CHAPTER XX

HEALTH SUPERVISION

THE RELATION OF HEALTH TO SCHOOL WORK

Ordinary school work is so dependent on health that one wonders how teachers of an earlier generation could have failed to see the absolute necessity of systematic supervision of health. When we think, for example, of the consequences of absence from class exercises because of illness; when we think of a child’s sense organs unable to carry to his mind the full message brought by the sounds and sights of the schoolroom; when we think of the nervous system dull and unresponsive because of malnutrition or hunger,—we begin to realize that the school is concerned in a very vital way with the problem of supervising health.

TREATMENT OF PATHOLOGICAL CASES

In order to exhibit something of the scope of the present movement toward complete supervision of health, we may begin with the extreme cases. In progressive school systems the children who are tubercular or anæmic or otherwise seriously affected are taken out of the regular classes and put where the whole educational program can be subordinated to the one consideration of bringing them back to physical vigor. Often these classes are conducted in open-air rooms, and often the equipment of the rooms includes cots on which the pupils may rest as a part of the regular school exercise.

SCHOOL LUNCHEONS

A second line of treatment deals with nutrition. The importance of one aspect of this matter is brought out in the following paragraphs:

Long ago Horace Greeley, in an address before a convention of teachers, called attention to one of the most perplexing social and economic problems of the age—a problem which still confronts school authorities of to-day.

“In vain,” he said, “shall we provide capable teachers, and comfortable school rooms, apparatus, libraries, etc., for those children who sit distorted by the gnawings of hunger, ... or suffering from the effects of innutritious or unwholesome food.”

Medical inspection is forcing upon public attention _this_ appalling fact—that a large percentage of children in school are in no physical condition, because of malnutrition, to profit by the present generous outlay of public money for school purposes. Practical educators, everywhere, are agreed that even the most patient, thoughtful effort to train under-nourished children is attended with but partial success. Out of their experience comes this plea—give the under-nourished child _body food_ first, before offering him the wisdom of ages.[88]

In view of the condition in which many pupils come to school, it has been found important for school authorities or philanthropic organizations to provide luncheons. These have been most successful where a small price is charged for the food.

CONTROL OF HOME FEEDING

The influence of this experiment in feeding is important not merely because of the positive nourishment given to the pupils but also because of the example which it sets in proper standards of eating at home. Many families do not know how to feed children. The son of a truck driver who breakfasts with his father on coffee, sausage, and griddle-cakes will spend the morning trying to digest the food which is appropriate to his father’s occupation but not to the sedentary life of the scholar.

PUBLIC ATTENTION TO NUTRITION OF CHILDREN

The importance of the whole problem of nutrition can be made clear by quoting from the work of a specialist. The paragraphs selected are the more impressive because they show that other nations as well as ourselves are confronted by these problems.

Recently there has been an increasing tendency to make the report on nutrition of different children the basis of the entire medical-inspection report. This is because it has been demonstrated again and again that the occurrence of disease and physical defects is largely conditioned by nutritional disturbances.

In Paris medical inspectors have charge of the school canteens and are required to report on the nutrition of each child. They are further expected to follow up any child with impaired nutrition and to administer tonics and special care.

In England, since 1907, compulsory medical inspection has included inspection of nutrition. Beginning with 1909, the chief medical officer of the National Board of Education has reported yearly on the nutrition of the children throughout the country and on the work of the school feeding centers. In Scotland the medical inspectors are required to see that children suffering from malnutrition are fed properly either by the school or by the parents. As a result of this systematic work British school doctors are developing methods of technique and standards for judging malnutrition, which, on account of its complex and interwoven causes, is very difficult to estimate accurately....

In American cities no record of the nutrition of the entire school population has been made. In 1907 in New York the Committee on Physical Welfare of School-Children reported 13 per cent of 990 children, selected as typical of the whole city, to be suffering from malnutrition. A similar investigation of 10,090 children in Chicago in 1908 revealed 12 per cent badly nourished in all grades, the proportion decreasing from 15 per cent in the kindergarten to 6 per cent in the fifth grade and above. Wherever an attempt has been made to include all classes of children in the examinations, the percentages found suffering from acute malnutrition run from 10 to 15. Where only schools in the poorer districts are included, the percentages are far higher, and vary between 20 and 40. However, it must be remembered that children from the poorer districts far outnumber those in other schools, so that in point of figures the actual proportion of children suffering from malnutrition is probably nearer the second estimate. Doctor Thomas F. Wood, of Columbia, gives 25 per cent as the estimate for the school population of the whole country.

