opmental defects, to evaluate screening tests which may have been given, to plan with parents and teachers for necessary treatment and for adjustments at school and home. Medical examinations as described are at present rarely provided. If such complete examinations were made, fewer children would go through school with neglected health conditions, and more parents and children would have conviction about the value of health examinations. High-school students frequently have even fewer health services than elementary school children. Though the stresses and strains of this period are very great, often all that is provided is examinations for the students taking part in competitive athletics. Studies of the reasons for failure to secure treatment of physical defects has shown that many children did not receive treatment because the condition was not accurately disgnosed. Perhaps the most conspicuous medical condition in this category is heart disease. This condition is the most serious disease among children of school age and yet measures for its accurate recognition and adequate treatment are not available to most school children. Diagnostic and treatment services should be provided to aid in the proper care of this condition.

Spécial medical facilities are needed also for many other medical problems of school children, such as malnutrition, orthopedic, hard of hearing, poor vision, and emotional abnormalities. In urban localities the problem may be solved by the mobilization and better utilization of existing resources. In rural areas it will be necessary in many localities to create the treatment facilities and provide adequately trained personnel.

Health services for school children require adequate medical and nursing skill in order to function properly. As a rule, schools in large cities have the services of both a physician and a nurse, although the ratio of nurses and physicians to pupils is not adequate to perform the desired functions previously mentioned. In rural areas where approximately 50 percent of the Nation's children live, except for some medical inspection by health officers and local physicians, little or no medical service is available to school children. Public-health nurses provide service, but this is not adequate in amount to maintain the necessary followup to secure treatment for physical and mental abnormalities. There are 845 of 3,000 counties in which there is no public-health nursing service.°

Because they function in the schools, physicians and nurses must understand school methods and problems. For this reason and because of the specialized character of many of the physical and mental abnormalities associated with normal growth and development, physicians and nurses planning to engage in school health work need specialized training. Today this is difficult to obtain. A key person in the school health service is the teacher. A major objective in school service is to provide for the day-to-day supervision of the child while he is in school. This is largely the responsibility of classroom teachers. But few of them are qualified either through preservice or in-service training to recognize the characteristics of normal, healthy children, or to detect the signs of illness or to utilize height and weight measurement, the school lunch, or vision testing as health teaching tools.

Supervisory medical and nursing personnel to guide physicians and nurses who render school health service is lacking in a majority of States. One State education department provides a supervisory physician and three provide supervising nurses. The extent and quality of such supervision are not known in those States where responsibility rests with health departments or is shared.

10

One other aspect of the preventive program must be mentioned. There is a growing realization among school health workers and persons interested in mental hygiene, that the school needs to look toward a program which will contribute in preventing behavior disturbances from occurring. Fifty percent of all hospital beds are occupied by individuals who were not able to cope with the realities of life. The need for educating youth to make adequate personal and social adjustments to glandular drives is generally accepted.

A realistic health program should include social-hygiene education to insure mature, balanced individuals with sound moral standards and socially acceptable personalities. The school health-service program if manned with professional workers experienced in child guidance could assist with this problem. The total number of trained psychiatrists in this country is small (3,000) and at present few are available to the civilian population. This need, however, must

Federal Security Agency, a report of the U. S. Public Health Service: Total Number of Public Health Nurses Emploved in United States, in Territories of Hawaii and Alaska, and in Puerto Rico and Virgin Islands for Years 1940-44.

10 U. S. Office of Education, Biennial Survey of Education, 1938-40-School Hygiene and Physical Education, vol. I, ch. VI. Washington, D. C., U. S. Government Printing Office, 1940.

be met, and school administrators and health officers should plan for services in this important long-neglected area of school health.

Research in school health problems is at the present time virtually nonexistent. For example, little is known as to the reason for the annual increment of vision defects or variations in growth which occur among school-age children. Study of the contribution which environmental factors make to the health of school children should be made with as much vigilance, and persistence as is done in the field of industrial hygiene..

