"A teacher affects eternity; he can never tell where his influence stops." So wrote Henry Brooks Adams in "The Education of Henry Adams" (1907). But how can today's teachers be effective in the classroom if the children are sick?

No longer are scarlet fever, tuberculosis and polio the major killers of young people that they were in the past century. Yet health concerns facing parents and their children have never been more pressing. AIDS, the most significant epidemic since polio, is the most frightening, but it's not the only threat to the nation's youth. In parts of the country, doctors are noticing a resurgence of rheumatic fever, a childhood disease that causes scarring of the heart and was thought to have been nearly eliminated. And once children go back to school, they pick up the traditional problems of head lice, colds and the flu from their classmates. Not to mention the behavior problems of alcohol and drug abuse.

American society has changed dramatically in recent decades as more mothers of young children go to work and more families are headed by a single parent -- shifting new responsibilities to teachers and principals.

All this puts a strain on school systems as they try to both teach children what they need to know and make sure the students are well enough to learn. Are children getting proper medical attention in school? Is there a shortage of school nurses in the Washington area? What kinds of health and sex education courses should be taught in the elementary grades? Do children understand how AIDS is spread? Do their parents?

In addition to the articles on the following pages, a special How & Why column for children, on Page 22, can help young people think clearly about the AIDS epidemic.

CHILDREN SCURRY DOWN corridors, clutching books, slamming locker doors and heading for classrooms before the late bell rings. But above this idyllic clatter of the first days of school are other familiar sounds: sniffling and sneezing and coughing and scratching and crying and spitting and wheezing and throwing up.

There's no official term for it, but school-borne illness is a common fact of classroom life -- kind of schoolitis, or back-to-school syndrome, that includes a whole host of contagious problems from germs and worms to a collection of dirty words to be brought home.

Regardless of the socioeconomic status of a particular school district, classrooms are breeding grounds for all sorts of disease organisms that kids pick up from other students and bring home to their parents and siblings.

The lice may come from a shared comb, the ringworm from holding hands, the cold from a coughing classmate.

"Children are beautiful containers of viruses and other organisms," said Dr. Catherine DeAngelis, deputy director of the Children's Center at the Johns Hopkins Medical center and a professor of pediatrics. "You increase the likelihood of exposures to these viruses by having more children around."

Now, the spread of acquired immune deficiency syndrome is focusing new attention on the risks of spreading disease in elementary schools. Health officials point out that the AIDS virus cannot be spread by casual contact. Children with AIDS or who test positive for the AIDS virus do not pose a threat to their classmates, they say. At the same time, the mounting concern about AIDS illustrates how schools are broadening their public health mandate to provide medical support for children with special problems. Schools are also developing prevention programs to teach students about the nature of different diseases and the hazards of certain behaviors such as smoking and drug use.

"Using the school setting as the site for delivery of health services, it is possible to promote the health of children and youth," said Diane Allensworth, associate director of programs for the American School Health Association.

But are the Washington area schools equipped to take on this expanded role in public health? Traditionally, children's health has been the domain of parents and private physicians. As the number of working and single parents increases, greater burdens have been placed on teachers and school nurses.

As a result, children's health has become a major issue for schools and communities. It's also key to academic performance. Under increasing pressure to improve educational standards in the nation's classrooms, school administrators and teachers know they can't begin to do their job if the kids are sick.

As DeAngeles of Johns Hopkins said: "A kid can't learn if he is sick and out of school -- or sick in school."Catching It in Class

For some parents, it comes as a shock. The letter from school reads: "There have been a few cases of lice detected in your child's class. As required, to control spread, there will be a head inspection by the Nurse/School representative. Should your child have head lice you will be informed." An accompanying information sheet recommends that "shampooing with a medicated shampoo especially for head lice is the simplest and most effective method of killing adult lice and eggs."

And ringworm? Some parents don't even know the symptoms -- a scaly, often ring-shaped inflammation of the skin that causes itchiness.

