Teachers’ Crucial Role in School Health

These days, many schools are becoming “community schools,” or centering on the “whole child.”  A focus of these efforts is often on physical health, especially vision and hearing. As readers of this blog may know, our group at Johns Hopkins School of Education is collaborating on creating, evaluating, and disseminating a strategy, called Vision for Baltimore, to provide every Baltimore child in grades PK to 8 who needs them with eyeglasses. Our partners are the Johns Hopkins Hospital’s Wilmer Eye Institute, the Baltimore City Schools, the Baltimore City Health Department, Vision to Learn, a philanthropy that provides vision vans to do vision testing, and Warby Parker, which provides children with free eyeglasses.  We are two years into the project, and we are learning a lot.

The most important news is this:  you cannot hope to solve the substantial problem of disadvantaged children who need glasses but don’t have them by just providing vision testing and glasses.  There are too many steps to the solution.  If things go wrong and are not corrected at any step, children end up without glasses.   Children need to be screened, then (in most places) they need parent permission, then they need to be tested, then they need to get correct and attractive glasses, then they have to wear them every day as needed, and then they have to replace them if they are lost or broken.


School of Education graduate student Amanda Inns is writing her dissertation on many of these issues. By listening to teachers, learning from our partners, and trial and error, Amanda, ophthalmologist Megan Collins, Lead School Vision Advocate Christine Levy, and others involved in the project came up with practical solutions to a number of problems. I’ll tell you about them in a moment, but here’s the overarching discovery that Amanda reports:

Nothing can stop a motivated and informed teacher.

What Amanda found out is that all aspects of the vision program tended to work when teachers and principals were engaged and empowered to try to ensure that all children who needed glasses got them, and they tended not to work if teachers were not involved.  A moment’s reflection would tell you why.  Unlike anyone else, teachers see kids every day. Unlike anyone else, they are likely to have good relationships with parents.  In a city like Baltimore, parents may not answer calls from most people in their child’s school, and even less anyone in any other city agency.  But they will answer their own child’s teacher. In fact, the teacher may be the only person in the school, or indeed in the entire city, who knows the parents’ real, current phone number.

In places like Baltimore, many parents do not trust most city institutions. But if they trust anyone, it’s their own child’s teacher.

Cost-effective citywide systems are needed to solve widespread health problems, such as vision (about 30% of Baltimore children need glasses, and few had them before Vision for Baltimore began).  Building such systems should start, we’ve learned, with the question of how teachers can be enabled and supported to ensure that services are actually reaching children and parents. Then you have to work backward to fill in the rest of the system.

Obviously, teachers cannot do it alone. In Vision for Baltimore, the Health Department expanded its screening to include all grades, not just state-mandated grades (PK, 1, 8, and new entrants).  Vision to Learn’s vision vans and vision professionals are extremely effective at providing testing. Free eyeglasses, or ones paid for by Medicaid, are essential. The fact that kids (and teachers) love Warby Parker glasses is of no small consequence. School nurses and parent coordinators play a key role across all health issues, not just vision. But even with these services, universal provision of eyeglasses to students who need them, long-term use, and replacement of lost glasses, are still not guaranteed.

Our basic approach is to provide services and incentives to help teachers be as effective as possible in supporting vision health, using their special position to solve key problems. We hired three School Vision Advocates (SVAs) to work with about 43 schools entering the vision system each year. The SVAs work with teachers and principals to jointly plan how to ensure that all students who need them will get, use, and maintain their glasses. They interact with principals and staff members to build excitement about eyeglasses, offering posters to place around each school. They organize data to make it easy for teachers to know which students need glasses, and which students still need parent permission forms. They provide fun prizes, $20 worth of school supplies, to all teachers in schools in which 80% of parents sent in their forms.  They get to know school office staff, also critical to such efforts.  They listen to teachers and get their ideas about how to adapt their approaches to the school’s needs.  They do observations in classes to see what percentage of students are wearing their glasses. They arrange to replace lost or broken glasses.  They advocate for the program in the district office, and find ways to get the superintendent and other district leaders to show support for the teachers’ activities directed toward vision.

