Narrow Thinking about Health and Schools

In 1965, Jack Geiger, a doctor working in the Mississippi Delta, founded one of the first federally-funded community health centers in the U.S. There he treated many children who were seriously malnourished. He wrote “prescriptions” for meat, milk, vegetables, and fruit that were to be “filled” at nearby grocery stores. Grocery store owners then submitted bills to the community health center where Geiger used the pharmacy budget to pay the bills.

The federal agency that funded community health centers, then called the Office of Economic Opportunity (OEO),  sent an official to tell Geiger that he cannot use health center funds for groceries called “prescriptions.” Geiger met with the federal official and said: “The last time I looked in my textbooks, the specific therapy for malnutrition was food.” End of OEO complaint in 1965. Community health centers  have grown since 1965 to number 1100 and serve 19 million low-income people.

Geiger knew then that supplying the right food would cure malnutrition. He understood that malnourishment does not come from mothers’ refusal to give their babies food; it comes from the lack of the right food and money to get that food. In a word, poverty. He saw malnutrition as a public health problem located in socioeconomic and political structures that cause and sustain poverty. He saw that for the health of the poor community to improve, the center he directed had to do more than diagnose medical conditions and write prescriptions for pills and ointments. He did not draw a line between his community health center and the poverty that Mississippi Delta families experienced daily. He saw the connection between better health and a better life for malnourished children and did something about it.

Since the mid-1960s, he and thousands of medical professionals and policymakers in the U.S. and internationally have come to understand that “social determinants of health,” especially the impact of poverty, affect which babies live beyond infancy, who succeeds in schools, who has access to high quality health care, and when we die (Marmot-Social determinants of health inqualities ).

Can anyone deny that ill health affects success in school? The stark example of malnutrition makes the connection obvious. Researchers and policymakers today know well the strong correlations between health and level of education. Whether more schooling creates better health (less smoker-related diseases, less obesity-linked conditions, etc.) or better health generates higher levels of education can be debated endlessly. What is less debated and generally accepted internationally and within the U.S. is that early education from birth to four years of age is crucial to both good health and school success (see Can Education Policy be Health Policy? In short, there are “social determinants of school success.”

These “social determinants of school success,” of course, are at the heart of the current debate among school reformers. One crowd–the “no excuses” reformers (e.g., Michelle Rhee, Joel Klein, Bill Gates, Eli Broad)–argue that schools alone can erase the achievement test score gap and insure that all student go to college. They focus on recruiting, training, and rigorously evaluating teachers–the single most important in-school influence on children–as the road to school success.  They say that effective teachers and schools can overcome the effects of poverty and other “social determinants.”

Another crowd–and I include myself among them–champion programs where schools not only prod and support low-income students to achieve academically in school but also provide ready access for students and their families to an array of social, medical, and mental health services from birth to adulthood. This crowd recognizes the importance of upgrading the teacher corps, having strong principals, and pushing students to achieve but also know that “social determinants” shape school success.

Surely, paying attention to “social determinants of school success” costs more money, funds that cannot be provided wholly by the private sector or foundations. Federal and state government episodically have provided such funds.  Like community health centers in the 1960s, community schools that see the child and family as as part of a social system, schools can and have provided an array of services that help toddlers, children, and youth achieve and grow into healthy adults.

At a time in U.S. history when the role and size of government are being heatedly debated and, for now, has tilted toward reducing government-sponsored social safety nets and cutting back expenditures in the name of controlling national debt and deficit reduction, the reform ideology of “no excuses” has the virtue of being less expensive. In the short-term, at least. In the long-term, as Jack Geiger knew in 1965 and does today, the “social determinants of health” cannot be ignored if children are to grow into healthy adults. And so it is with the “social determinants of school success.”


Filed under Reforming schools

8 responses to “Narrow Thinking about Health and Schools

  1. graingered

    Brilliant perspective. I could literally not agree with you more on every aspect with one exception; paying attention to “social determinants of school success” does not have to cost more money fro govt., the private sector or any member of society.

    In our pointed effort to create a paradigm of “better, faster and less costly education for all, my EduKare partners and I are tweeting, blogging and dialoging vigorously with anyone who will listen about our new paradigm for struggling schools. Our original framing can be found at It is our strong belief that through a collaborative, wrap-a-round support network based inside school buildings, helping professionals and active citizens of the business and broader community can provide the supports necessary to create social determinants to school success that work positively instead of negatively. I’d be honored if you were to take a look and provide feedback.