"One of the hazards of growing up is you are going to have frequent infections, and we do see families who are alarmed by this," said Dr. Georges Peter, director of the division of infectious diseases at Rhode Island Hospital in Providence. "People have to learn to live with the fact that infections are common."

Every year, school nurses and parents cope with the most frequent causes of empty classroom desks -- colds, flu, asthma, bronchitis, occasional pneumonias, strep throats, gastrointestinal viruses and chicken pox.

Until this century, infectious diseases and malnutrition were major killers of school-age children. Improvements in sanitation, medicine and education have significantly lowered a child's risk of dying from these problems.

But they still exist. And so do a lot of other health problems for school-age kids: The common cold accounts for nearly 60 percent of school days missed by children ages 5 to 17. Chicken pox is still very common, and 60 percent of all cases strike children ages 5 to 9, the Centers for Disease Control (CDC) reported. Last year, 6,255 cases of measles were reported to the CDC. Children 5 to 14 accounted for 1,988 of these cases. The reported incidence of pertussis, or whooping cough, among children 5 to 14 -- 858 cases in 1984 and 1985 -- has doubled since 1979, CDC experts said. By age 15, about 15 percent of children have asthma or allergy problems, and 10 percent have heart or kidney problems, Johns Hopkins reported. Out of every 100,000 school-age children 5 through 14, 12.5 died from accidents and injuries in 1985. In 1986, children in that age group were involved in more than 5 million accidents, according to federal reports. Although few U.S. children today are undernourished, many have poor eating habits, according to a report by the Department of Health and Human Services Division of Maternal and Child Health. Diets high in sugar, fat and salt -- which increases their risk of obesity, hypertension and heart disease -- are common.By the time children reach high school, 40 percent have had surgery, and more than 50 percent have been hospitalized at least twice, according to Johns Hopkins.In 1980, 7.4 percent of children ages 5 to 12 -- more than 2 million children -- had no regular source of medical care. And more than 8 percent had no health insurance.

With the decline in deaths from major childhood illnesses like diphtheria, typhoid and tetanus, there is more time to pay attention to other health concerns such as learning disabilities, stress and behavioral problems.

"These issues are more important in a world where literacy is fundamental to getting along," said Mary Grace Kovar, a senior statistician at the National Center for Health Statistics.

An estimated 10 to 12 percent of school-age children have some problem that limits their full functioning, Kovar said.

Besides the physical and emotional problems that can affect a child's ability to learn, kids develop attitudes about social issues, such as smoking and drinking, which they pick up from classmates. Peer pressure can influence a child to start using cigarettes and alcohol, and they may continue these habits into adulthood.

"We see the beginnings of alcohol and drug abuse in upper elementary schools, where children start off with wine coolers and cigarettes," American School Health Association's Allensworth said.

People who start smoking before age 20 are more likely to be heavy smokers as adults and to continue smoking throughout their lives, concluded the 1986 Health and Human Services report on the nation's health.

Where Have All the Nurses Gone?

In the competition for educational dollars and resources, health personnel and physical education instructors play second fiddle to reading, writing and arithmetic teachers. This often means there are not enough doctors and nurses to go around.

In the District, with 124 elementary schools and 47,181 students, there are six part-time and one full-time physician. On the average, there is a doctor present at a particular school two half-days a month. Ten community health nurses -- about one for every five schools -- are usually present in a school one day per week. In addition, eight pediatric nurse practitioners come in one day every other week to give screenings and physical examinations, and 15 school health technicians assist the nurses and doctors.

Burroughs Elementary School on Monroe Street Northeast, for example, has a part-time nurse who comes in twice a month and a nurse's aide who is available once a week.

Gretchen Langford, president of the Parent-Teachers Association at Burroughs, put it this way:

"What nurse?" she said. "The secretary in the office deals with emergencies."

Geraldine Chiles, who has been the secretary at Burroughs for 19 years, spends a lot of her time taking care of sick children and trying to locate parents.

"I have no medical training," Chiles said. "It makes me very uncomfortable dealing with sick children, and frequently I don't know what to do."