“The longer a medical officer remains at school inspection,” remarks Doctor Hope, of Liverpool, in a report for 1912, “the more severe becomes his standard of nutrition, and the less readily does he pass a child as being well nourished.”[89]

One reason that health conditions in rural schools have been so long neglected is because of the common idea that country children are naturally vigorous and healthy. “This ought to be so but unfortunately is not,” says Doctor Ernest Hoag, in a recent government report. He finds that, “in general, food is not as well prepared in the country as it is in the city; the available variety is smaller.” Bad methods of ventilation and heating at home and at school, exposure to wet in the long walks to school, and overdressing in the house—all are inroads on the already badly nourished bodies. Investigations show that malnutrition and its accompanying diseases are quite as frequent among country as among city children.[90]

CONTROL OF CONTAGION

Turning from nutrition to another aspect of the physical condition in schools, it is easy to show that the school must control contagion. The bringing together of hundreds of children increases so greatly the probability of spread of disease that the health authorities always welcome the arrival of the summer vacation as a relief from the most strenuous of their duties.

THE SCHOOL HEALTH DEPARTMENT

The kinds of demands described have led to the development of health departments in many school systems. The various functions served by a school health department have been described by Dr. E. A. Peterson, a health officer in one of the largest cities of the country, in a report from which the following paragraphs are extracted:

The problem of checking contagion is an acute problem in the schools. The facts show that in the early years of a child’s school life he has more of the diseases of childhood than at any other period, especially more than he had when he was at home during the period immediately preceding school. Furthermore, as soon as school breaks up for the long vacation, contagion subsides. The bringing together of large groups of children in schools is one of the most prolific methods of spreading contagion....

But the school health service soon developed far beyond this first stage of merely policing the schools. Indeed, one sees the real justification of a separate school health department if he follows this health department into what may be called its second, third, and final stage of evolution....

Examinations by physicians within the last decade indicate that as many as five per cent of school children suffer from defective vision to such an extent that they cannot see lessons on the board unless they have the services of expert oculists, that one in every hundred cannot hear what the teacher is saying, that ten in every hundred are so “stopped up” by adenoids that attention to school work is nearly impossible until the science of medicine gives them relief.

This drew the attention of the educational world to the necessity of ridding children of these defects in order that they may take advantage of the educational opportunity offered in the schools....

One characteristic development shown at this second stage of school health organization is the employment of the school nurse. The school nurse marks the growth of the health era away from its first or merely policing stage. The school nurse is at once a medical officer and a teacher. She teaches the parents in the home and she teaches the children. She becomes a most important link between the home and the school. Her methods are those of persuasion, not those of the emergency police officer....

Once the idea of making health a matter of intelligent interest took root, it was sure to grow. Correction of physical defects is itself a tardy method of dealing with the situation. Why not prevent the defects? This kind of thinking turned attention to the environment of the child and the necessity of making it as conducive to health as possible....

Finally, it is by no means satisfactory that we should stop with the negative work of preventing disease and unfavorable conditions. We must be positive in our treatment of health. We want more health, more vigor, more efficiency. The fourth stage of medical inspection may properly be called the health development stage and has to do not only with the teaching of hygiene but with the development of higher ideals of wellness, with the raising of the standard of normality, with taking a person who is well and making him “wellest.”...

The department must constantly assume new functions without dropping any of the old. If it is to be an efficient department, it must carry on all of the activities suggested in the summary which can be made up from the foregoing study.

First stage—Inspection

1. Inspection of children for contagious diseases

Second stage—Discovering and correcting defects

2. Physical examination of all children

3. Follow-up work in the home to get corrections

4. Maintenance of school clinics

Third stage—Prevention

{ Hygiene of building 5. Sanitary inspection { Hygiene of curriculum { Hygiene of instruction { Special schools for special cases

6. Examination and inspection of principals, teachers, janitors and other employees

Fourth stage—Health development

7. Health teaching at school and at home

8. Establishing health habits by means of

_a._ Toothbrush drills _b._ Handkerchief drills _c._ Bathing, etc. _d._ Health clubs[91]

DIFFICULTIES OF INTRODUCING HEALTH INSTRUCTION

Health work in the schools, as it has risen to the level of a subject of instruction, has encountered the kind of obstacles met by every new school subject. Teachers are ignorant on medical matters, and the doctors who come into the schools are ignorant of methods of teaching. The result is that the instruction given by teachers is sometimes formal and unscientific, while the work of the doctors does not prove as effective as it might because it does not reach the pupils. A partial corrective for this difficulty can be supplied through a better system of training teachers.

The following extracts from a paper by Dr. Allison show how one state is attempting to cope with this problem:

In this tremendous but not superhuman task of teaching health, there seems to me no more effective method than to commit it to those who are and are to be the teachers. Progress in these matters cannot be made without an intelligent understanding on the part of the teacher. It is therefore important to teach the teacher. It is said that the normal school is historically the only institution in the country which has aimed to deal with the teaching problem.

