Our study of children suffering from cancer [5] allowed us to conclude that the decline in school performance exhibited by these children could be due in very many cases not only to the disease itself or to the specific treatments against cancer they were receiving, but to the social circumstances in which these treatments were given and to the social responses they may evoke in their peers. (Since long absence from school could result in the child being subjected to ragging on returning to school, and since exposure to harassment produces reluctance to go to school, these social factors could create a vicious circle that has an adverse affect on school performance [1, 2, 4-5].) 

We also know that children suffering from cancer received the same amount of "teaching" as their normal fellows at their ordinary school because they were continuously receiving instruction by the hospital teacher when they were at hospital and by a regular teacher when treatment was given at home, according to the Swedish educational law, children who cannot attend school for more than two weeks because of illness have the right to receive instruction at home through the ordinary school. 

For this simple reason we could lay aside the hypothesis that these children should succeed on their return to school if they were to receive special instruction. The fact was that they were already receiving it. But as we could observe that knowledge did play an important role not only in children's intellectual (cognitive) development but also in their emotional development (in comparing their abilities with each other children build their self-image), we understood that we need to prevent the preventive quarantine against infections. In other words, we needed to make these children remain in touch with their peers to ensure "normal" development.

We asked us how to achieve this, how to eliminate isolation and at the same time maintaining the necessary quarantine these children must undergo in order to ensure their protection against infections. If we succeed, we would make it easier for these children to successfully resume their life in school. And the greater their success, the better these children should later be integrated in the society. 

For this reason, we decided to develop a special program to be applied at the Karolinska and the Huddinge University Hospitals, the St. Goran and Danderyd Hospital in the county of Stockholm; the Academic Hospital in the county of Uppsala; the Ostra Hospital in the county of Goteborg and the Linkoping University Hospital in the county of Linkoping, in order to transform the classroom of the hospital schools into a part of the ordinary classroom or kindergarten by "virtually trans-porting" the sick children to the ordinary class-room or kindergarten. That is, we created a virtual space including both real spaces, making use of the possibilities offered by the new technology. But, as we believed that the causes of children suffering from cancer performing a little worse than their control peers were not to be found in the specific disease or the treatment but in the social circumstances to which they are subjected, we decided that the program should apply to all categories of sick children undergoing long treatments that prevent them from going to school. The necessary funds for the capital investments needed to develop the program were provided by the Foundation for the development of knowledge and competence (Stiftelse for kunskap- och kompetensutveckling) and by Telia AB (= the Swedish Telephone Company.) 

The program was first demonstrated during the 3rd. congress of Hope (Hospital Organization of Pedagogues in Europe) which was held in Uppsala on May 13-17 1996

· On this occasion contacts were made among hospital teachers of different countries (Sweden, Belgium, Spain, Italy, Holland, and Germany) in order to apply to the European Commission for funds to develop a similar program for Europe. We started the ordinary broadcasting December 12, 1996 linking a patient at the Huddinge University Hospital with the same virtual class of his comrades at the ordinary school in Stockholm. This way, we ensured that these children should not only acquire the same knowledge that their peers are acquiring (thus eliminating the fears they will otherwise feel when the time comes for them to return to their ordinary school), but also experience a continuity in the relationships with their peers and teachers that they enjoyed before they fell ill. These relationships are important for their moral and social development as well as a more efficient and personal support from the hospital teacher.

We are firmly convinced that both hospital schools and ordinary schools will develop in the direction we have pointed out in our program, developing a new pedagogy in accordance with the new IT-technology. By the use of computer based information for instance, a reference library is at hand for a sick child treated at home or in a hospital as well as for a healthy one attending school. The distance separating an ordinary teacher and his/her sick pupil in the hospital is eliminated. A sick child does no longer have to receive teaching only during "school hours" but whenever he or she may benefit from it because it is now perfectly possible for the child to save the received information in digital form and study it whenever it is convenient. A sick child in hospital must undergo treatments which are given at the same time that schools or libraries are working. But by collecting information from libraries or by receiving information and home lessons by internet or by e-mail, a hospitalized child can work even at midnight if he or she wants so and if the child feels it is more comfortable to do it a long time after receiving a painful treatment. The notion of time and space is changed by the new technology, the pedagogical technique applied just now in education should evolve in accor-dance with these changes. 