    I am now following your writing with intense interest. Our paths converge on many levels.

    • larrycuban

      Thanks, Sean, for your comments about wrap-a-round support networks that not only provide social, medical, and other services but also build on the strengths of students caught in impoverished settings. Rather than argue now about the cost of the model and where the money comes from, wrap, reminding me and readers of the concept is most useful.

  2. graingered

    Yes, thank you. I think the point of “better, faster, cheaper” needs to be clarified. Currently, services for children (health, social, psychological, recreational, etc.) are provided in communities, but spread out acrosse the landscape in separate locations and buildings, all costing money to operate and maintain. Accessing these services is inefficient and very costly when all is accounted for. The EduKare idea is to, as often as possible make these services available at the school, but not to be payed for by the school. The coordination of services by location in the school means that helping professionals won’t be populating all of those offices and centers around the community, thereby reducing cost for their department and for their clients who don’t have to get there anymore (the idea being that kids are present everyday in the school already, and their parents are typically comfortable visiting their child’s school also.)

    One question is how to do accommodate these wrap-a-round personnel in schools that may be overcrowded? That challenge would play ut over time. As new schools are built, public/public (interdepartmental) funding structures would reduce the cost to school boards and other helping agencies by avoiding either having to pay a full bill for a new building. Creative spaces would emerge in schools to be used for multidisciplinary purposes. In previously existing schools that are under-enrolled, the space to convert is already there, and in schools that are full the use of relocatable buildings (offices, meeting rooms, classrooms) is a good option. In my jurisdiction we routinely use uniformly designed relocatables for classroom space, and when they aren’t need anymore in one location, they can be moved where they’re needed once again reducing new construction cost.

    Another (perhaps bigger) challenge is getting all of these professionals to work together. Social workers, health care professionals, psych folks, etc. should be on the same page serving the same clients, but we aren’t always. I think the paradigm shift here needs to begin in pre-service training, but that’s another story.


  3. Gary Ravani

    I hope you don’t mind if I include a recent piece I wrote for the Washington Post.

    The hard bigotry of low expectations and low priorities
    By Gary Ravani

    Perhaps the single best-known piece of social science research ever done in this country is the study produced by James Coleman in 1966 under the authority of the 1964 Civil Rights Act, commonly called “the Coleman Report.” Coleman’s work is the second largest social science research project in history, covering 600,000 children in 4,000 schools nationally.
    Coleman concluded that school-based poverty concentrations were negatively impacting school achievement for the minority poor. His proposed solutions were the impetus for the school desegregation movement and specifically busing. Coleman later admitted to the ultimate failure of busing as a consequence of “white flight.”

    Coleman found those two factors – poverty and minority status – more predictive than just differences in school funding. This is frequently distorted to suggest “research shows school funding doesn’t matter in achievement.” Coleman never said that. He just said parental economic status and segregated schools were the most important factors. Results from “The Nation’s Report Card,” the National Assessment of Educational Progress, or NAEP, show that states with the highest education spending (and highest percentages of unionized teachers) are the highest performers.
    The impact of family economic well being on school achievement continues to be studied. The Educational Testing Service (ETS), California’s state testing vendor, has conducted two such studies: “Parsing the Achievement Gap” (2003) and “The Family – America’s Smallest School” (2007).

    In “Parsing,” the authors are careful to assert, “We know skin color has no bearing on the ability to achieve,” and “… it is clear that educational achievement is associated with home, school, and societal factors, almost all having their roots in socioeconomic factors affecting this country.”
    This report, “based on a careful review of the synthesis of research,” identifies 14 correlates of elementary and secondary school achievement. There are six correlates related to school: curriculum, teacher preparation, teacher experience, class size, technology, and school safety. The remaining eight correlates are categorized as “Before and Beyond School”: parent participation, student mobility, birth-weight, lead poisoning, hunger and nutrition, reading in the home, television watching, and parent availability.
    Note that at least three of the six school-related correlates are actually resource-related and, with the other eight correlates, are beyond the control of the school and teachers.

    The other ETS study, “The Family – America’s Smallest School,” goes over much of the same territory as “Parsing,” noting the negative impacts on school achievement of single-parent homes, poverty in the minority communities, food insecurity, parent unemployment, child care disparities, substantial differences in children’s measured abilities as they start kindergarten, frequency of student absences, and lack of educational resources and support in the home.

