Back to School

I’ve promised at least a dozen people that I would write about this over the past month and have so far utterly failed them. The truth is that it’s such a huge topic, and so fraught with the risk of saying something too extreme and dogmatic, that it’s hard to even know where to start. In a way, being at least a month late to this topic is much, much more comfortable, because not only do we have much more data now, but I can write in the certain and comfortable knowledge that my essay will have no impact whatsoever on what we do about reopening schools (not that it would have anyway). My goal therefore, besides keeping out of trouble, is to provide whatever insight I can into whether or not it’s safe to reopen schools and then what you, dear reader, can do to mitigate the inherent risks within your own scope of influence. I don’t always lay out a thesis statement at the beginning of these essays, because despite what I learned in Freshman honors English, I usually don’t have one (sorry Mrs. Greer!); but today I want to address whether going back to school is going to worsen the pandemic, whether it is worth the risk, and what parents, educators, and we as a society can do to make this situation as safe as possible.


Is going back to school going to make the pandemic worse?

Answer: Yes, absolutely.

Did you want me to elaborate, or is that sufficient? The reality is that I can see no way that this isn’t going to make the pandemic worse. On some level this math is incredibly simple; more people in close quarters means more cases, and more cases means more deaths. The real question is how much worse will reopening schools make the pandemic, and as we discuss below, whether that risk is justified right now. This question is going to answer itself in a few months, maybe even within a few weeks; but right now the best we can do is guess.

When I first started writing about this issue, I wasn’t sure what conclusions I would draw (which is generally a good way to start, if you can do it). I actually expected to arrive at answers that were cautiously optimistic, but as I went through the current data I became more concerned. My goal in writing this was not to sound an alarm or argue a point but to evaluate the evidence, and if you find my conclusions somewhat more discouraging than you had hoped, please know you aren’t alone; I was discouraged too. We are going to look at three types of evidence; what the epidemiological and experimental data tells us about how children and adolescents spread the virus, what has already happened in other places that have reopened schools, and what the risk is to these populations, to educators, and to the family members of school aged children and adolescents.

Can children spread the virus?
I’ve said before that for any discussion of whether or not children and adolescents can spread the SARS-CoV-2 virus, the burden of proof would be on the side of proving that they don’t, not proving that they do. We have decades- nay, millennia- of experience with and evidence of children spreading viral respiratory illnesses. I see it literally every day in my clinic and have experienced it within my own body when I have been laid up for days (I’m told this is called a “man-cold”) from a virus that one of my adorable walking fomites brought home from parents-day-out or Sunday School (or whatever your church calls it to avoid having to call it Sunday School). Under normal circumstances we take this very seriously; we cancel birthday parties when one of our kids has a fever and we regretfully reschedule plans with friends when a respiratory virus has affected our family, because we know that we could spread it to their family. In fact, this is such a truism that it is accepted conventional wisdom, and I regularly have parents tell me of a cold or the flu that their children got it from a cousin and are “just passing it around” within the home. Barring some compelling microbiological difference, there is no reason to assume that it would be any different for COVID-19. Without definitive evidence, I simply do not find claims that ‘children don’t spread the virus’ convincing. It is well and good for people like British Epidemiologist Mark Woolhouse to say that there have been ‘no recorded cases worldwide of a teacher catching the coronavirus from a pupil’ (‘pupil’ is a British word for ‘student’), but aside from the problem of seeming to claim categorical knowledge, saying this in July when schools had been closed since the early days of the pandemic in March paints the risk as being low with much more confidence than the evidence warrants. But epidemiology is an applied science, and what we get wrong in our models and assumptions, the virus will correct for us in the bodies of students and teachers.

Nevertheless, the evidence was initially encouraging. A review of available evidence published on July 31st in the journal of the American Academy of Pediatrics asserted that “children most frequently acquire COVID-19 from adults, rather than transmitting it to them,” while acknowledging that this is a significant divergence from transmission patterns in other viral respiratory illnesses such as influenza. The authors concluded, “On the basis of these data, SARS-CoV-2 transmission in schools may be less important in community transmission than initially feared.” This conclusion is based on a study from Switzerland that tracked cases in 39 households, and another in China that included 68 children with confirmed COVID-19.

The same month, a study from Korea that traced contacts of 5,706 individuals with COVID-19 found that the highest transmission rates were for the household contacts of school-aged children with the virus, and concluded that “rates were higher for contacts of children than adults.” Because we are talking about COVID-19, this claim might be considered controversial. If we were talking about literally any other respiratory virus, every parent I know would respond by saying, “well… yeah.”

