m ■ ■ I I ■ I m ■ WBtBrnaBa HP Stye €0tnm0ntoealtl) of Jtta00axt)U0ett0 DEPAKTMENT OF PUBLIC HEALTH SCHOOL HYGIENE BkwI ,1 M ^: : ii BOSTON WRIGHT & POTTER PRINTING CO., STATE PRINTERS 32 DERNE STREET 1920 Reprinted feom the Commonhealth, Vol. 7, No. 3, 1920. :ARY Oh GO.-,:i\LSS FEB281921 documents Division Publication of this Document approved by the Supervisor of Administration. ^tvrk* AtS> SCHOOL HYGIENE. By Merrill Champion, M.D., C.P.H., Director, Division of Hygiene, Massachu- setts Department of Public Health. IN all the field of public health activity there is surely no corner which offers greater returns in the way of health dividends than does school hygiene; and yet it must be said with regret that there is no program more promising on paper and more disap- pointing in execution than is the school hygiene program. There are many reasons for this state of affairs. Foremost, is the fact that school hygiene is essentially a community responsi- bility, and as yet the sense of responsibility of the community for the health of the school child is not any too well developed. Next, there is still much uncertainty in the minds of many as to whether medical school inspection is more properly a function of a school committee or of a board of health. Lastly, in Massachusetts, am- biguously worded laws and an overdeveloped sense of independence on the part of cities and towns have prevented proper co-ordination and stimulation of local activity. As the result of all these forces, the sum total of medical school inspection in this State has been most disappointing. A curious haziness exists in the minds of many as to the meaning of the term "school hygiene." Hygiene may be defined as the science of the preservation of health; school hygiene is the science of the preservation of health as it applies to the school child. Conditions surrounding the school child cannot be said to be normal. He has graduated from the free, nomadic life of the pre-school child into an environment of restriction and discipline. It is a period of adjust- ment to the treadmill of civilized existence. Physical and mental changes are taking place which will have a profound effect upon later life. It would seem as if little thought were needed to con- vince any one of the desirability of constant supervision of the health of the school child. In these days when money seems the criterion for so many things we can estimate the value placed by the community upon the serv- ices of school physicians by a study of salaries paid such officials. Studies made in 1915 and 1916 by the State Department of Health show that most communities place a very low money value upon medical school inspection. Some school physicians are paid as little as $10 per year, in spite of the fact that the law calls for an annual examination of each school child of a character sufficiently searching to detect defects which are likely to prevent the child from taking full advantage^ of the educational opportunities offered him. It is fatuous to suppose that this service can be obtained for $10 a year or ten times that sum, except in our tiniest communities. We can- not get something for nothing, whether it be groceries or medical service. Let us now consider what constitute the essentials of school hy- giene. We must have, first, a law under which to work; this may be of a permissive nature or mandatory. The latter is the type of legislation under which the work is carried on in this State. It should be recalled, in passing, that before such a mandatory law was enacted, the board of health of the city of Boston, in 1894, un- dertook medical school inspection, as did the town of Brookline. Other places followed shortly after. Antedating this by many years, however, the commission, appointed by the Governor in 1849 to make a sanitary survey of the State, recommended that "in erecting schoolhouses, churches and other public buildings, health should be regarded in their site, structure, heating apparatus and ventilation;" and again, that "measures be taken to ascertain the amount of sick- ness suffered among the scholars who attend the public schools and other seminaries of learning of the Commonwealth." Following the latter recommendation, studies were made by Dr. Henry P. Bow- ditch of the physical growth of school children in Boston, descrip- tions of which may be found in the annual reports of the State Board of Health of Massachusetts for the years 1877 and 1879. In spite of these excellent beginnings, it was 1906 before legisla- tion was enacted upon the subject of school hygiene. In accordance with this and subsequent legislation, Massachusetts now has a system whereby each city or town is supposed to have adequate medical examination for its school children, and adequate instruction in hygiene. That the majority of places have neither is a fact not sufficiently well recognized. It would seem worth while to point out in some detail various points in the law under which school inspection is administered. The first striking fact is that the law is mandatory and applies to every city and town in the State. The examination provided for must be sufficiently thorough "to ascertain whether he [the pupil] is suffering from defective sight or hearing or from any other disability or defect tending to prevent his receiving the full benefit of his school work or requiring a modification of the school work in order to prevent injury to the child or to secure the best educational results." This, it is easily seen, calls for medical school examinations and not medical inspection. A second point to be noted is that although school physicians are provided for in the act, no mention is made of the school nurse — obviously because school nurses were almost unknown in 1906. A third and most fundamental point is that the work is really left in the hands of the local authorities with practically no State super- vision. Theoretically this is an ideal plan, calculated to get the utmost out of community interest and pride. Practically, however, the result has been an utter lack of co-ordination, so that we have as many types of administration of this law as we have cities and towns in the Commonwealth. Fourthly, provision is made for safeguarding the