    The study concludes that these factors “account for about two-thirds of the large differences … in NAEP eighth-grade reading scores.”
    Many of the same factors described by ETS as causal in school achievement can also be found elsewhere, for example, in “Life and Death from Unnatural Causes,” by the Alameda County (CA) Public Health Department.
    In a resounding echo of Coleman’s conclusions about poor students and low achievement, the Alameda study states, “A main way that place is linked to health is through geographic concentration of poverty.”

    In “Life and Death,” the factors of family wealth, environmental issues (exposure to lead), lack of access to health care – in so many words the conditions of poverty – result in a “life expectancy gap.” Children, overwhelmingly minority children, born in the flats of Oakland “can expect to die almost 15 years earlier than a White person born in the Oakland Hills.” The same results have been indicated by the Census lifespan data. A recent study on AIDS find concentrations of the disease in geographic concentrations of the poor in the southern states.

    It appears that the medical experts doing the research for this study didn’t realize that using the conditions of poverty found in economically segregated communities to explain different life span outcomes is really all a matter of “making excuses.” They should have known that dying early results from the “soft bigotry of low expectations.”

    There are those who will argue that there is no established causal relationship between conditions that contribute to poor life expectancy rates and the conditions that contribute to low school achievement; that conditions that can grind 15 years off a child’s life span don’t also grind off abilities to succeed in school. Such arguments are the “hard bigotry” of ideology.

    There are those who will suggest that the richest nation on Earth doesn’t have the ability to correct in large part the conditions of concentrated poverty that ETS identifies as contributing to low achievement and that the Alameda study identifies as contributing to abbreviated lives. That, indeed, is an example of low expectations – of the variety that can be found when people fail to prioritize education.

    Gary Ravani taught middle school for more than 30 years in Petaluma. He served for 19 years as president of the Petaluma Federation of Teachers, is currently president of the California Federation of Teachers’ Early Childhood/K-12 Council.

    • larrycuban


      Thanks for sending along your Washington Post op-ed piece. I believe that most school reformers understand that poverty has enormous impact on children and adult lives. The issue dividing many such reformers today is the potency of the school alone to overcome the powerful influence of being poor and the degree to which school and community work together in coordinating services to help children and their families. The problem that has arisen is in the rhetoric around urban school reform. To acknowledge that there are social determinants for school success translates far too easily into slippery coded accusations of low expectations for urban students and even racism from the “no excuses” crowd. And that is unfortunate since both sets of reformers work hard and want the best for children and youth in urban and rural poverty.

  4. Jeremy Giller


    I just want to point out that the first paragraph of this post bears a striking resemblance (without attribution) to a July 28 piece by David Bornstein in The New York Times’s Opinionator section ( To wit:

    “In 1965, in an impoverished rural county in the Mississippi Delta, the pioneering physician Jack Geiger helped found one of the nation’s first community health centers. Many of the children Geiger treated were seriously malnourished, so he began writing “prescriptions” for food — stipulating quantities of milk, vegetables, meat, and fruit that could be “filled” at grocery stores, which were instructed to send the bills to the health center, where they were paid out of the pharmacy budget. When word of this reached the Office of Economic Opportunity in Washington, which financed the center, an official was dispatched to Mississippi to reprimand Geiger and make sure he understood that the center’s money could be used only for medical purposes. Geiger replied: “The last time I looked in my textbooks, the specific therapy for malnutrition was food.” The official had nothing to say and returned to Washington.”

    Always better to attribute.

    • larrycuban

      I thought by using the link (embedded in first paragraph, second sentence in word “There”) that credit to the David Bornstein piece would be evident since a click on “There” would bring up the New York Times article. I guess not. Thanks for calling my attention to it.

  5. I was a kid during the Great Society and remember a host of social services that were provided through my extremely rural PA elementary school (shots, dental checks, as well as subsidized and free meals). Thanks to monies provided to the NEA and NEH, we also had a pretty lively arts scene (and I saw a very young Patty Lupone perform outside behind my elementary school).

    Today, the arts, shots and dental checks are gone and the money for the lunch program has been greatly curtailed….while the economy is in far worse shape. While kids from that area have always had the deck stacked against them, they’re now UNDER that proverbial deck. Unless we tackle poverty, we, as a nation, are just not serious about improving public education. It’s all just a smoke screen and delusion (see Gates, etc).

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