This finding, from a much larger study, provides a more balanced context for the major enigma from the AAP article; a German experiment that showed that viral loads in the nasopharynx (nasopharynxes? nasophari?) of children were as high as those in older people, “raising concern that children could be as infectious as adults” (Update: this result has since been confirmed by a study at Massachusetts General Hospital released yesterday, August 19th, which actually found viral loads in children with COVID-19 that were higher than that of severely ill hospitalized adults). The AAP article offered a few possible explanations for why this did not line up with the reassuring findings from the small epidemiological studies they reviewed. First, because children are more frequently mildly symptomatic or asymptomatic, releasing fewer infectious respiratory particles during their illness compared to adults. Sure; but adults don’t generally pick their noses and then touch every single muffin before deciding which one they want for breakfast. Maybe with this disgusting example from my life this morning in mind, the AAP article added, “Another possibility is that because school closures occurred in most locations… most close contacts became limited to households, reducing opportunities for children to become infected in the community and present as index cases.” And if that is the analysis of the most optimistic academic article on reopening schools I’ve seen yet, what will be the conclusions of the epidemiological studies from 2 months from now?

Are we actually seeing COVID-19 cases transmitted by children?
The second type of data reveals yet another benefit of pathologic procrastination, because if I had written this a month ago we wouldn’t have some of this data at all. A recent analysis showed a surge of nearly 100,000 new pediatric COVID-19 cases in the latter part of July, prompting Pediatric Infectious Diseases specialist Dr. Sean O’Leary of Children’s Hospital Colorado (where I did all of my pediatric rotations in med school) to say “I think it’s showing that, yes, kids can get infected and can spread the infection.” This trend continued this month, with 75,755 new cases from 7/30 to 8/13. To put this in context, that means that nearly half of US COVID-19 cases in children have been confirmed in the last 4 weeks. Still, while some school-related activities and sports camps were happening over this time frame, this was before most schools actually reopened; once they do, these numbers may end up looking small. In places where they have reopened, we have read about high schools, middles schools, and kindergartens shutting down, quarantining massive number of students, or further delaying reopening due to large numbers of exposures to the virus and increasing numbers of confirmed cases among students and staff. This is mirrored in other places where young people are together en masse. University of North Carolina at Chapel Hill has switched entirely to online classes (and now Notre Dame and Michigan State) for the semester due to multiple clusters of transmission on campus, and we have read reports throughout the Summer of camps closing due to massive outbreaks among campers and counselors.

More to the point, I see this all the time. I’ve evaluated hundreds of patients for COVID-19 over the past several months, and there has not been a strange, unexplained phenomenon of patients not getting sick from their kids. I know there are some people who will never believe in COVID-19 transmission in children from studies in Korea that demonstrate thousands of cases; so I’ll just tell you now, I’ve personally seen many people who got COVID-19 from their children. We’ve seen children stay with cousins who tested positive, and then bring the infection to the adults and other children in their own household. We’ve seen families of 5 or 6 all test positive for COVID-19 after one of the children developed symptoms first. I haven’t seen any teachers get COVID-19 from a student; but I don’t think any of our local schools are actually open at this point. But transmission from children is happening and has been happening, and as much as we all wish against it, there is simply no chance that we won’t see community transmission clustered around schools once they are reopened.

Yeah, but children aren’t at a high risk from COVID-19, right?
The inevitable questions is, so what? Aren’t kids immune? Or if not immune, at least far less susceptible to COVID-19 than adults? To some degree, the answer is “yes, thank God.” If this were the Spanish Flu of 1918, which disproportionately killed children, our society would not even be dreaming about reopening schools. As a parent of four small children, the fact that children are relatively safe from the virus has been the main reason I have felt comfortable seeing large volumes of patients with COVID-19-like symptoms daily over the past several months. As we discussed in the article addressing the America’s Frontline Doctors video, and again when discussing misinformation around COVID-19 and Human Trafficking, we don’t actually know the exact mortality rate among children. We do know it is much lower than for other groups.

My 5 year old son is 64x less likely than me to die from COVID-19, and 12,364x less likely to throw out his shoulder playing catch.