The Board of Regents of the normal schools of Wisconsin felt the need of making the normal schools of the state instruments of public health and in 1912 appointed a physician for this work. The work as organized consists of: (1) exclusion of the physically unfit among the normal-school students; (2) detection of remedial physical defects with suggestions in regard to same; (3) instruction in preventive medicine.

1. The term “physically unfit” is very elastic, but we should have some physical standard. The public has not been in a position to protect itself against those physically unfit in the profession, but it is beginning to make certain demands. For example, what community will now tolerate a teacher who is known to be tuberculous? It is well to enlighten these physically unfit, and stop the source of the physically undesirable, as we would the intellectually undesirable.

My experience with several thousand young men and women during the last three years has shown me that the health habits of teachers need improving....

2. In the normal schools of Wisconsin a health-record card for each student is on file in the department of physical training. The side filled out by the physical-training teacher consists of a record of height, weight, and lung capacity, the neck, chest, and hip measurements, and a detailed record of posture. The physician’s report includes a record of the past medical history, personal history, sex history, family history, and the present condition of nutrition, skin, eyes, ears, nose, throat, teeth, glands, lungs, heart, and elimination. Each student is advised in accordance with the conditions which are found....

3. Instruction in preventive medicine consists of individual advice and classroom instruction as follows:

(_a_) Personal hygiene. This supplements what they have studied from the text and what they have received from the instructors of hygiene and physical training.

(_b_) A couple of lectures are given on the physical examination of school children. Teachers should be taught the essential facts about defective vision, defective hearing, adenoids, catarrh, diseased tonsils, nervousness, and mental defects....

(_c_) Lectures are given on the cause, avenue of infection, mode of transmission, period of incubation, symptoms, complications, results, and prevention of the following communicable and preventable diseases: measles, scarlet fever, chicken-pox, smallpox, mumps, whooping cough, grippe, pneumonia, tuberculosis, diphtheria, meningitis, and infantile paralysis.[92]

HEALTH AS A SUBJECT OF INSTRUCTION AND AS A MODE OF LIFE

A movement such as that described in the paragraphs just quoted shows perhaps better than any general description the strength of the demand that the schools teach and train for health. Health must be acquired as well as thought of in abstract terms. The school methods of dealing with it require a rational combination of the work of the physical-training department with that of the school physician and the teacher. The movement is therefore one of those broad movements in education which require the introduction of new materials of instruction but also call for a general and constructive administrative policy which shall support instruction by opening the way for an enlargement of school work of a practical type.

EXERCISES AND READINGS

What devices other than school luncheons can the school adopt in the effort to make people intelligent about the feeding of school children? What are the symptoms exhibited by children who are badly fed at home? What are the different types of difficulty which arise in the matter of nutrition?

Are the public-health controls in the city adequate to take care of contagion in the school? Should the school be dismissed in time of contagion? It is noted that pupils have a great many contagious diseases when they first come to school. This is sometimes explained by saying that the age from 6 to 8 years is more susceptible to disease. Is any other explanation to be offered? At what time in the year is contagion most common?

Would children’s health be endangered by continuing school during the summer? Are physical examinations of pupils justified in public schools? What objections are raised to such examinations? Who should make them? It is sometimes argued that the expense of medical inspection and physical examinations is too great. Is there any answer?

Here, as in the case of play, the administrative question arises, should all teachers have a part in the health supervision, or should the task be assigned to specialists? Argue the case.

GULICK, L. H., and AYRES, L. P. Medical Inspection of Schools. Charities Publication Committee, New York City. This is the book which contributed very powerfully to the beginnings of the movement for school departments of health.

WOOD, T. D. National Welfare and Rural Schools. _Proceedings of the National Education Association_, Vol. I-IV, 1916. Report of investigations of country and city children.

FOOTNOTES:

[88] Sarah Webb Maury and Lena L. Tachau, A Penny Lunch, p. 8. 1915.

[89] Louise Stevens Bryant, “School Feeding.” Educational Hygiene (edited by Louis W. Rapeer), chap. xvi, pp. 286-287, 289. Charles Scribner’s Sons, 1915.

[90] Ibid. p. 285.

[91] Dr. E. A. Peterson, “Medical Inspection.” Survey of the St. Louis Public Schools, Vol. VII, Part II, pp. 41-45. Published by the Board of Education, St. Louis, Missouri.

[92] Elizabeth Wilson Allison, “The Teacher’s Field in Public Health Work.” _Proceedings of the National Education Association_, pp. 676-678. Published by the Secretary of the Association, Ann Arbor, Michigan, 1915.