She recalls the time when she couldn't stop a nosebleed and the time she had trouble treating a cut from a playground injury during lunch hour. Last year, a child with asthma walked into the office gasping for breath.

"All I could do was call the mother," Chiles said.

Burroughs has about 436 students and one educational aide trained in first aid who is there daily.

Depending on the severity of the sickness, a teacher will usually send a sick child with another student to the principal's office, where it is determined whether the parents should be called, said Nae Davis, the principal at Burroughs. This is a system used throughout District schools.

"We have to try and handle emergencies within the office and if it is very serious, we have to call 911," Davis said. "It would be wonderful if we could have a nurse in the building, say, on a weekly basis."

The situation in Montgomery County is not much different. Of the 103 elementary schools, there are 50 with no health room technician or school-based health person, said Clare Kownacki, director of the division of school health services for the Montgomery County Public Health Department. And some nurses are covering three to four schools.

"We staff because of tradition," Kownacki said. "Traditionally, secondary schools and special schools have gotten more services."

Standards written by six nursing organizations concerned with school health issues call for one nurse per 750 students.

More realistic, said Victoria Hertel, president of the American School Health Association, is one nurse per 1,300 students, provided the nurse does not have to travel far and cover numerous buildings.

On the national level, lack of funding for additional nurses, Hertel said, "may be related to the fact that administrators see health as a supplemental service in the schools rather than a basic service."

In the District, there is one nurse per 2,621 students, said Dr. Mary Ellen Bradshaw, chief of the Bureau of School Health Services (BSHS), which is part of the Commission of Public Health. "If you include the health technicians, we have one nurse per 1,430 students."

Bradshaw, aware of the suggested standards regarding nurse-to-student ratios and under mounting pressure from parents who would like to see full-time nurses in the schools, has lobbied for a staff increase.

A school nurse assignment bill, currently under discussion in the City Council, would create about 37 new nursing positions. If passed, the bill would reduce the gap to one nurse per 704 students.

Last year, the District's Bureau of School Health Services, which hires school health personnel, had a budget of $3.4 million covering health staff and support services for 181 schools and 81,170 students. The annual school budget is about $500 million.

But an increase in the number of nursing positions may not be enough.

The salary for school nurses is not competitive with what hospitals pay, said Hattie Waller, acting nurse coordinator for BSHS.

Starting salary for community health nurses, who are required to have a bachelor of science degree in nursing and two years of experience, was $24,463 in 1986.

A salary of $31,789 can be reached, but it takes 15 to 20 years to get there, Waller said. Nurses start out with the same pay scale at hospitals, but they accelerate at a much faster rate.

Diary of a School Nurse

At West Elementary School on Farragut Street Northwest, Pecolia Davis, a pediatric nurse practitioner handling five schools in the District, juggles sick students, children with learning disabilities and routine health screenings. She is only there for one half day a week.

Lately, Davis has noticed that more students are coming to school sick.

School starts "at 9 a.m., and at 9:05, a student will come in with a fever and say, 'My mother told me to have the nurse take my temperature,' " she said.

Changes in the nature of families -- increases in single parents, latchkey children and more kids lacking medical care -- create a dilemma for school administrators who have traditionally viewed education, not medicine, as their primary responsibility.

A child sick in school and unable to go home because the parents can't be reached illustrates this dilemma.

Nurses are not allowed to administer any type of medication in public schools, except in special education schools. A sick child remains in the school until someone can come.

In some schools, there is no health suite or bed where sick children can lie down, so they usually wait in the principal's or counselor's office, Bureau of School Health Services' Bradshaw said. The child could wait in school all day.

The nurse will send a note home to the parents indicating the child's condition and making recommendations on what should be done. A follow-up call is made the next week to check on the status of the child.

In addition to caring for sick children, school nurses carry out major screening programs.

One of the day's tasks for Davis at West Elementary School is to check the height and weight of six kindergarten girls. Nurses spend the first two months of the school year checking vision, height and weight. Children are later screened for scoliosis (curvature of the spine), hearing and dental problems. The children are both excited and nervous about visiting the nurse.