We also know it is not zero. While 20 of the states included in the latest analysis by the CDC reported zero child deaths, the rest reported at least one, and the mortality rate was as high as 0.6% in confirmed cases. The state with this frighteningly high mortality rate? Texas. Now before we break out our calculators and start to panic at the realization of what a 0.6% case fatality rate in children means, this is definitely an outlier (and I believe drastically overestimates the actual infection fatality rate in children), and of course it only includes identifiable cases; this mortality rate still cannot account for asymptomatic cases or minimally symptomatic children who don’t get tested. Nevertheless, not-zero multiplied by a lot is still a lot, and there is reason to expect that the 400,000 child cases of COVID-19 in the US so far may soon be a drop in the bucket. Some of the children who become infected over the coming weeks and months as schools reopen will, in fact, die, and for many of us who are affected by these deaths, this pandemic will no longer seem to have miraculously ‘spared children’ the way it has over the past 6 months with schools closed and children mostly kept at home.

But more importantly, death rates do not tell the entire story. While we have seen few child deaths, we have seen many children hospitalized for COVID-19, and an analysis of hospitalizations published just last week reveals that out of all hospitalized children with COVID-19, about one-third require ICU level care (though require mechanical ventilation far less frequently than adults). There are many ways to explain and understand this data, some of which are included in their analysis and some of which aren’t; but their conclusion is 100% spot-on:

“Children are at risk for severe COVID-19. Public health authorities and clinicians should continue to track pediatric SARS-CoV-2 infections. Reinforcement of prevention efforts is essential in congregate settings that serve children, including childcare centers and schools.”

Dr. Lindsay Kim, et. al

Finally, at the risk of sounding like a broken record, we aren’t actually most worried about the kids. If you look back at the chart from the CDC above, the groups that we are worried about most are the ones who are 1,400 times, 3,500 times or 10,000 times more likely to die from COVID-19 infection than school age children; their older parents and grandparents. Without any conclusive evidence that children ‘can’t spread the virus’ and more than enough compelling data that they can, we have every reason to believe that the population at greatest risk from reopening schools will be the grandparents of school-age children, not to mention older parents, teachers, and educators. As a society, we are now in the impossible position of choosing whether our children will forego being educated, socialized, fed, and nurtured inside of schools or whether they will be exposed to a deadly virus (soon, two deadly viruses; flu season is coming) that they can bring home to vulnerable family members.


Is it worth the risk?

Answer: I have no idea.

Child abuse
So we know that the COVID-19 pandemic is going to get worse when schools reopen, but we don’t know by how much; and the other side of the equation is the risks associated with not reopening schools, which go far deeper than a semester or two of stymied educational attainment and missing out on the various intracranial and orthopedic injuries associated with high school sports (yes, I was on the Quiz Bowl Team. How did you know?). Since the beginning of the pandemic and the early closing of schools, cancelling of Summer programs and camps for children, and other mitigation measures that meant keeping children within the confines of their homes and family circles, we have been talking about, writing about, and worried about the possibility of child abuse and neglect going up during this crisis, especially when combined with unemployment, increased stress and anxiety, and grief related to the pandemic. And while this has been written about extensively by child advocates and physicians (like myself) who are also very concerned about the very real threat of COVID-19, it has also been used, similar to the issue of human trafficking, by people whose only real goal has been to diminish the threat of the virus and fight against any and all mitigation efforts.

So let me be clear. There is something gross and disturbing about people who have done everything within their power to make the pandemic worse, from neglecting social distancing to spreading misinformation and fighting against mask wearing, now saying that it is the people with legitimate epidemiological concerns about reopening schools who don’t care about child abuse. If it weren’t for people like this, we would be in a position to reopen schools much, much more safely and mitigate both threats more effectively. I deal with child abuse and its ramifications every day of my life; people don’t get to use it to try to give their deliberate pattern of denialism and irresponsibility throughout this pandemic the moral high ground. Reopening schools in the middle of a pandemic is an incredibly complex and difficult decision; but we are in this position, at least partly, because of them.

Well, so much for not getting myself into trouble.

