There are about 37,000 students in Oakland, Calif., public schools.

And 22 school nurses.

“It’s challenging. It’s nerve-wracking,” says Oakland school nurse Liz Hurt. “Nurses are going to work and they’re afraid. They’re just praying to get to Friday with nothing bad happening!”

The extreme lack of school nurses to keep Oakland students safe and healthy is just one of the reasons that the 3,000 members of the Oakland Education Association (OEA) went on strike for seven days this month. Their demands at the bargaining table also include smaller class sizes, and greater student access to school psychologists, counselors, and teacher-librarians. (There are just four credentialed teacher-librarians in the district.)

“You can’t feed the minds of our students by starving their schools,” OEA President Keith Brown has said.

As school nurses come and go, the average caseload per nurse in Oakland is about 1,750 students, says OEA. It’s at least 1,000 more students per nurse than the minimum recommendation, which is at least one nurse per school, according to the American Academy of Pediatrics, or one nurse per 750 students in “healthy student populations,” says the National Association of School Nurses (NASN). In places with high rates of poverty, hunger, and environmental stresses, NASN cautions, children will have more health issues and need more nurses.

That sounds a lot like Oakland, where 75 percent of students live below the federal poverty line, an increasing number live in homeless encampments called tent cities, and environmental hazards aren’t rare. In 2017, while researching Oakland’s sky-high rate of hospitalizations among children with asthma, a San José State University student found that seven of 10 schools in Oakland Unified are located 500 feet from a major freeway. Meanwhile, Oakland also has several industrial chemical and fuel release sites that may affect public health, an Alameda County Public Health Department analysis found.

Not surprisingly, as of 2015, nearly one in five children in Oakland had asthma. More than 700 students have severe allergies, 50 have diabetes, and almost 30 have sickle cell disease.

“We’re an urban district,” explains Hurt. “The incidence rate of everything—all pathology—is much greater here… Our asthma rate is higher. Our Type 1 diabetes is very high and growing. Lots of severe allergies. And we also have families who move here for the great medical care and climate for sickle-cell disease.”

The Life of a School Nurse

Hurt’s work begins with about 1,250 children in two schools perched along the fault line in Oakland’s hills—one elementary, one middle. These include “numerous children who are medically fragile, in wheelchairs for cerebral palsy or paralysis, or traumatic injuries, some the result of violence. Some are dependent on procedures, like catheterization every three hours, some require regular insulin…” she says.

Caring for those 1,250 students already represent a job and a half, but that’s not nearly the total of her work. The district is supposed to have 30 nurses—eight positions are currently vacant —so the 22 nurses also take up the schools and students that should be covered by absent colleagues. (Even if the district filled those jobs, the staffing ratio would be a still unacceptable 1,350 students per nurse.)

The nurses are constantly running from school to school, trying to distribute medications and treatments on time, attempting to triage the most critical cases. In their absence, in case of emergency, untrained office staff or school security staff may have to step in, says Hurt. “I got a call once about a kid who was having trouble breathing. I came in and his eyes were puffy, his face is all blown up, and I said, ‘this is a severe allergic reaction!’”

On top of that, school nursing today isn’t just patient care. Every week, Hurt and the others spend days working to develop accommodations for medical 504 plans, as well as all the individualized health plans that are developed for kids with leukemia, cancer, seizures, and other chronic diseases. They’re also responsible for vision and hearing screenings of every student, and work with families to get dental care, mental-health treatment, and proper nutrition. In Oakland, this is complicated by the 50 languages spoken in students’ homes.

“Time for lunch?” Hurt laughs. “During lunch time is when you’re providing direct care for students with diabetes. Most of us don’t take lunch, and definitely not breaks!”

The job is unfair. Unrealistic. Underpaid. And, under current conditions, undesirable. Many dozens of school nurses have come and gone from Oakland schools over the past six years, says Hurt. “The new people come in, see what’s going on, and say, ‘There’s no way!’ and then they leave.”

But the job also is so, so, so important to keeping kids healthy, in school, and learning. When a school nurse is present, researchers found, school principals gain nearly an hour and teachers gain an extra 20 minutes a day to focus on educationinstead of asthma inhalers. School nurses also are linked to better student attendance, which, in turn, is linked to better reading skills, higher graduation rates, and more.

It can be a life-or-death matter. In 2014, two student deaths in Philadelphia were linked to insufficient school nursing levels.

In late September, months before OEA members went on strike, school nurses and teachers showed up at an Oakland school board meeting to demand more nurses and to share statements from parents and pediatricians.

“You need to take this seriously,” Oakland Education Association treasurer Deirdre Snyder told the board. “You’re going to be sued by some parent! It’s a travesty. I have seen seizures in my room, all kinds of problems, more and more as the years go on. You cannot pretend this isn’t happening. You need to act now.”