Those of us working in school health live in interesting times. Our knowledge base is better organized conceptually, and better validated empirically, than ever before. Over the last 25 years, the development of an unprecedented national school health infrastructure has supported the field's growth and increasingly rigorous evaluation. We know more than ever about what young people and their families are doing in terms of both risk behaviors and assets. Most important, we have considerable evidence of the compelling need for, and efficacy of, school health programs and policies and of their popularity with the public and professionals (Marx, Wooley, & Northrop, 1998).
Yet we find ourselves having to fight for every scrap of funding, every minute of teacher training and curricular time, every ounce of administrative support. We eagerly courted school reform, expecting it to lead to more holistic education; but in many places, a promising courtship has become a strained engagement. Is there hope for an eventual happy marriage between school health and school reform?
Disparities
We must do everything in our power to improve both education and health outcomes for all children and youth. Because educated people are healthier people and healthy students are better learners, these goals are interdependent. Since 1991, we've made progress in reducing violence in schools and early sexual activity. Other risk behaviors, such as alcohol abuse, have not diminished; still others, such as cigarette and marijuana use and behaviors that contribute to obesity, are getting worse (Centers for Disease Control and Prevention [CDC], 1999). But adverse health and education outcomes coincide most powerfully in the persistent disparities related to race and class. When compared with students in other developed countries, middle-class whites and many Asian groups in the United States are doing reasonably well by most measures, whereas African American and Hispanic youngsters experience severe health and learning inequities with lifelong effects.
As a nation, we remain both terrified and exhausted by the issue of race and in denial about class, even as we become a predominantly nonwhite society. Can anyone seriously argue that race is no longer an issue that profoundly affects our everyday lives and our institutions? Today, racism is more subtle and has different dynamics today than it had 30 years ago (Batts, 1998). People working with children and youth must purposefully learn to understand it, just as they must understand child development or new brain research.
One of the most vexing problems we face as school health professionals is that some of our nation's best educators are so correctly concerned with disparities in academic outcomes that they lead inner-city schools to focus with laserlike intensity on teaching academic skills. Even as we strenuously contest the distorted argument that the drive toward better standardized-test scores justifies the evisceration of coordinated school health programs, we must also credit the "good faith" of those who argue for high standards and ally ourselves with their best strategies for achieving them.
Excellent coordinated school health programs—programs that include health and physical education, health services, and a healthy school environment—do not teach children to read. They are necessary complements, especially if we hope to address the pervasive health impediments to learning that arise from, and perpetuate, disparities. As health promotion specialists, we recognize that unless schools provide high-quality instruction, they will not produce readers; globally, educational success contributes more to health than any other long-term intervention. So we should applaud schools that ask, What must we do if we are determined that no child shall be left behind academically?
Congruities
Many of the things these schools must do are not only congruent with, but also essential to, effective health promotion. For example, conferences on brain research are drawing attention to the scarcity of quality early care and education programs. School readiness is the quintessential issue around which health and education blur and blend. Talk about disparities: Some preschools are treated as if they were the first step toward the Ivy League, whereas our poorest and most recently arrived parents cobble together ways just to keep their kids safe while they are at work. Daunting economic and social hurdles stand in the way of establishing an adequate and equitable system that ensures that children are cognitively, emotionally, socially, and medically ready for school and that their families are ready to support them. Necessary changes in early education—in pay scale, standards, status, professional development, and program evaluation—must integrate health and education objectives, methods, and personnel. These are the headwaters of both school health and education reform.
Respectful and effective classroom management is the first requisite of learning; it is no less a cornerstone in building health (Hawkins, Catalano, Kosterman, Abbott, & Hill, 1999). Much, perhaps most, of child and adolescent health development is mental, emotional, and moral. The social cohesion, mutual protection, and respect for diversity that characterize our best classrooms bond students to school and to one another. Schools teach social responsibility when they systematically support students in helping one another academically, socially, and emotionally. Mental illness intervention programs will help prevent school tragedies large and small if they are part of systems that methodically support and conspicuously reward effective classroom management and healthy school climate.