The question of child abuse during the pandemic is one that remains unanswered. We all intuitively feel the danger of having children at home more and not having teacher’s eyes on children, especially in the midst of all the other risk factors we mentioned above. We all know of cases where a teacher or other educator has been the key person to report an abusive or neglectful situation and allow social services to intervene; I have seen this happen myself. But the idea that keeping children home from school will lead to a drastic rise in missed child abuse cases may overestimate the efficacy of the systems we have in place to report and investigate child abuse under normal circumstances. An in-depth article from The Marshall Project provides a careful analysis of the dynamics of mandated reporting, and while I think this is still an essential function of teachers, articles like this one from Mother Jones that list the huge drop-off in reports of suspected child abuse following school closures in March may be engaging in sensationalism; the vast majority of calls are not found to represent confirmed child abuse or neglect, and saying that, for instance, Illinois officials “received 6,672 reports of abuse in the week before the governor’s order to close, and 3,675 in the week after” does not mean that 2,997 abused or neglected children were missed.

There’s a balance here; early detection is the key to protecting children in child abuse situations, and there have been some reports by ER physicians that while the numbers of children presenting for child abuse are going down, the cases they do see seem to involve more severe or extensive injuries. Intuitively, we may believe that this is because of school closures… But most of this pandemic has so far taken place during months when schools would have been closed anyway, and it seems every bit as likely that the worsened severity of these child abuse cases is due to the other pressures of the pandemic not related to schools, like stress and anxiety and economic hardships. As the article above points out, we saw similar increases in child abuse severity during the 2008 recession even without school closures. Moreover, the long-held belief that child abuse peaks at all times children are home from school – the Summer, Christmas break, etc- seems to be a myth, and we are left to conclude what we really should have known already about the causes of child abuse; that they are complex. Blaming school closures for child abuse ignores this complexity in favor of a narrative that only seems to make the decision to reopen schools easier.

Other risks to children due to school closures
I have a friend who spent his entire Fall and Summer, before leaving a few weeks ago for Physician Assistant school, trying to get food to thousands of children who normally rely on school breakfasts and lunches for a substantial part of their weekly nutrition. I should note that he was working with an organization; he wasn’t just making tons of sandwiches and then driving around handing them out across Texas and Louisiana. Without people like Dustin and organizations like Texas Hunger Initiative, many of those children would have faced significant nutritional deficits throughout this pandemic, and many children across our country don’t have access to programs like this. Moreover, school is not just a center of learning; many essential services such as counseling, speech and physical therapy, and support for learning disabilities and learning disadvantages occur within school walls. Moreover, the families who have least need of these services and the least reliance on school lunches are also the families that are most likely to have educational books in the home, stable internet and redundant internet-capable devices that can be used for distance learning, and other privileges that allow them to engage with learning resources regardless of the status of in-person school. The real threat to education posed by the pandemic isn’t the risk of students missing a year of school across the board (what, are we trying to beat the Russians to the moon?), but the risk of perpetuating and amplifying educational disparities.

But to make things murkier still, those are also the same students that are themselves most likely to become seriously ill from COVID-19, and whose parents and grandparents are at the greatest risk from the pandemic, due to healthcare disparities that often cut along the same racial and socio-economic lines as educational disparities, due to the same historical, systemic injustices. I hope you didn’t come here for answers; it really feels like we are stuck between a rock and a hard place, and the only certainty is that the families and children in our society who are already the hardest pressed on all sides at baseline will suffer the most dire consequences from whatever decision we make. Trying to correct this and share our portion of the burden should be at the forefront of whatever policies or personal decisions we make going forward.


What can we do as parents?

Be responsible
I hesitate to put this one first because I realize it might sound accusational. Please look at the section heading; ‘what can we do as parents’; please understand that I’m including myself in this category (since I am not an educator or a society) and preaching this mini sermon to myself as well. Nevertheless, this is not an admonishment but a plea, to all of us, to take this virus seriously. As a primary care physician who sees many children, I have some version of this conversation a few times a week:

Me: Good morning, tell me what brings you guys in today.
Parent of child: The school called this morning and said he had a fever of 119.
Me, panicky: Wait… 101.9?
Parent of child: Right.
Me, less panicky: Whew… Ok, so when did his symptoms start?
Parent of child: He started with a cough 3 days ago and felt warm last night, but I didn’t have a thermometer. They checked him at school today and called me.

As a parent I’ve done this myself; not just misspoke and said the wrong temperature because I had been up with a fussy child all night, but also sent my child to daycare or school because I didn’t really believe they were sick and I was able to rationalize away their symptoms. I’ve received that phone call before; your 2 year old has a fever at parents-day-out, your 5 year old threw up at Vacation Bible School; come and get your child. And the thing is, out of anybody, I should really have known better. But some children have minor coughs and off days so often that under normal circumstances playing a game of chicken with the symptoms and letting the school or daycare be the ones to make the final call that they are really sick is understandable. Not justified, but understandable.