"Are you going to give us a shot?" asked one child.

Davis finds that one 5-year-old only weighs 34 pounds and is 27 1/2 inches tall. The growth charts nurses use as a guide indicate the child is small for her age.

"Sometimes the family is small," Davis said, "but I will watch her to make sure it is not because of a chronic disease or nutritional deprivation."

She will then contact the parents to learn about the student's home life. If a health problem is discovered, Davis can refer the parents to places where they can get help.

Davis' role at the school goes beyond medical service. Talking with parents is considered a normal part of her job, even though she may do it after working hours. Davis is popular with students, and she attributes her success to praising kids instead of criticizing them.

"If I criticize, it is their actions and not the child," she said. "I believe that if we take the very young child and tell that child he or she is worthwhile and deserving of respect, we will wind up with better children."

Still, Davis does not believe that school budgets should increase the number of nurses in elementary schools. "It's too expensive. You have to look at the salaries {of the nurses} and the number of students."

Closing the Gaps

In assessing the current role schools play in children's health, some experts argue that not enough is being done.

Said American School Health Association's Allensworth: "We are looking at a lack of comprehensive health services for students in kindergarten through 12th grade."

Sixty-one percent of the states mandate that schools conduct hearing tests, 57 percent mandate vision tests and 33 percent have laws requiring physicals, notes Allensworth. Only five states say teachers must be advised of student health problems.

"These are only the basic services that should be standardized across the nation, but are not," Allensworth said.

Health regulations for schools, such as laws requiring immunizations against childhood diseases, are also left up to individual states.

Besides, having a law on the books is just the first step.

The District, for example, requires immunizations against measles, polio, rubella, tetanus, diphtheria and mumps for all students from the time they enter a day-care center to college. Children under 6 must have a pertussis vaccine.

According to District law, a student can be dismissed from school within 10 days if he or she fails to get the proper vaccinations.

The decision to expel a student for this reason, however, is left up to the school principal. What's more, there is no penalty if the child is allowed to remain in school. "You want kids in school," said Dr. Martin Levy, administrator for the District's Preventive Health Services Administration. "Part of {the lack of enforcement} is a reluctance to put kids out."

Principals of small schools have an advantage when it comes to enforcing immunization laws. LeGrande Baldwin, principal of Maury Elementary School in Northeast Washington, has an enrollment of 177 students, which allows him time for more contact with parents. If a student didn't have any record of immunizations, "I would take the necessary steps to have a child sent home until the immunizations are received," he said.

School physicals are a new requirement for District students entering kindergarten, first, third, fifth, seventh and 11th grades. But students are not going to be excluded from school if they fail to get a doctor's examination. According to the law, students should have a certificate proving they have had a physical when they register for school.

If a student fails to get a physical, the principal is to call the parent. Then a written notice is to be sent. If the physical is still not done, it is up to the school nurse to get in touch with the parents and see that the physical is performed.

"I don't know how that is going to work. A nurse has five schools and three grades per school," said Hattie Waller, nurse coordinator for the Bureau of School Health Services.

"To me, if it is a law, it should have some teeth in it," she said. "Why fill up the books with laws you are not going to enforce?"

The politics of school health, moreover, are not limited to making -- and implementing -- regulations. Most controversial are proposals to set up school-based clinics, where medical professionals would diagnose, treat or refer problems ranging from hearing deficits to sexually transmitted diseases.

Under study in the District is a plan for a school-based adolescent health center. In most states, the main focus has been at the level of junior and senior high school.

But prevention should begin at a younger age, Hopkins' DeAngelis said, when children develop attitudes about their health and before the problems adolescents face actually begin.

To many in the school health field, it is never too early to learn about disease prevention, whether it's lice or AIDS or depression, and the place to start is in the elementary grades.

"People would rather pay a $100,000 hospital bill for a kid who was drunk and in an accident than pay $1,000 for prevention," DeAngelis said. "Kids have problems early on in school and act out, kids come from families where there is no future for them, and it goes beyond just taking care of their physical health."