Active learning is as essential in health as it is in biology or social studies. We cannot teach health from the front of the room, much less in the auditorium. Constraints often force us to use pedagogy in health education that we would never take seriously in other subjects. It largely involves methods that promote awareness, and students are beyond the awareness level on most health issues. The need to use accurate knowledge to critically examine existing attitudes, strengthen positive but often invisible social norms, and enhance skills. In some sense, every teacher is a health teacher; many districts demonstrate extraordinary creativity in integrating health themes into academic subjects and designing health lessons that pointedly reinforce academic skills.
Improved classroom management and better pedagogy depend on opening up the classroom. On-the-job, collegial learning is increasingly being built into the job description, the union contract, the career ladder, the budget, and the school day. We in school health have been trying for decades to spread our perspective and techniques by asking the teachers we've trained and inspired to attract and prepare their colleagues. We promote the long-term strength and stability of school health programs when we ally ourselves with this issues. Conversely, the public's demand for more effective attention to schools' social and emotional climates can fuel reforms that structure teaching as an intensely collaborative process.
Finally, school health and school reform properly dovetail on the issue of expectations and standards. We do not help a capable child—indeed, we practice a form of modern racism—when we lower our expectations and standards. Standardized tests may well be suspect and premature, and in their worst aspects, they are already falling under their own weight as states lower passing scores and postpone deadlines (Steinberg, 1999). And too many streets and homes are indeed dangerous; there are too many children whose very survival is a miracle. But all children deserve to be expected to succeed as learners. We need an approach that searches out, acknowledges, and contends with the impediments to learning and still insists that academic success is nevertheless not only possible, but also necessary. Do communities want schools to search out impediments to learning? They expect schools to identify and remedy dyslexia. If excessive anxiety, lack of sleep, and fear of violence are obstacles to learning, isn't it the school's job to recognize a causal condition, such as parental substance abuse?
High Double Standards
For schools to set, enforce, and realize high expectations and standards for academic achievement, they must join with allies who set comparably high expectations for systematically preventing and addressing health impediments to learning. We are beginning to see such alliances, and although medical and education professionals have more than a few cultural divides to overcome, they share a crucial and problematic assumption.
Teachers encourage individual effort and responsibility; medical professionals, too, spend most of their time treating individual problems with individual solutions. However, a public health perspective is also essential. A system can be structured to respond to individuals who ask for help, or it can estimate an underlying prevalence and be proactive in finding those who need help. Replacing the soft drink machine with one that dispenses water and juice does more for the health of the student body than urging students to make healthier choices. We must still teach and inspire students to take charge of their learning and their health, but the adults who work with them should be under no illusions.
Health and learning outcomes, and their circular inequities, are driven by powerful and remediable social environments, not by nominally individual "lifestyle choices." Through a grant from the Robert Wood Johnson Foundation, ASCD will prepare teachers and students to learn this public health perspective and to engage in health-promoting activities [see p. 10].
The ASCD “Health in Education” Initiative
The ASCD “Health in Education” Initiative
Talk of “healthy lifestyles” can be misleading. We can say that we are all free to choose, for example, a snack of carrots rather than potato chips. But which is more available in schools and convenience stores? Which has millions of dollars of marketing invested in it? Which is more common and accepted among young people? Are these choices equally attractive and easy for all students? What do data about young people's actual eating practices tell us about how individual choice operates in powerful environments?
One goal of school health programs is to help young people become active participants in creating communities that make healthy choices more likely than unhealthy ones. Another goal is to help students understand the increasing media coverage of health issues and research. The public, and youth in particular, lack the tools to distinguish between good science and bad journalism. Conflicting and confusing reports breed skepticism and fatalism.
The Robert Wood Johnson Foundation has funded ASCD to stimulate partnerships between schools and public health organizations to increase students' knowledge of issues, methods, and careers in public health. From more than 175 applicants, ASCD has chosen 10 schools or districts to receive up to $20,000 for each of two years. These model programs will develop integrated, experiential curriculums that enable students to address local needs by employing the best public health methods. A list of pilot schools is posted on the ASCD Web site ( www.ascd.org ).
