We’ve heard a great deal about teachers and their struggles through the covid-19 pandemic, but one group of school personnel that has gotten little attention is school nurses.

Even before the pandemic began in 2020, school nurses played a critical role in schools, often serving as primary health-care providers for many students — but covid-19 has made their role much harder.

In this piece, freelance writer Eli Cahan looks at the plight of nurses. Cahan, who reports on health and society, has published work in Newsweek, the Los Angeles Times Times, VICE, the Guardian, and elsewhere. He is also a medical student at New York University’s School of Medicine and a master’s degree student in health policy at Stanford University.

By Eli Cahan

School nurses have been quietly doing their jobs throughout the pandemic to try to keep students and families healthy, but some now say they are being left out of conversations about reopening schools as districts have moved from hybrid to in-person teaching and make plans for the fall.

Nurses have been working — mostly remotely — throughout the pandemic, acting as “scouts looking for the hotspots” in school communities, conducting webinars and listening sessions, and undertaking one-on-one check-ins with families, said Andrea Tanner, past president of the Indiana Association of School Nurses.

They have also leveraged Zoom, YouTube, Facebook, WhatsApp, and TikTok to ensure that students and families understand how to comply with prevention, isolation, and quarantine procedures, Tanner said.

And they have been on the front lines giving injections to adults and students at school-based coronavirus vaccine clinics, such as at Virginia’s Amherst County High School and at Laing Middle School in Mount Pleasant, South Carolina.

“Morning and night, Monday to Sunday, we’ve been on call,” Tanner said.

But when it comes to discussions in communities about safe school reopenings and health precautions, nurses are often left out.

Linda Mendonca, president-elect of the National Association of School Nurses, said there has long been tension between education officials and school nurses. She said that lack of understanding related to health issues have historically led education officials in charge of district decision-making to push these discussions “down the totem pole,” which often “keeps nurses from having a seat at the table.”

“I’m not surprised that some nurses are … marginalized in their districts,” Mendonca said.

Robin Cogan, who teaches in Camden, N.J., and runs twice-weekly national support groups for school nurses, said the tension has produced numerous issues. Nurses’ hygienic protocols have been overlooked, she said, and their quarantine rules have been flouted. Their recommendations to shut down high-risk contact sports have been ignored.

“Districts have been playing fast and loose with the CDC [Centers for Disease Control] guidelines,” said Cogan, “clawing back authority … from school nurses as they do.”

“It’s stripping us of our agency and our voice,” she added.

Last August, the school in Paulding County, Ga., where nurse Amy Westmoreland work, got national attention when a photograph showing unmasked students packed into a went viral. As cases surged, her efforts to promote social distancing, enforce mask-wearing, and enact testing and contact tracing protocols were cast aside. “They kept us on the sidelines,” she said. Later, she resigned in protest.

“I felt, by staying, I’d be betraying the trust of these kids and their families,” Westmoreland said. “I could not be an accomplice.”

Last November, some school nurses working in the D.C. public schools protested outside of the home of D.C. Mayor Muriel E. Bowser, demanding that the school nurses’ union be included in public school reopening discussions.

School nurses are often the only source of regular medical care for many of the 57 million K-12 students across the country, including the one-quarter with chronic diseases and those from low-income or minority communities. That includes many of Cogan’s Black students in Camden, one of the nation’s poorest cities.

According to the National Center for Education Statistics (NCES) Cogan’s district serves about 7,600 students, of whom 40 percent are Black and 44 percent live in poverty.

But many schools don’t have a nurse. According to the National Center for Education Statistics, only 52 percent of public schools had a full-time nurse in the 2015-16 school year, the last year for which data is available. Eighty-two percent had at least one full-time or one part-time nurse. But while the federal government recommends that elementary, middle and high schools have one nurse for every 750 students, the National Association of School Nurses says that the average nurse cares for 1,000 students.

In California, a 2015 study found that over half of the state’s schools lacked a full-time nurse. Regions like Yuba County have one nurse per 14,755 children, according to KidsData.

In Fresno, every school has a full-time nurse, said Jane Banks, the district’s health director. But these 106 schools serve 71,152 pupils, according to NCES, many of whom belong to migrant Hispanic families seeking seasonal farm-work. They face considerable barriers to health care outside of school, Banks said.

“If we don’t provide the care they need, they may never get it,” Banks said.

Nurses perform a sweeping array of tasks, Banks and Cogan said: monitoring the growth of undernourished children; conducting vision, hearing, and dental testing; and administering medications to asthmatics and diabetics.

They also represent a growing fraction of the slimming U.S. public health workforce. There are now fewer than 200,000 public health workers nationally, a 2018 analysis found; budget cuts have eliminated 56,000 jobs since 2010.

In past epidemics, nurses’ public health role has come into full relief. For example, according to the New York Times, Mary Pappas at St. Francis Prep in Queens identified the country’s first eight cases of swine flu in 2009.

For school nurses, reopened schools will mean new tasks on top of the old ones. Tanner said school nurses will not only help students one-on-one but will analyze everything from classroom seating charts to bus routes to hours of sports practice footage.

Though cases of covid-19 have been falling across the country, there have been flare-ups in school communities where school buildings reopened. Now students 12 and older are permitted to be vaccinated, but younger students still are not, and it is unclear what percentage of older students will wind up getting vaccinated with immunization rates stalling across the country.

When schools that reopened last fall, only about two-thirds of students wore masks consistently in classrooms and hallways, a CDC study found. Compliance during sports, recess, and lunch was lower still.

According to the American Academy of Pediatrics, as of June 10, over 4 million U.S. children had tested positive for the coronavirus; as of June 2, according to the CDC, 4,018 kids had developed severe inflammatory syndromes associated with the virus — 36 of which turned fatal. Emerging data suggests these syndromes are becoming more common and more extreme.

With the more virulent delta variant of the novel coronavirus spreading around the world — including in the United States, where it was nearly 21 percent of covid-19 cases — some scientists across the globe remain worried about the potential for schools to fuel covid-19 superspreading in part because it is more infectious.

For nurses, that could mean putting their lives on the line: 14 nurses whom were contacted for this article acknowledged the likelihood they’ll be exposed to the virus.

“I do worry about my scrub sisters out there,” said Kim Lowe, a school nurse in Utah.

It is not known how many school nurses have died from covid-19.