These are not normal circumstances.

As parents, now is the time to take those minor symptoms more seriously and call your PCP or bring your child to their doctor for milder symptoms than you might have otherwise; or even just to keep them home for a day and monitor their symptoms to see if they really do develop into something serious. This is especially important if your job provides sick days or personal days and you have HR policies and supervisors that don’t penalize you for actually using them, which is a privilege so many people simply don’t have. A certain percentage of those runny noses and mild coughs are going to be COVID-19; better my child stay at home and me call in sick, than him give it to a classmate whose parents’ only option when he becomes ill is to leave him with a grandmother already in poor health. As a community, we have to take the responsibility of protecting other people’s children, and families, as seriously as we do the responsibility of protecting are own; and the time to start that is right now.

Consider alternative schooling/home schooling/schooling at home
Homeschooling has always involved a good deal of privilege. I say that as someone who homeschooled until 8th grade, whose wife was homeschooled through highschool, and who(se wife) currently homeschools our children. We did not grow up wealthy and my mother enjoys working (and started working again once we had graduated), but my parents made more sacrifices than I realized at the time to allow her to stay home and teach us, and I’m incredibly thankful for that. Most of the homeschooling families I know (and we know a lot) are not wealthy; keeping one parent at home to teach means financial hardships they wouldn’t have to bare otherwise. And the sacrifices aren’t just financial; my wife has left hobbies unpursued, books unread (and unwritten, if I could ever get her to write that series of children’s books), and a nursing career she loves temporarily on hold, all to teach our children at home.

But the fact that we can choose to make those sacrifices in the first place represents an awful lot of privilege, and there are many, many families for whom homeschooling is just not a viable option. Under normal circumstances, homeschooling is a hard decision for us. We believe in the public school system, and we realize that keeping our children at home means our voices aren’t contributing to the PTA, advocating for issues at the local elementary school or before the school board, or supporting the teachers and students and families that our own children would be interacting with every day. We try to be involved in and advocate for our community in other ways, but there’s no denying that we are less effective in this by homeschooling. It also means that our children miss out on opportunities to show love and kindness to people outside of their family circle every day. Sure, I guess there’s a possibility that my 8 year old would be the Regina George of the local 3rd grade or my 5 year old would be the Flash Thompson of Kindergarten, but I have enough pride as a parent and faith in my kids that I think it more likely they’d be an influence for good than otherwise. I think it’s fairly certain that somewhere in town an 8 year old is deprived of a best friend because my daughter is doing school at home with us.

So far we still feel that that’s the best decision for our family, but it’s definitely an ongoing discussion each and every year. But right now, with COVID-19, the privileges inherent in schooling at home can actually be used on behalf of the other children and families, and the teachers, at the local schools that our children won’t be attending. Each child that can safely be kept at home and successfully educated this year through distance learning or homeschooling makes it that much easier for teachers to maintain social distancing in the classroom, that much safer for teachers and other school staff in terms of transmission risk, and that much less likely that other students will become infected and bring the virus home to parents and grandparents. This year, at least, homeschooling was an easy decision for us; and if you have the resources, financial and otherwise, to successfully school at home for a semester or a school year, this is definitely the year to give it some careful consideration.


What can you do as an educator?

I just want to say, at the outset of this section, that I think that asking teachers and school principals to do the work of epidemiologists and government health officials and keep children safe from the virus is pretty lame. I am sorry that you are in this position; I hear your stress. I taught high school physics and physical science (and theatre!) for 8 months after college, and realized it was not something I was good at and certainly not something I could do for the rest of my life; I admire anyone who does it, and particularly anyone who does it well. When I left teaching to go to med school, I knew on some level that I was signing up to be on the front lines of any global pandemic that might happen to come our way; but when you became a teacher, you weren’t. So even though this shouldn’t be your job, I’d like to share some advice for how you can help keep yourself and your students, and their families, safe. Being months late with this post, I’m certain that any educators who might read this are already far along in the planning and implementation of their COVID-19 response plan, and those who have reached out to me have shared incredible, creative ideas to keep themselves and their students safe that I never would have thought of.