Redefining "Access"
Most every school acknowledges that what happens within its walls pales by comparison, in terms of long-term consequences, with what happens, or fails to happen, in the home. Yet where in the typical school's budget, staffing plan, or school day is this reality reflected? The single most important objective in improving both health and education outcomes may be constructive, early, and sustained contact with the families whose children are likely to be subject to the disparities we observe.
This is one aspect of our need in both health and education to redefine the concept of "access." Is access opening a door as soon as people knock, or is it coming out toward them because we know that many cannot or will not knock? Making something that people need attractive, convenient, and free usually has one result: the most privileged or healthiest people take advantage of the offer. When stigma, fear, or discomfort are at work, the cycle of disparities is in force. If we do no more than offer and invite, we get no more than the usual participants and effectively deny the families that might benefit most. Knowing what we know, this can hardly qualify as a good-faith effort at providing access.
"Optional offerings" constitute another illusion regarding access. To focus on academics, schools are putting content formerly considered integral—music and art as well as health and physical education—into optional before- and after-school programs. Anything that is optional will almost by definition contribute to greater disparities.
To improve access, we can more creatively match the incentives we have with the things people want. Towns charge fees for participation in sports leagues or the use of recreational facilities. Suppose that this fee included an occasional interactive session chosen from a menu of important child health topics? The typical counterargument is that the youngsters most in need might not have a parent who could attend; but where this is the case, we've created the opportunity to put another adult into constructive contact with that child. Done well, health promotion is one of our best community-building vehicles. It is central to the growing community-schools movement, which seeks to change the meaning of access.
Partnerships
If there is one crucial need that is being talked to death, it is better partnerships. We talk about them as if they were exhilarating, but they are usually exhausting and sometimes maddening. Partnerships are not inherently virtuous; they have to focus relentlessly on results or they are apt to get lost attending to process. All partners must benefit for partnerships to be sustained, but many people confuse this concept with notions of equality among partners. Partners typically bring different resources, play different roles, reap different benefits, and have unequal power. Yet some of the most promising schools in the country are those with exciting partnerships among education, health, social work, and other professionals and the school's adult and youth community. Sustainable partnerships require conscientious nurturing: It has to be someone's job to focus on measurable results and to report to a person or a body with real power.
Most conspicuously absent from these emerging partnerships for children are our colleges and universities. Individual faculty engage in "projects in the community" that proliferate and then vanish. Students volunteer in droves. But uncoordinated fragments, however excellent, will not solve complex problems. The community's distrust of academia is legendary; state government and academia also stare across a widening gap. These divides, and an incentive system that penalizes faculty interested in applying what they know in community settings, waste knowledge and talent that could improve children's health and learning.
Led by children's systems that set a specific and measurable priority, with incentives and structures nourishing institutional collaboration, our post-secondary institutions could integrate their relevant disciplines in a variety of key supportive roles, including research, evaluation, training and professional development, and public education. Indeed, in some states and cities—Florida, West Virginia, and El Paso, Texas, for example—children's systems are beginning to ask for, and to find ways to reward, systematic, results-oriented help from their colleges and universities (National Committee on Partnerships for Children's Health, 1999).
A Stable Marriage
Through a combination of strategies, including coordinated school health programs, the United States has made significant headway against many threats to health and learning. But we are making less progress than we want or might expect, especially for African American and Hispanic youngsters. Because health and education are so closely related, our chances of improving outcomes for each depend on how closely we can collaborate, even in these challenging times.
Signs abound that the premature rush to "test and burn" is giving way to more measured consideration of how to create a system, pre-K–16, that will in time produce the results we want. If we who practice coordinated school health can persevere against today's excesses and remain articulate and passionate about our common cause with school reform's core principles, we may well find ourselves partners in a marriage with an exciting and stable future.
