The paradigmatic shift in the past decade in our understanding of the role of health and nutrition in school-age children has fundamental implications for the design of effective programs. Improving the health and nutrition of schoolchildren through school-based programs is not a new concept. School health programs are ubiquitous in high-income countries and most middle-income countries. In low-income countries, these programs were a common feature of early, particularly colonial, education systems, where they could be characterized as heavily focused on clinical diagnosis and treatment and on elite schools in urban centers. This situation is changing as new policies and partnerships are being formulated to help ensure that programs focus on promoting health and improving the educational outcomes of children, as well as being socially progressive and specifically targeting the poor, girls, and other disadvantaged children. This evolution reflects five key changes in our understanding of the role of these programs in child development.
First, ensuring good health at school age requires a life cycle approach to intervention, starting in utero and continuing throughout child development. In programmatic terms this requirement implies a sequence of programs to promote maternal and reproductive health, management of childhood illness, and early childhood care and development. Promoting good health and nutrition before and during school age is essential to effective growth and development.
Second, operations research shows that the preexisting infrastructure of the educational system can often offer a more cost-effective route for delivery of simple health interventions and health promotion than can the health system. Low-income countries typically have more teachers than nurses and more schools than clinics, often by an order of magnitude.
Third, empirical evidence shows that good health and nutrition are prerequisites for effective learning. This finding is not simply the utopian aspiration for children to have healthy bodies and healthy minds, but also the demonstration of a systemic link between specific physical insults and specific cognitive and learning deficits, grounded in a new multisectoral approach to research involving public health and epidemiology, as well as cognitive and educational psychology.
Fourth, the provision of quality schools, textbooks, and teachers can result in effective education only if the child is present, ready, and able to learn. This perception has additional political momentum as countries and agencies seek to achieve Education for All (EFA) by 2015 and address the Millennium Development Goals of universal basic education and gender equality in education access. If every girl and boy is to be able to complete a basic education of good quality, then ensuring that the poorest children, who suffer the most malnutrition and ill health, are able to attend and stay in school and to learn while there is essential.
Finally, education, including education that promotes positive health behaviors, contributes to the prevention of HIV/AIDSβthe greatest challenge for generations to come. School health and nutrition programs that help children complete their education and develop knowledge, practices, and behaviors that protect them from HIV infection as they mature have been described as a "social vaccine" against the disease.
Because of the success of child survival programs, the number of children reaching school age (defined as 5 to 14 years of age) is increasing and is estimated to be 1.2 billion children, with 88 percent living in less developed countries (U.S. Census Bureau 2002). As figure 58.1 illustrates, the pattern of disease is age specific. A large body of evidence shows that these conditions affect cognition, learning, and educational achievement (see Jukes, Drake, and Bundy forthcoming; Pollitt 1990 for reviews of this extensive literature).
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