child about to go into industry. The system of working certificates whereby the child before going to work must bring to the school a promise of employment, and must pass a physical examination to determine his fitness for the job in question, seems well calculated to protect the child. In practice, however, the results have been extremely poor. Outside of Boston these certificates have, for the most part, been handed out indiscriminately, as is shown by the percentage of rejections of those examined. Cities have reported as many as 2,000 examinations for working papers without a single rejection for physical defect — manifestly a ridiculous result. The rejections should probably be at least 4 or 5 per cent or more. A factor in this result is undoubtedly that advantage has been taken of that provision of the law which allows the acceptance of certificates from private physicians who get paid little or nothing for the work. Un- der such conditions the temptation to shirk is well-nigh overwhelm- ing. It must be said, however, that the record of the underpaid but regularly appointed school physician in many places is scarcely better. The fifth point to be noted is one already referred to and which has been and is the subject of much controversy. The Massa- chusetts law provides that the school physician shall be appointed by the school committee in all towns, and in such cities as do not have the medical school inspection carried on by the board of health. It must be acknowledged that much can be said for this plan. In the first place, it is argued that as medical school inspection con- cerns the school child, and is carried on in the school, to avoid con- fusion it ought to be under the school authorities. Again, it is pointed out that the school committees have a full-time agent in the person of the superintendent, while the average board of health 6 does not have any such full-time agent. This is at present a good argument, though it is becoming increasingly less so as boards of health take their jobs more seriously and are taken more seriously by the communities they serve. On the other hand, much may be said in favor of board of health control. The community interest in the health of the individual centers in the board of health. It is not very logical to single out a few years in the life of the individual, and to say that during this time he is to be considered as apart from other human beings younger and older than himself, and there- fore must have his health needs supervised by a separate body. Further objections to school committee control of medical school examinations are that the control of communicable disease — an important factor in medical school supervision — is vested by law in the board of health, and in it alone; and that under the law the school committee can furnish medical supervision to the public schools only, while as a health measure the board of health can extend it to private schools as well. As a result of this discussion, let us see if we can construct a ra- tional scheme for the medical supervision of the school child. In so doing, statements will have to be made rather dogmatically, so as to avoid interminable explanation. The elements of a successful plan for the State of Massachusetts might be set forth as follows : — State Guidance. — In view of our 354 municipalities, large and small, it seems probable that real progress will be slow in caring for the health of the school child unless there is some measure of State guidance. This, it may be said in passing, is not the same thing as State control. Individual initiative and growth should be preserved as far as possible. The question then arises, should this State guid- ance center in the Public Health Department or in the Educational Department? Here we must differentiate between physical educa- tion, so called, and medical school examination. Physical education consists largely in teaching to children the simple rules of health, — how to exercise, sleep, eat, breathe, rest and play. For a long time to come this will have to be done by non-medical teachers, and of course should be a part of the regular school curriculum. There- fore physical education may be said to be a prime interest of the Educational Department. But it is also of the greatest interest to the Public Health Department, and must be co-ordinated with medical school examination. Hence the guidance of the State policy as regards physical education should be in the hands of the educa- tional department, which should consult with the Public Health Department as regards the broad health principles involved. When we come to medical school examination, on the other hand, conditions are reversed. Here the chief interest and responsibility should be with the Public Health Department, which should con- sult with the Education Department, especially in matters affecting school routine. Local Control. — What has been said of the distribution of State responsibility is equally true of local conditions. Both the local school committee and the local board of health have legal and moral responsibilities for the health of the child in the public school. At present, under the law, in all the towns and in most of the cities the actual administration of medical school inspection is in the hands of the school committees. This should not preclude free co- operation between the school committee and the board of health. In fact, anything less is inexcusably bad civic policy. It would be advisable to have this co-operation enjoined by an amendment to the law. Personnel. — Medical school inspection calls for a high degree of medical skill on the part of the school physician, and training and experience in medical and social work on the part of the nurse. Both doctor and nurse are essential to efficient control of school hygiene. Much has been said and written on the question of whole-time or part-time service on the part of the physician. Expediency usually dictates part-time service. At best, however, such service must be relatively unsatisfactory; especially is this true of a combination of general practice and school work. A general practice is a hard task- master. When people are sick they want a doctor at once, and it is for the doctor's