Samantha Davis-Francis is one of a handful of students at the heart of a mounting debate over health care in Howard County schools.
A severe asthmatic, the sixth-grader uses a misting device called a nebulizer. Under state law, it cannot be administered by the health assistant at her neighborhood school, Ellicott Mills Middle. So she must go to Mayfield Woods Middle School, where there's a registered nurse.
"It's a waste of time and money, and she had to leave all of her friends behind," complains her mother, Cynthia Davis-Francis of Ellicott City.
In Howard County, more and more families are facing similar problems. Contrary to the assumptions of some parents, only 16 of the county's 60 schools have full-time registered nurses.
And as an increasing number of children show up in the school system with chronic health problems that need daily treatment, the issue of using health assistants with limited training looms larger.
The gravity of the issue was driven home Oct. 18 by the death of a Mount View Middle School eighth-grader who collapsed during recess while wearing a heart monitor. A nurse was at the school at the time of the incident, and no one questioned the school's emergency medical response.
A citizens advisory committee -- which has been studying school health care services for 16 months -- is expected this month to recommend to the superintendent that the school system move to a new health-care delivery system.
The committee wants the schools to put health assistants in each school -- with nurses supervising and training groups of about three to five of them and performing tasks that the assistants are not allowed to do. The nurses, armed with pagers and cellular telephones, would move among their small groups of schools as needed.
In May 1995, school health officials proposed virtually the same model for delivering health care. The committee's plan would require the system to hire more nurses and more health assistants -- adding between $200,000 and $400,000 per year to the $1.5 million the schools already spend on health services.
Most school health assistants praise the idea, saying it would help give them more training and more supervision. Last year, budget cuts to the school system's central administration reduced the number of health supervisors from three to two -- too few for the growing number of schools and increasing health problems, health assistants say.
Nurses say that putting nurses in every school -- instead of the proposed system -- could be cheaper because it would require less total staff. But in the long term, it likely could be more expensive because the top salary for a school nurse is $15,000 more than that of a health assistant.
In the end, the decision likely will wind up before the school
board, which must juggle dollars among various needs of the system. Putting a nurse in every school could add $500,000 in costs in the long run.
"It's all going to come down to the budget," says Donald McBrien, the system's director of pupil services. "The question will be balancing what we might like with what the system really needs and what is the least expensive way of doing that."
Adds Rosemary Mortimer, president of Wilde Lake Middle School's PTA, a faculty member at the Johns Hopkins University School of Nursing and a member of the advisory committee studying school-health services: "It's a real difficult issue. If we had lots of money, we would do anything we wanted for health care, but it just isn't there."
There are no national or state requirements for health services in schools, nor is there a clear consensus, says Alain Joffe, director of adolescent medicine at the Johns Hopkins Children's Center. "It depends on the nature of the school, the population it serves and its goals."
For decades, Howard schools have relied on health assistants, who are required to be certified in cardiopulmonary resuscitation and first aid. They used to receive two weeks of training each summer and several days more of education during the school year, but much of that training has been eliminated to save money.
Only three systems in Maryland have registered nurses in every school: Allegany, Baltimore and Harford counties. Baltimore and Harford counties have a long tradition of nurses in schools. Allegany recently decided to add nurses as a means of providing better health care for students in impoverished areas of that rural county.
Meanwhile, in Howard, the number of students needing health care -- and the types of services they require -- are increasing dramatically, school nurses and health assistants say.
In the 1994-1995 school year, the number of visits to health rooms increased by 18 percent over the prior school year, while enrollment increased by less than 5 percent, according to school system data.