WITH a 25 percent poverty rate ($23,050 or below for a family of four) - up from 18.5 percent in 2000 - Philadelphia is the country's biggest poor city. Seventy percent of its children have public health-insurance coverage.

Yet, since the summer, the Department of Public Welfare has removed 25,000 city children from the medical assistance rolls, kids whose family incomes are believed to still fall within the qualifying guidelines. For these now-uninsured children - and every other child who attends the city public schools - the district's layoff of 47 school nurses means that the children's health and educational prospects have taken a step backward.

The result - predicted a school nurse who barely escaped losing her job - will be "more chaos" added to an already overburdened system of no-fee health services that acts as a safety net. "The public needs to understand our function," she said. "The role of the school nurse is to keep children healthy enough to be educated and make sure they have no barriers to education from a health-care standpoint."

Identifying health care needs before students get an illness - that is, prevention - is critical, the nurse explained, recalling a school open house last fall at which she distributed vision and dental paperwork, and Children's Health Insurance Program (CHIP) applications. "I had more parents stop for CHIP forms than I ever had before," she said. "People are suffering, getting jobs without health insurance, so they don't qualify for medical assistance. But so many kids are medically fragile."

Sick children going to school is "nothing new," happening even when she was a child, noted a veteran Philadelphia teacher with 50 years of classroom experience. "Kids would get sick on Saturday and the parents would say, 'Go see the school nurse,' especially during tough economic times. Nurses were a mainstay during the Depression, when parents didn't have money for the doctor."

Changes in the ranks of school nurses and their duties began during the 1970s. "At first they were in school every day," said the teacher. "Then they knocked it down to three days a week and started sharing nurses." In days past, she noted, nurses would hand out toothbrushes and toothpaste, teach students about health and explain the food groups and the food pyramid. Since they visited classrooms for mandatory examinations, nurses would spot communicable diseases, such as ringworm and lice. If a child was absent three days in a row or sick, the nurse would send a note home, sometimes telling the principal that the student would not be allowed back without a doctor's note.

"A lot of parents didn't realize their children were sick until the nurse alerted them; all of that is gone," the teacher lamented.

Over the years, ailments that were rarities in the classroom - high blood pressure, food allergies, obesity, etc. - have become commonplace. "Asthma is rampant," she observed, "and diabetes; a whole lot of them have it and don't even know it. We didn't have these conditions in the '60s, '70s and '80s. And there are now more medications, too."

Having teachers or principals dispensing meds or dealing with, say, an asthma attack, is an unwanted responsibility, the nurse explained, since nurses are the only trained personnel who can effectively assess a child's respiratory attack. "They can fail to detect how sick a child really is or overreact and call an ambulance," she said. "Plus, you can teach someone how to handle an inhaler, but nebulizers require a technique."

Both agree that the layoffs will end up costing the school district more money than it would save in the long run. "More sickness, more kids in the hospital and more illness not picked up early," speculated the nurse.

"Once again poor children will just suffer, getting sick and losing school time," the teacher echoed. "I foresee the teachers getting sick along with them. It's a lose-all situation."

Sid Holmes

communications director

Public Citizens for Children and Youth