Without adequate health care, parents are sending ill children to school.
HEALTH Approaching 21 years old, Julia aspires to be an R&B singer. But that dream has become a background melody to life's current realities. She rents a make-shift garage conversion with a poorly lit alley entrance in the west side of Chitown. During the day, she sports a colorful uniform at a nearby fast food restaurant, which saves on the grocery bill. A local nightclub hired her four months ago as a waitress to work the graveyard shift with a short-term goal of serenading guests while sitting atop the piano Thursday through Sunday. She says the extra tips are needed to care for her six-year-old son, Nathan. Julia muses that she hopes to get her own GED before Nathan graduates.
With her income, if someone gave Julia a car, she couldn't afford to maintain it. That's why she considers her apartment, within walking distance of her two jobs and her child's school to be a blessing. "I don't stress over luxuries. We get by." Her "cell" phone is a calling card she purchases every few months. There is no monthly bill but finding a working phone booth to use with the card is becoming more difficult.
Medical insurance is as elusive as Julia's R&B career. The closest thing to a family physician is perhaps an ER triage nurse. Each visit to Cook County Hospital emergency room is as much an exercise of patience as stamina. The minimum 10-hour wait following a 45-minute walk overlaps two work shifts. "It's temptin' to shoot yourself in the leg or somethin' so you can be seen faster by a doctor," says Julia.
Nathan's asthma interfered with a good night's sleep. He has enough albuterol to get through another school day. Julia is planning to stop off at the drug store and refill a prescription after work. An unsightly rash on Nathan's abdomen has his mother more concerned. The mattress examination for bedbugs in the dim Thursday morning light is inconclusive. She wonders if it could be caused by something more serious as she urges Nathan not to scratch and soothes the itch with petroleum jelly.
Considering all the options, Julia bundles up Nathan and walks him to school. "Stay in class until the long hand of the clock reaches the 6 and then tell teacher you need to go to nurse's office." Julia is really concerned about her son but can't miss another day's work. With unemployment rates higher than the national average, there are too many others waiting to replace absentee workers.
Julia is ficticious but the circumstances are real to many. Schools are breeding grounds for infectious disease — colds, influenza, tuberculosis, lice can all be spread too quickly. Who protects the nation's children?
Valuable School Nurses In Short Supply
School nurses are well aware of the choices low-income parents face. In many cases they willingly assume the role of de-facto family physician. Advanced far beyond placing bandages on knee scrapes, teaching newly diagnosed diabetic children how to manage their new routine around classwork is common for school nurses. They screen for vision impairment or developmental auditory problems. They care for students with disabilities and for those who depend on medical devices such as gastrostomy tubes, insulin pumps, and urinary catheters. School nurse Mary Pappas at Saint Francis Preparatory School in Queens, New York, alerted the local health department when numerous children became feverish. She is credited with alerting the nation that the H1N1 virus had reached U.S. soil.
The U.S. government's recommended ratio of registered nurses to student population is 1:750. Sadly, this target is reached in only 13 states. In three states the ratio is less than 1:4000 and in 10 states the ratio is 1:2000 – 3000. Approximately 56 million students and another 3.8 million teachers, administrators, and support personnel gather regularly in the nation's schools, placing school nurses on the frontlines of disease surveillance. 
A Patchwork of Funding
As valuable as they are, funding the nation's nurses is a serious problem. The Individuals with Disabilities Education Act (IDEA) legally obligates schools to provide special education and related services, including direct-care nursing services, to students who need them to participate in school. Federal IDEA funds cover less than half the cost of educating children with disabilities. Medicaid payments contribute a limited amount of support. Hence, States must prioritize creative methods of meeting the shortfall.
Delaware leads the nation with school health services. The state pays 64 percent of the cost of public education, which includes a full-time registered nurse in every school building. Accruing financial rewards for increased education, the state's school nurses are among the most credentialed in the nation. 
Austin Independent School District (AISD) and Miami-Dade County (MDC) employ health aides and legislate dedicated taxes, respectively. In some states, schools receive assistance from local nursing schools and health professionals.
Inadequate education or unfortunate parental life choices place heavier demands on school nurses. Yet, in a medical emergency, a school nurse is obligated to contact emergency services. Often times that means phoning 911 or child protection agencies. For emergency care, parent's don't save time by sending ill students to school and may jeopardize custody if negligence is established. It's a gamble many "Julias" take to provide for their "Nathans."
With school nurses in short supply, the sacrifices and dedication so few make to keep a nation of children healthy and focused toward education is applauded. Julia choice, like so many other poverty-stricken households, depend upon the nurses in schools and emergency rooms. To learn more about nursing or how you can help provide healthcare to more people visit the sidebar links.
- Charting Nursing's Future. (PDF) Robert Wood Johnson Foundation, August 2010