Administrative studies of the most effective way to organize a program of instruction and service and to reach the goals described are greatly needed. 3. An opportunity to realize their potentialities of growth and development Adequate medical and dental care.-For many years school health services have been discovering defects in school children, but little has been done to correct these defects.

The Hagerstown study "showed that a relatively large number of the selectees who had been rejected because of certain defects already gave evidence of the same defects 15 years before as shown by school examinations.

From all available sources of information, estimates have been made of the number of children under 21 years in the United States with various physical handicaps. They are as follows:12

In addition, it is estimated that at least three-fourths of all school children have dental defects.

Examination of youth of 14-17 years participating in National Youth Administration programs in 1941 revealed a startling number of conditions needing correction.

Number of specific recommendations for medical services and corrections for 100 examined youths, aged 14-17"

13

Percent

74.5

15.2

12.2

3

15. 1

3.8

.3

.8

.9

9.0

2.6

6.0

2.4

9.3

9.3

11.5

11 U. S. Public Health Service, Child Health and the Selective Service Physical Standards, by Ciocco, Antonio. Klein, Henry, and Palmer, Carroll E. Public Health Reports, vol. 56, No. 50. December 12, 1941. Washington, D. C.

12 Wartime Health and Education-hearings before a subcommittee of the Committee on Education and Labor, U. S. Senate, 78th Cong.. 2d sess., pursuant to S. Res. 74, nt. 5. Washington, D. C., U. S. Government Printing Office, July 10, 11, and 12, 1944, p. 1857. 13 Ibid., p. 1858.

Factors which prevent school children from receiving adequate medical and dental care are:

(a) Inadequate and inappropriately distributed medical personnel and facilities.

(b) Lack of desire for services.

(c) Inability to buy services.

As reported to the Pepper committee, "40 percent of the counties of the United States lack full-time local public-health service. Many of the existing health departments are inadequately financed and staffed. Minimum preventive services under the administration of full-time local public-health departments staffed with qualified personnel should be provided in every community.

"Data submitted by the procurement and assignment service show that at the end of 1943, 553 counties had more than 3,000; 141 counties had more than 5,000; and 20 counties had more than 10,000 people per active physician in private practice. In addition, 81 counties, 30 of which had populations of more than 3,000, had no practicing physician.'

Services of specialists are even more inadequately distributed. Of the 2,609 pediatricians in the country, 1,000 serve the 4,500,000 children living in the large cities, while to meet the needs of the 20,000,000 children living in small communities, there are less than 100 pediatricians.

"The wartime shortages are merely sharper manifestations of the long-standing and steadily growing maldistribution described above. There is every indication that maldistribution will become even more marked after war unless effective steps are taken to reverse the trend." There are indications that dental and nursing services involve similar problems.

"Good medical practice today requires a concentration of skilled personnel and equipment that is found only in good hospitals, medical centers, or group clinics. "Whereas the national ratio of general hospital beds was 3.4 per 1,000 population in the year just before the war, the ratio in such States as Mississippi and Alabama was less than half that. According to the Surgeon General of the United States Public Health Service, 40 percent of our counties, with an aggregate population of more than 15,000,000 have no registered hospitals. Many of the counties with hospitals have poor ones, even though they are registered."

15

Family income definitely influences ability to obtain medical care. It is estimated that it takes approximately $150 per year to provide adequate medical care for a family. Fifty percent of the families in this country earn less than $2,000 per year, and it is evident that they cannot afford $150 per year without imposing hardship upon their families.

Medical services have to be available and readily accessible everywhere if people are to learn to use them and want them. In sections which have medical services, extensive educational programs need to be inaugurated so that people will learn how best to use these services. Even in areas that now have a reasonable degree of medical services, educational programs with the children and parents would help to see that these services were used properly.

