope of school health services should and does vary. The content reflects community standards as well as the interests and commitment of School Board, Health Department and community leadership. ’

Whatever the scope of services, comprehensive school-based health services address the following issues: 1) access; 2) cost; and 3) compliance.

Placing services where the students are increases accessibility to these services. Adolescents have difficulty making and keeping appointments. This limits their ability to receive preventive and primary care services on a timely basis. Parents are often both working and this further complicates the manner by which non-emergent care is secured. School-based

. . . School health offers the student not only the opportunity for improved health status, but also the opportunity to achieve a life-style that will lead to a satisfying and productive life ,! .. .

services obey Sutton’s law and that is when Willie Sutton was asked why he robbed banks, his reply was “that was where the money was.” Schools are where the children and adolescents are.

The cost of a school-based clinic is relatively low - $l00,OOO per year is a ball park figure. Does the creation of school-based services contribute to higher or lower total health costs? On a national basis it is difficult to say. On the one hand, such services should reduce emergency room visits for non-emergent conditions both by preventing certain health problems and by identifying others at an early stage when treatment is less costly and more effective. On the other hand, these services may increase costs by providing more services through the identification of previously undiagnosed problems. This access vs. cost issue is complex and has not been studied nationally.

Let me cite my experience with this question in Cambridge. By reorganizing school health services in that city, we were able to reduce the cost to the city by 6% and at the same time made primary health care serv- ices available to all children in the city. We were also able to show a reduction of 50% in emergency room visits by this population of children for non-emergent conditions.

While the question has national significance, it is my belief that the majority of communities are going to decide how to proceed based on their concern about how best to address the needs of children and ado- lescents and on local issues.

Compliance is always a clinical concern. This is

418 journal of School Health December 1987, Vol. 57, No. 10

Page 3: School Health is a Place, not a Discipline

9 ff. . . I do not believe that there is only one format for school health services. The scope of services must be one that meets both patient needs and community standards. The program must include the support of the community, faculty, the school administrators and elected officials . . .I’

particularly true for adolescents who as a group do not follow directions. Having the ability to reinforce treatment recommendations on a daily basis if necessary is a unique aspect of working in a school.

What do I see in the future? Forecasting future health events is an inexact science, but I will attempt a few timid remarks.

I think that the evolution of school health services will continue at its present rate. School health is now in the vanguard when one discusses how to deliver health care to children and adolescents. I do not believe that there is only one format for school health services. The scope of services must be one that meets both patient needs and community standards. The program must in- clude the support of the community, faculty, the school administrators and elected officials. It must be seen as a value to students and parents. No matter what the final formulation, future services will be broader and more integrated than in the past. I see the services meeting traditional needs as well as addressing the new morbid- ity that is looming increasingly large on the horizon. I

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think a school-based approach is an idea whose time has come.

A major factor in the future development of children and adolescent services is the realization that an increasing number of children will live below the poverty level. Demographers tell us that by 1990 the largest group of poor people in the U.S. will be children. Some will be covered by Medicaid and many will not. Depending upon the state in which they live, between 26% and 80% of all children below the poverty level are ineligible for Medicaid. These uninsured children are usually without a source of continuing care. They may well present to the school a multiplicity of problems that limit their ability to learn. I believe that this cohort of children is going to influence the way that a community looks at the needs of its children and I believe that comprehensive school-based services will become even more attractive as a way of meeting these needs.

Only time will tell and my batting average may be not worth mentioning. Although I am not certain as to what the future holds for school health, I do think I know who holds its future. Those who hold the future are here in this audience and are in a position to lead their communities to a greater and broader commitment to children who are in need of comprehensive health services.

Again I am honored by the Howe Award and proud to join those who have preceded me. Thank you so much. 0

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~~

)ournal of School Health December 7987, Vol. 57, No. 70 479