Seek counsel
A physician friend and residency classmate reached out to me in May when her child’s school asked her to give recommendations on reopening school safely. At the time we were operating under the assumption that the pandemic would be well in hand by the Fall, and that the biggest concern would be preventing a second surge. Clearly, this is no longer the case. Nevertheless, we brainstormed on the best and most practical ways to reduce transmission between students while interrupting their education as little as possible. We had ideas for reducing transmission during PE, music class, alternatives to all school assemblies, managing bathroom breaks and lunch and hallways during class changes. I briefly considered sharing a big list of ideas here, but the reality is that the changes that would help will be different for every school, every building and class schedule, and every situation. You know your school, I don’t; your ideas will be better than mine. And better still will be your ideas with the input of a physician or epidemiologist or other medical professional who has an intimate understanding of infection control and viral transmission and who takes the pandemic very seriously. Reach out to one in your community and ask them for help; they have a vested interested in keeping your school safe, even if they don’t have a child that attends there. Most would be honored to help with this work (and would be even more honored if you then actually followed their advice!). This works best as a two-way conversation; the medical professional is going to see opportunities for changing processes and physical spaces and creating a safer school that wouldn’t occur to someone without their education and experience; and you, the educator, are going to be in a position to tell them which of their ideas will work for your students and your classroom, and which need to be modified or scrapped. Then, when things have calmed down and we’ve finally got this virus under control, you can reach out again to seek their advice on deescalating the measures you’ve put into place and slowly returning to normal. And then later in the year when you need someone to speak to your students about going into healthcare at the next career day, guess who you are gonna call…

Get clever
As I’ve worked on this post, I’ve heard from teachers whose schools have implemented some incredibly clever and ambitious ideas. I’ve been told about schools keeping kids in cohorts throughout their entire daily schedule, even organizing sports activities and lunch and recess around these small, consistent groups. I’ve heard of multi-grade classrooms to keep siblings, cousins, and neighbors together, limiting the network of contacts per child. I’ve heard of classroom modifications, curriculum changes, changes in sports schedules, and restructuring of school-wide events. I’ve also heard of schools that are doing next to nothing (besides enforcing stricter social media policies for teachers), and teachers who are scrambling to keep their own classrooms as safe as possible within a school that is essentially denying that any danger exists. I’ve even heard of teachers taking a break from teaching this year because they couldn’t see any way to keep themselves, aged parents, or at-risk household contacts safe while being in the classroom every day. As a society, there is no denying that we’ve failed these teachers.

The classroom or school-wide plan that protects children from getting and spreading SARS-CoV-2 better than any other plan in the country is probably not “just keep children 6 feet apart,” “put up plexiglass between desks,” “masks at all times,” or “check temperatures at the door,” though it almost certainly will include some of those components. No, the best plan has probably already been devised by some creative, well-informed, scientifically minded out-of-the-box thinker somewhere. With any luck, it has been listened to and implemented; but unfortunately, too often it will probably be ignored by decision makers for being too weird or wonky, too conceptually challenging, or too inconvenient to implement. But now is exactly the moment that we need those creative and wonky ideas, because the stakes are too high to just hope it goes away if we can just ignore it hard enough.

Can your track or cross country team set up a Fitbit team challenge instead of practicing together after school?

Can you use pegboard and cardboard and printouts (that you’ll have to buy yourself, I realize) mounted on the walls of your STEAM class to make an interactive workspace that keeps students facing toward the walls for most of the class period instead of toward the teacher or across a table toward each other?

Or better yet…
Also, is this me? I pulled this image off of google, I don’t remember this at all, and I didn’t wear glasses at that age… But from this angle I feel like there’s still a good possibility that that’s me.

Can you recruit that pop culture savvy AV kid (this is an oxymoron; none of us AV kids are pop culture savvy) to create some awesome Cast of Hamilton style video mash-ups so that your Zoom band rehearsals are Youtube worthy instead of unmitigated disasters?

If this is your music class, I’d be willing to substitute.

Can you use your school’s external doorways and internal layout to create a continuous one-way circuit during classroom changes, like Sylvester McMonkey McBean’s star belly tattoo machine?

Bad social distancing there in the middle, but pretty good otherwise.