Our idea was to place a computer prepared for visual communication in the hospital. To this end some room at the hospital should be equipped with a telephone plug appropriated for PC communication, with another such in the ordinary classroom of the child undergoing long treatments. In some cases it will also be necessary to equip children suffering from long treatments given at home with one connection at home if they are subject to long "home quarantine" to prevent them from catching infections. If children suffering from serious diseases they can directly see and compare their own and their peers' skills or intellectual performance in just the same way they used to do when they were all physically present in the same classroom, we should succeed in putting all children (the sick child as well as his or her peers) "together" in the "same room" in spite of the fact that one is actually in hospital and the others are in their ordinary school or kindergarten. 

In this way, learning and playing "together" with the other children, and being taught by the same ordinary teacher they had in their ordinary school or kindergarten, sick children should also come to feel assured that they are acquiring the same skills and knowledge their comrades are being taught, something which will relieve the sick child of anxiety generated by the fear of falling behind its peers. And the more the child is reassured about this, the less the child will be afraid to go back to school or kindergarten. In this way it is possible to prevent the later staying away from school (and all this entails [1, 2, 4-5]) when the treatment is over. Moreover, as they all receive not only the "same amount" of pure knowledge or skills from their teacher in charge but see each other, they become simultaneously conscious of their respective performances. In this way they acquire, apart from knowledge of a school subject, knowledge of their own position in the hierarchical structure of their school or kindergarten class. Consequently, they don't need to start a new competition to determine a new hierarchy when the sick child is back in school or kindergarten. 

Children subjected to long hospitalization encounter difficulties not only in learning mathematics at secondary school level [3-5] but also when acquiring other "cumulative knowledge" like foreign languages [4, 5]. We consequently assume that mathematics and foreign languages are subjects in which visual computer programs should be most useful. Taking into account the different learning needs children have, we calculate that it should be necessary to have for each region or hospital 10 to 12 computers to develop a complete program of distance education for each pilot and regional program: two at hospital(s), six to eight at the different schools in the region covered by the hospital(s) and perhaps one or two more at home for those children suffering from leukemia who must undergo long quarantine to avoid infections. But this being our pilot project, we reduced the number of computer to a minimum. 

We started our program with a total of 40 computers. Among them, only 18 are prepared for visual communication, in some cases because of the high costs of the program, in others for specific pedagogical reasons: children suffering from "psychological" or psychiatric illness (they are included in our program) don't wont to be seen even when they want to be in touch with some of their former schoolmates as well as want to be on the net. The program should be working in all its extension by 1997. Both teachers (the one at the hospital and the teacher in charge) and the play therapist as well as the kindergarten personnel should coordinate their work in order to schedule the use of their respective computers. The hospital teacher should also assist the child when it uses the computer for the first time. Instruction to its use must also been given to parents when computers are placed at home. Otherwise the hospital teacher must assist the sick child at home. When teachers are coordinating their work (by using internet, e-mail and visual communication between themselves) they should pay special attention both to cumulative knowledge (mathematics and foreign language) and to the psychological and emotional aspects of acquiring knowledge. For this reason they may allow the whole class (the sick child and its comrades) to freely communicate in order to maintain as normal a contact as possible.

Selection criteria
All information pertaining to individuals is treated confidentially, and transformed into impersonal data immediately after these data have been statistically worked out, and no later than a year after reaching us. 

1) The parent (or the adult) who has legal custody of the child must give a signed authorization allowing the child to participate in the program. But in addition, each child must accept to participate. This is to make the child feel that he or she doesn't lose his or her decision capacity, therefore that he or she still actively decides in matters concerning his or her own life.

2) Children participating in the program must know what they are suffering from. Otherwise there is a high risk that they may be informed about their own illness by classmates or by other children.

3) Subject to parents' agreement, the hospital should get in touch with the school to inform the teacher and the patient's peers about the patient's situation. The patient will also have the opportunity to discuss, assisted by a nurse, his or her situation with classmates through visual communication.

4) The hospital teacher or the play therapist should get in touch with people responsible for the child in the school or kindergarten to establish a routine for contacts between the child and its classmates. (In this way the child is guarded against developing after-effects typical of isolation. In addition, this contact should enable the child to maintain a psycho-social identity at the very moment when it feels that it is losing its physical identity as a consequence of the physical transformation that surgical treatments, illness and medicine induce. The better they collaborate together, the better the patient is able to keep up with his peers.