The medical profession has long suggested that the after effects of many of the so-called childhood diseases are more injurious to the child than the disease itself. School health workers and school administrators must become more conscious of this fact and explore ways of adjusting school programs so that they will not prevent a child from making a satisfactory recovery. It seems reasonable to suppose that many of the defects found in children can be attributed to a complicated recovery from seemingly unimportant infections.

Nutrition.-Dietary deficiency diseases (scurvy, rickets, pellagra) in severe form are not so common among children as a decade or two ago, but they still exist, and mild forms of these diseases are prevalent among children of lowincome families. Secondary anemia in children and pregnant women is usually related to a diet deficient in one or more respects. Data from recent studies compiled by the National Research Council 16 indicate that in some parts of the country as high as 72 percent of pregnant women and as high as 85 percent of children of early school age are suffering from secondary anemia.

Many more children suffer from general malnutrition than from any one specific disease. These children grow at less than the normal rate; their musculature is poor; they have less than average resistance to infections. That the effects of childhood malnutrition may be lasting is indicated by a study of the data from school health examinations of a selected group of young men rejected

14 Thid., p. 14.

15 Thid., D. 12.
10 Ibid., p. 1858.

17

by selective service, for whom records had been kept over a long period of years.1 The study showed that there was a definite association between the childhood state of nutrition and the development of defects that 15 years later disqualified the adult for selective service.

Children need enough of the right kinds of food if they are to achieve optimal development and maintain a high degree of health. Responsibility for nutrition rests with the home during infancy and the preschool years, but later it is divided between the home and the school. Most children spend the noon hour at school, consequently the school should provide a complete noon meal, available to all children without discrimination. For children who must travel long distances or who require more food than is supplied through the usual number of meals, the school may need to provide supplementary midmorning and midafternoon nourishment. The serving of food should be an educational experience and should be accompanied by instruction that will enable children to choose the foods that contribute most to meeting their nutritive requirements.

Physical education.-All children need physical activity if they are to achieve maximum growth and development. So that children may build organic power, strength, and endurance, and learn how to use their bodies efficiently, physical education programs have functioned in some of the schools for many years. The Society of State Directors of Health and Physical Education states that 18 "27 States reported having a law making physical education compulsory. enteen States which directors and ten without directors); five States reported that physical education was compulsory, due to State board of education regulations.

(Sev

"The requirement in regard to time allotment varies from two times a week to five times a week, and from 60 to 300 minutes." These data would indicate that State departments of education have not, for the most part, recognized the importance of incorporating physical education as one of the curriculum requirements for all children. Children in the elementary grades need a total of from 3 to 4 hours of physical activity daily.19 Children in the junior and senior high schools need at least 60 minutes per day of physical activity adapted to individual needs and capacities within the school program and an equal amount after school hours. This is essential if the school program is to contribute to the attainment of a vigorous youth. Physical-education programs should be conducted and supervised by properly trained teachers. Adequate space and facilities are also a requirement.

Recreation. If education builds for the assumption of responsibilities in adult life, consideration must be given to the recreational needs of children. Varied programs both in and out of school, under school sponsorship and in cooperation with other agencies, should be developed for children. Children need to learn through profitable experiences how to make wise choices in the use of their leisure time. This is both a school and a community responsibility and should be solved jointly.

School administrators must consider the schedule which is developed for children. Too often individual differences are overlooked and all children of one chronological age are made to fit the came pattern without due consideration being given to the needs of individual children. A school staffed with personnel who know the needs of children can be of immeasurable assistance in advising adjustments for particular children, and thus serve to prevent emotional disturbances and forestall impediments to the orderly growth and development of the child.

4. To learn how to live healthfully

Schools in the past have placed great dependence upon health knowledge to motivate improved health behavior. This approach did not take into account the elements of the learning process, and we now find adults who failed to learn how to live healthfully while in school. The attainment of health is an individual responsibility for which children must be educated. The foundation for healthful living is based on scientific knowledge. The manner in which we acquire this knowledge, however, determines to a large measure, the degree to which it is utilized in our daily lives.

