Many urban schools at the turn of the century conducted classes in poorly lit, under-ventilated basements, corridors, and temporary wooden structures called “portables.” Inadequate plumbing and sewage systems meant that these “halls of learning” were often filled with the stench of poorly working toilets.9
Given these conditions, improving the public school facilities and sanitary or health conditions for students became of great concern to the American public. For example, between 1908 and 1909 alone, more than 500 articles on school hygiene appeared in the medical literature and popular periodicals.10
The development of school hygiene programs was seen as an essential component of modern societies that sought to cultivate healthy intelligent populations.11,12
On one hand, the focus was on schools themselves, as a new cadre of experts determined with mathematical precision how to make classrooms salubrious by installing ventilation and lighting systems, arranging desks and classroom furniture in an organized fashion, and ensuring access to safe drinking water.13
At the same time, the spotlight also turned to the children themselves, who could be assessed by a district doctor or school nurse for potentially contagious diseases, such as measles or diphtheria, and examined for a plethora of conditions including physioskeletal deformities, myopia, and rotting teeth, as well as diabetes and other chronic ailments. Before the Progressive era, afflicted children were identified and ejected from school, and little if anything was done to assure the treatment needed for reintroduction into the classroom. Schools lacked the resources for effective follow-up to assure proper treatment for the children, or even assurance that children's families understood the illness or medical condition. Once public health departments and school systems brought on nurses to make routine, systematic contact with all students, both medical inspections to identify communicable diseases and the physical exams to uncover diseases and defects gradually became the norm in hundreds of cities and towns.
Some cities, such as Boston and New York City, established school corps, comprised of medical inspectors who made daily rounds through the public schools to determine the health status of individual children and entire classrooms. For example, in 1893, the City of New York appointed the nation's first medical inspector, Dr. Moreau Morse. The following year, the City of Boston appointed Dr. Samuel Durgin to organize a team of 50 physicians to oversee the health needs of that city's 50 school districts.14,15
A decade later, in 1904, 36 cities and towns had such systems. By 1913, when Luther H. Gulick and Leonard P. Ayers reissued their landmark study, Medical Inspection of Schools
, there were 443 American cities or towns that conducted medical inspections of schools.12,16,17
Furthermore, cities such as New York published monthly school health bulletins to inform physicians, nurses, and educators about how to respond to infectious and chronic diseases among their student populations.18
By the early 20th century, expanding knowledge of bacteriology and the mechanisms of pathogenic disease transmission had convinced many scientific experts that the careful medical monitoring of students in the school setting during an epidemic was the best way to ensure their health and safety. As Alvah H. Doty, the health officer of the Port of New York, wrote in 1911, “.. . children who remain in school and are subjected to careful surveillance are probably better protected than those who are out of school and about the street, and mixing indiscriminately with others, particularly if the outbreak is widespread.”19
The earliest school medical inspection programs in New York (1893), Boston (1894), Chicago (1895), and Philadelphia (1898) were centered around medical doctors making prescribed visits to assigned districts to examine the pupils. Most implicit in the motives behind these programs was the surveillance for the many contagious diseases of childhood and, if discovered, their rapid containment in the form of quarantine. In an era framed by the specter of contagious disease, speed in such endeavors was of the essence. Doctors, nurses, social workers, and, on the front lines, schoolteachers worked assiduously to facilitate these methods of disease control.
Still, Progressives' efforts to merge medical science with the burgeoning health hygiene programs in schools didn't always yield positive results. New York, for example, looked to decrease absenteeism by assembling surgical teams consisting of doctors and nurses to remove tonsils and adenoids from afflicted students at public schools. This 1906 project led to riots in several locations when rumors spread that school doctors were cutting children's throats as the first step in a planned massacre of the city's Jews.20
This ill-fated experiment serves to illustrate how earnest were the developers of early 20th-century health hygiene programs to provide infrastructure that helped unhealthy students return to the classroom.
During the Progressive era, public schools became the homes of “Health Leagues,” “100% Hygiene Classes,” and “Little Mother's Clubs,” all promoting the gospel of public health for the children and, by extension, for their parents and families. In keeping with Progressive-era rationality, early health hygiene programs readily embraced the most basic metric for success— lower death rates among infants—and expanded the metrics to school systems where program results demonstrated a decrease in contagious illnesses and a corresponding decrease in school absenteeism.
In parallel with the increased willingness among municipalities and some private schools to fund nurses who carried the gospel of good health to immigrants and others who might benefit, conditions were right for creating a role for public health nurses in education.
The first school nurse program began in 1902 when New York's board of education and its health commissioner asked veteran settlement nursing expert Lillian Wald to design a demonstration program. She tasked Lina Rogers to place nurses in four of the city's schools, where nurses began routine inspections on 10,000 children, with home visits for any needing follow-up treatment. The program quickly expanded to all of New York's public schools, where absenteeism fell from 65,294 in 1903 to 18,844 in 1905. There were nearly 500,000 students at this time.20
Typically, New York's nurses arrived at school at 9 a.m. and went from class to class, lining up children to examine eyes, hands, throats, and hair, and provided a written report of their findings for the physician, whom they also met regularly to review the status of any children under treatment. The day also included time in an examining room to treat children, change dressings, or provide any other needs of daily care including minor emergencies such as scraped elbows and knees. Home visits focused on diagnosis-specific information and general hygiene education for parents and family. As New York's program developed, Rogers showed that nurses could properly examine and care for about 3,000 children per week and each nurse was assigned between two and five schools.12,21
By the time the second wave of the influenza pandemic struck the U.S. in the fall of 1918, medical inspection of the schools had become more formalized and broader in reach. Many individual schools were staffed with full-time nurses. There were organized plans for the isolation of children suspected of a contagious disease. Vaccinations for smallpox were offered on a routine basis. Vision, hearing, and dental examinations were instituted. Developmental and physical abnormalities began to be addressed by pediatricians of this period as well. Some of the most common concerns were the predicted effects of enlarged tonsils and adenoids on a child's health and development; pediatricians ascribed almost everything from mouth-breathing and apnea to a propensity toward tuberculosis, hyperactivity, enuresis, and feeblemindedness to the hypertrophied lymphoid tissues.22,23
The inspection of school buildings by sanitary engineers and public health workers also became routine during this period. But perhaps the widest-reaching activities of this endeavor revolved around educating children and their parents about personal hygiene and disease prevention. Indeed, these topics eventually became standard elements of most public school curricula, surviving well into the 1950s.
The United States' entrance into World War I heightened the Progressive-era awareness of the health of schoolchildren and the importance of school sanitation. As the U.S. sent millions of men across the Atlantic to fight on the European front, calls for patriotism rang louder and Americans of all ages were urged to carry out the duties and responsibilities of citizenship, which included proper personal and social hygiene. By September 1918, the battle against foreign enemies came to include campaigns against influenza. Schools across the country responded to influenza using similar tools and theories from modern bacteriology, public health, and school hygiene. Despite this shared armamentarium, from September 1918 to March 1919 American communities and schools approached and experienced school closure policies and implementation in differing ways.24
Diverging from the dominant trend in urban America, three cities—including the country's two largest—decided not to close schools and instead to amplify and extend existing school medical inspection and disease surveillance programs.