5) Eventually, the teachers of siblings should also be contacted in order to minimize the risk of psychological and educational problems for them. [6-8]

6) Parents must accept that teachers or kindergarten personnel speak relatively freely about the child's disease. Otherwise the teachers and other people involved may suffer constant stress due to the fact he or she never knows when what he or she is saying is right or wrong. Under such circumstances, work becomes impossible.
7) Children partaking in the program must accept to be graded (judged) by their ordinary teacher in charge (or personnel at kindergarten). The reason for this is that they cannot maintain their own self-esteem if they feel that they are given different treatment than their peers.

8) Initial information about the program should be given to them either by their physician, by the hospital teacher or by the play therapist. Later the hospital teacher or play therapist should take care of the subsequent contacts with the ordinary school or kindergarten.

9) The person primarily responsible for the direct application of the program and for the direct evaluation of each child and for each hospital program should be the hospital teacher or play therapist (depending on the child's level and age).

Evaluation
Five months after school re-entry each child partaking in the program should be evaluated (tested) by its ordinary or kindergarten teacher in both mathematics and in languages. The mean results reached by a group constituted by patients should be compared with a mean achieved by ordinary classes.

Another evaluation should be a financial one. We should measure the general costs of the program without taking into account the capital costs, since we assume that computers should become cheaper in the near future and also in a near future all schools should have computers connected by telephone lines or an international communication net as a normal part of their education program.

One should also take into account the improvement in the quality of teaching that hospital schools should achieve through the proposed system, because of the new functions assigned to hospital school teachers as mediators between the hospital and the ordinary school or kindergarten, leaving more time for the specific teaching functions needed in case the child is a beginner. They should become more specialized in computer and telematic.

Computer equipment
We are employing now a new technology based in a standard ITU-TH 124 which has recently appeared. As it is cheaper, more flexible (more effective than our "old program") 

The choice of hardware and software has been made taking into account the problems of compatibility which can arise when combining different systems or technologies in different countries because we must also make plans with future needs in mind, and so, the possibility to develop a European program (we contacted different hospitals and organizations having this goal in mind). By using a common technology (a standard ITU-T H.320, possible to update to T120) we make it possible to form a common European network in total independence of the chosen PC platform. For the same reason we chose a telephone line connection through an ISDN card and ITU 124 because there is no school without telephone even though very many of them have no connection to the net. Furthermore, the use of ISDN card doesn't exclude the possibility of connect with the net. As the choice of a ITU-T H.320 standard allows us to use another platform than IBM compatibles (Macintosh, for instance) we are allowed to use it. Teachers preferring these other kinds of platform are therefore allowed to use them.

References
1. Ramholt, B. Making school a success for the child with cancer (meeting abstract). in ECCO-4. Fourth European Conference on Clinical Oncology and Cancer Nursing. November 1-4. 1987. Madrid.: Federation of European Cancer Societies. 
2. Klopovich, P., et al., School phobia: interventions in childhood cancer. J.Kans. Med. Soc., 1981. 82(3): p. 125-127.
3. Charlton, A., D. Pearson, and M.-J. P.H., Children's return to school after treatment for solid tumours. Soc. Sci. Med., 1986. 22(12): p. 1337-1346.
4. Pérez-Bercoff, E., O. Björk, and P. Ljungman, Social integration of children suffering from cancer. An existealist approach. Report on the project n° 327 of the General Heritage Foundation of Sweden. 1996, Stockholm: Department of Philosophy. University of Stockholm. 84.
5. Pérez-Bercoff, E., Paideia y oncología, in A saúde como desafio ético, G. Caponi, S. Caponi, andM.T. Leopardi, Editor. 1995, Sociedade de Estudios em Filosofia e Saúde: Florionópolis. p. 73-86.
6. Illes, J.P., Children with cancer: healty siblings'perceptions during the illness experience. Cancer Nurs., 1979. 2(5): p. 371-377.
7. Evans, C.A., et al., Sibling response to childhood cancer: a new approach. Child: care, health and development, 1992. 18: p. 229-244.
8. Spinetta, J.J., The sibling of the child with cancer, in Living with childhood cancer, J.J. Spinetta and P. Deasy-Spinetta, Editor. 1981, C.V. Mosby Co.: St. Louis. p. 133-142.