preventive services only toward children at high risk. The population-based approach has the advantage of producing a large potential impact on the population as a whole, but a major disadvantage is that the benefits are frequently very small for the individual. Another potential disadvantage is that all interventions have a finite risk of unintended adverse side effects, which are also amplified along with benefits in the population-based approach, possibly resulting in an unfavorable benefit-risk ratio. Depending on the health issue, one approach may be superior to the other, or a combination of the two may be appropriate. For example, the National Cholesterol Education program recommends a population-based approach for implementing dietary guidelines for children, combined with a high-risk approach to blood lipid screening targeted only at children considered at risk based on family history (Starfield and Vivier, 1995).

Further, schools are strategically positioned to serve in the public health battle against the resurgence of infectious diseases, such as tuberculosis and hepatitis. Another feature of school health services—one that is often overlooked—is its potential for expanding the knowledge base. School health services can be a rich source of data for studying the relation between health status and learning capacity, and for assessing unmet needs and monitoring the health status of children and adolescents.

Given the above needs and benefits, a basic health services program must be in place in all schools. The issues currently generating much discussion and debate, however, are the role of the school in providing access to primary care, the appropriate lead agency for the more traditional basic school health services, the advantages and disadvantages of a population-focused versus a high-risk approach to the delivery of health services in schools, and the need to develop an integrated system of school health services.

The role of the school in providing access to primary care is a particularly difficult and critical issue. Since schools are a public system whereas health care is predominately private, there appears to be a fundamental mismatch between the two systems. Many students already have their own source of primary care, but a significant and growing segment of the student population does not. Those students without access to primary care are usually poor and are often at greatest risk of academic failure.

Special Needs Due to Poverty

Chapter 1 of this report documents some of the major problems facing children and adolescents in this country—the new social morbidities, changing family structures, limited access to health care, and lack of health



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