interest to go at once. School work, being appar- ently less urgent, is pushed to one side. The job of school physician, properly understood, is a big enough one to take the whole of a man's best energies. The school nurse is almost always a whole-time worker; that is, she gives her whole time to some form of public health work-. Be- cause of this very fact she has an advantage over the part-time school physician. The latter is competing with other practicing physicians; the school nurse is in competition with no one, and so arouses less enmity. This is not true of the nurse who practices medicine by making diagnoses and advising treatment, a procedure which is always to be deplored. In the case of the school nurse, however, as in the case of the school physician, the exigencies of circumstances in many localities seem to make it necessary that the school nurse do other types of nursing as well. It is unfortunate if the other types must include bedside nursing. It happens almost invariably and inevitably that the bedside care of the sick sooner or later takes precedence in her 8 thoughts over the apparently less urgent care of the comparatively well school child. Nevertheless, the small rural community, for the present, at least, probably cannot get school nursing upon any other terms. In certain Massachusetts towns it would be well worth while to try the scheme of having several small towns employ a school nurse (as well as a school doctor) in common. A county school nurse is also a promising possibility, though this would neces- sitate enabling legislation. During the school summer vacation the school physician and school nurse can profitably be employed on other types of child welfare work. This is more easily arranged where the medical school work is in the hands of the board of health. One word may well be said here as to the number of school phy- sicians and nurses needed properly to carry on the work in a given community. This will, of course, vary with the type of population served and with the distances to be covered. The standards set up at the Child Welfare Conference at Washington serve as a good guide; namely, 1 school nurse for not more than 1,000 school chil- dren; a part-time physician with 1 full-time nurse for not more than 2,000 children; or 1 whole-time school physician and 2 whole-time nurses for each 4,000 school children. School Examinations. — By statute in Massachusetts it is required that an annual examination be made of each school child. JThis examination is expected to be sufficiently thorough to detect any defect which would tend to prevent the child from getting the full benefit of his schooling. The average inspection which the school child undergoes falls miserably short of this. The child is entitled to a careful physical examination, embracing heart, lungs, nose and throat, sight and hearing, posture and especially nutrition. This examination should be done in private, and should include weighing and measuring. The latter phase of the examination should be re- peated at frequent intervals, — monthly, or even weekly under certain circumstances. Children found below normal should, of course, be the ones to get the more frequent weighing. Taking the height and weight may well serve as a rough test at the beginning of the year to pick out the pupils most in need of early intensive attention. The mental examination of the child is also indicated, though for the present it will probably be limited to the atypical or retarded child. Need of Co-operation. — One of the points most in need of em- phasis is that the supervision of the school child, whether from the point of view of medical school examination or physical education, 9 should be a joint affair on the part of the school authorities, health authorities and parents. Much of the friction arising in adminis- tration conies through a failure to recognize this. The school and health authorities must themselves co-operate whole-heartedly. The school doctor must co-operate with the supervisor of physical edu- cation, and vice versa. It is illogical and sometimes dangerous to inaugurate or continue physical exercise without physical examination to determine existing physical defects. It is futile to examine chil- dren without some provision for getting something accomplished when defects are discovered. The parent must not be overlooked in this scheme of things. She (it is usually the mother who responds) should be invited to be present when her child receives his annual physical examination. Both the school authorities and the parents will learn something from an interchange of ideas. Incidentally, much of the opposition to the physical examination of school children, seen in certain local- ities, would be obviated in this way. Such opposition is based largely upon misapprehension and ignorance rather than upon prin- ciple. Such a method takes a little longer, but shows greater ulti- mate results. Conclusions. — We may briefly summarize this discussion on school hygiene thus : — 1. The medical supervision of school children and the teaching of the simple health habits are now recognized to be essential by all who have given any real thought to the subject of school hygiene. 2. Both these matters are of vital concern to parents, to school committee and to board of health. 3. Rules and regulations regarding both these phases of school hygiene should be made jointly by both education and health de- partments. 4. Administration of medical school inspection should be the job of the health department; administration of physical education and teaching of health habits, that of the school department. 5. Adequate supervision, as outlined above, calls for trained school physicians and nurses and teachers of physical education, and suf- ficient remuneration for these workers to enable the community to get efficient service. 6. Careful physical examination should be followed by every ef- fort to get defects remedied. This means clinics or private medical care for the defective child, and physical education for the child when he is well. The defective child should be made well; the well child should be taught how to keep well. Gaylord Bros. Makers Syracuse N.Y. PAT. JAN. 21, 1908 5II$fI m LfeSSffiftS ■ s