By using initiative, imagination, and the resources of the school and community, an alert teacher can expose children to experiences in which their knowledge will be tried and tested. Health is dependent not only on a balance

between the physiological requirements of the body, but also on a balance between the emotional and thinking qualities of the child. Attitudes which build up unreasonable likes and dislikes, fears, repulsions, or overdependence all affect the equilibrium essential for the attainment of optimum health. The educational, program should be concerned with the total child in relation to his needs and his environment.

The program for healthful living is not dependent solely upon what is done during the health education period. Since all experiences of the child condition his behavior, health education must be thought of as a product of a great variety of experiences in home, school, and community. The organization and atmosphere of the entire school has a bearing on healthful living. All teachers who come in contact with the child exert an influence which must be considered. Healthful behavior as revealed through daily habits is dependent upon the expression of scientific and intelligent attitudes which give a basis for self-education. Not only is the provision of opportunities basic for good health practices but actual pupil participation is essential.

Data regarding the programs of health instruction in the schools of the country are not plentiful. The Society of State Directors reports that 20 "21 States reported that health instruction is given in the elementary school; 19 States reported that health instruction is given in the junior high school; 23 States reported that health instruction is given in the senior high school."

The amount of time devoted to this activity is not given nor are there data on the number of special teachers of health education employed in the schools. 5. Teaching personnel

"Examination of health teaching practices from the standpoint of those who administer the schools reveals, in general, two apparent needs: (1) The need for specialists in health teaching fields, and (2) the need for a better healtheducation background for teachers of all subjects." "1

Kleinschmidt points out that teachers have not been prepared adequately to understand the health needs of children or how to meet them because:

"(a) School administrators have been slow to recognize the need for college hygiene programs;

66

(b) Health instructors have not been well prepared;

(c) There has been ineffective leadership in school health education; “(d) School curricula are overcrowded; and,

"(e) Hygiene courses have been inadequate in regard to content."

He further comments, "Without suitably educated health instructors in charge of teacher-education institutions, it naturally follows that these institutions can neither prepare the ordinary classroom teachers in the elementary and secondary schools for their tasks as health educators, nor equip the health supervisor or health coordinator for leadership in the field."

22

Another need to improve the teaching personnel is inherent in the compensation that they receive for their work. Salary schedules show that the average teacher's pay in 1941-42 was $1,441 per year, $1,955 in urban communities, and $959 in rural communities. "In the 14 Southern States reporting on this item for 1941-42, average salaries for the Negroes ranged from $226 in Mississippi to $1,593 in Maryland, in comparison with a range for white from $712 in Mississippi to $1,796 in Delaware. In 6 of the 14 States reporting, the average salary for Negro teachers was less than $600." 23

24

There is also the need to attract the kinds of individuals who are equipped to work with children. The physical, mental, and emotional status of a teacher is of more importance to the growth and development of children than the teacher's command of subject matter. If schools are to make a contribution in preventing the 1 in 22" of the 15-year-olds who will eventually find his way into a mental institution, the health and emotional stability of teachers should receive serious consideration. Fenton warns that, "The most serious hindrance to efforts along the line of mental hygiene in the schools is inadequate training and understanding of the average school administrator and classroom teacher." 25

20 Proceedings of the Nineteenth Annual Meeting, op cit.

21 U. S. Office of Education. Opportunities for the Preparation of Teachers in Health Education, by Earl E. Kleinschmidt. Washington, D. C., U. S. Government Printing Office, 1942. 117 n. (Bulletin 1942, No. 1), p. 11.

22 Thid.. n. 14.

23 Biennial Survey of Education, 1938-40, and 1940-42, op. cit., pp. 37-38.

24 Wartime Health and Education-Interim Report from the Subcommittee on Wartime Health and Education to the Committee on Education and Labor, U. S. Senate, pursuant to S. Res. 74. Washington, D. C., U. S. Government Printing Office, January 1945, pp. 2. 3. 25 Opportunities for the Preparation of Teachers in Health Education, op. cit., p. 11.