Amanda’s research found that introducing SVAs into schools had substantial impacts on rates of parent permission, and adding the school prizes added another substantial amount. Many students are wearing their glasses. There is still more to do to get to 100%, but the schools have made unprecedented gains.

Urban teachers are very busy, and adding vision to their list of responsibilities can only work if the teachers see the value, feel respected and engaged, and have help in doing their part. What Amanda’s research illustrates is how modest investments in friendly and capable people targeting high-leverage activities can make a big difference across an entire city.

Ensuring that all students have good vision is critical, and a hit-or-miss strategy is not sufficient. Schools need systems to bring cost-effective services to thousands of kids who need help with health issues that affect very large numbers, such as vision, hearing, and asthma. Teachers still must focus first on their roles as instructors, but with help, they can also provide essential assistance to build the health of their students.  No system to solve health problems that require daily, long-term monitoring of children’s behavior can work at this scale in urban schools without engaging teachers.

Photo credit: By SSgt Sara Csurilla [Public domain], via Wikimedia Commons

This blog was developed with support from the Laura and John Arnold Foundation. The views expressed here do not necessarily reflect those of the Foundation.


Evidence-Based Resources Needed for Flint

I’m sure you are aware of the catastrophe in Flint, Michigan. 100,000 citizens of that city were exposed to water contaminated by lead and other toxic chemicals, and were then lied to about it by their state and local political leaders. Flint was the topic of the cover story in the February 1 Time magazine (“The Poisoning of an American City”). The story has been reported coast to coast, and in one of the presidential debates, Hillary Clinton noted the perfectly obvious, that this could never have happened in a middle-class suburb.

I won’t retell the whole story, but in essence, Flint, which is primarily under the political control of unelected state managers, made two disastrous decisions. First, in response to an increase in costs for clean Lake Huron water, Flint leaders decided to pump water from the nearby Flint River (“a sewer,” a resident noted). Second, the same leaders failed to add chemicals to keep the polluted water from dissolving lead in old pipes, also to save money. The result was drinking water with lead levels far higher than national standards. Early on, a courageous pediatrician, Dr. Mona Hanna-Attisha, noted elevated lead levels in young children and many other symptoms of poisoning, including anemia, rashes, hand tremors, and seizures. She persistently complained to anyone who would listen, but no action was taken until a September 2015 study found that children under five had twice the lead levels prevailing before the change in water sources.

Lead poisoning is devastating to the nervous systems of infants. It leads to diminished cognitive functioning, as measured by IQ tests and school performance, across a person’s entire life. Even low-level exposure has destructive effects. Dr. Hanna-Attisha noted, “If you were going to put something in a population to keep them down for generations to come, it would be lead.” It so happens that Baltimore has also long struggled with lead poisoning due to peeling paint in poor sections of the city. Freddie Gray, the young man who died in a police van, had lead poisoning as a child, performed poorly in school, and as a result was supporting himself with petty crime and drug-dealing. That’s how he got into the van in the first place.

In a January 30 article in the New York Times, the heroine of the Flint story, Dr. Hanna-Attisha, was asked what should be done for the roughly 8,000 children under 6 who were exposed to lead-contaminated water for up to two years. She said, “We have to throw every single evidence-based resource at these kids, starting now.” Since the effects of lead poisoning itself cannot be reversed, what she was referring to was proven early childhood programs, visiting nurse programs, and nutrition improvements. She might have added tutoring for children who need it, eyeglasses, and proven comprehensive school reforms, among many other interventions.

The kids in Flint certainly deserve special attention and immediate effective intervention. But in what disadvantaged area in the U.S., or anywhere, would we not say the same? Flint is remarkable because it is acute, and because the political betrayals expose the system that disregards the needs of disadvantaged people. But the chronic problems of poverty in America need just the same solutions.

There are approximately 52,000 Title I schools in the U.S. I would suggest, for starters, that every principal of every one of these schools, and every mayor, governor, legislator, and national, state, and local education leader, frame and display Dr. Hanna-Attisha’s statement in their office:

“We have to throw every single evidence-based resource at these kids, starting now.”

And then they should do it. Starting now.