I don’t know. Some of those ideas are probably things you’re already doing, or that you’ve already thought of and abandoned because there was just no way to make it work at your school or in your class. That’s my point; decreasing transmission right now is going to mean sound epidemiology principles combined with creative teaching ideas and applied to your individual teaching situation. Even for those schools that are very well prepared already, we have to keep in mind that no battle plan survives first contact with the enemy; once schools do reopen, one size fits all solutions or rigid adherence to plans made over Zoom during the Summer are likely to mean insufficient protection and excessive interruption of learning if they aren’t reevaluated and readjusted. It’s a lot, I know; but all of us fighting to stop misinformation and promote mitigation efforts and health behaviors that would have slowed the virus have, so far, pretty much failed; so now it is apparently your problem to deal with. You need bold strokes because we’ve failed to convince more folks.

Advocate, advocate, advocate
Me using my blog to tell educators to advocate for each other, their students, and their communities is like hospital administrators pulling doctors aside to tell us how to treat patients (oh wait, that happens literally every day); this is clearly something you are already doing and is, in fact, a major part of your job. Nevertheless, this is now a more important job than ever, because there are so many stake-holders when it comes to reopening schools and not all of them care about the health of your students or their families.

In a moment we are going to talk about what the rest of us can and should be doing to support you during this time. Please keep lending us your voices. I know it feels like society has decided to ignore the collective and individual voices of teachers (I’m a doctor who writes a blog on medical misinformation; trust me, I feel you), but without understanding what’s happening in your schools and classrooms the rest of us have no hope of advocating for you in the ways you need most. We want to help. If your school has enforced social media policies that don’t allow you to say when you are concerned about the safety of your colleagues or your students, find ways to get that information out there anyway. Be sources of good health information and fight misinformation in the classroom every day. One thing I’ve heard from teacher after teacher is that their students have been amazing; wearing masks at a high rate without grumbling or complaining, practicing good distancing in the classroom, and in general being the best of us in taking the pandemic seriously. That is going to fatigue over the next few months without your example and reinforcement, but you are in a much better position than any of the rest of us to help lead this generation in doing the tedious day-to-day epidemiology work that we, their forebears, have failed at.


What can we do as a society?

Fight the virus on every possible front.
If I had written this post a month ago when I should have, I’m sure I’d be saying that the best plan to reopen schools safely would be to spend the next month doing everything in our power to decrease community transmission, and then only reopen schools once we knew it was as safe as we can reasonably expect (for a more epidemiology minded discussion of what that would look like, check out Waco Epidemiologist Emily Smith’s post on “Can we open schools safely?“). In fact, this is still what I think, and if I thought there was any chance of getting it to work, I would be strongly advocating for schools to delay reopening while mitigation efforts were redoubled. In cities like my own, where our testing positivity rates have been steadily declining over the past several weeks, this might not even take that long. But if we’ve learned anything through this pandemic it’s that we cannot rely on strategies that require small individual efforts but a large degree of buy-in. So here we are, with schools reopening in the midst of a pandemic, and bracing ourselves to see how much worse it will get as a result. But as one comedian said, I guess all the bad decisions we’ve made up to this point have made this a good one?

But even if school reopenings aren’t going to be delayed until a set community prevalence or test positivity rate is reached, we can still make every effort now to decrease transmission, especially with a few weeks still to go before all of our schools are opened. We need to be practicing good social (physical) distancing and mask wearing. We need to be participating in the work of informing our own contacts when we are diagnosed with COVID-19 since our public health sectors simply have not had the manpower to keep up. We need to practice diligence in our personal mitigation efforts, even though we are all incredibly fatigued from thinking about this virus and how it has affected our lives. As a society we claim that the safety of our children in schools is one of our highest priorities, and we take massive steps to protect them. Yes, I know there are some pretty obvious areas where we haven’t been taking common sense measures to keep kids safe in schools, but we do a pretty good job of slowing down to 20 MPH and putting down our cellphones when we drive through a school zone, and we make sure kids have those safety scissors that won’t actually cut anything just to reduce the chances of one of them losing a finger. Right now, the efforts you can make to reduce community transmission- social distancing, washing hands, getting tested if you are ill, and wearing a mask- are the efforts that will keep children, their teachers, and their families safe in the coming weeks.

What even is this?

Extend Trust
We’ve talked a lot about the role of educators and parents in fighting the virus and keeping our schools safe, but the reality is that those groups are limited in the actions they can take, with freedom from judgement and repercussions, without buy-in and affirmation from the rest of us. It’s well and good to tell parents to keep their child home for a day when they think she might be getting sick, but this requires policy changes that refrain from punishing parents for taking such a responsible action and trusting them to occasionally know, without a doctors note, when their child is too sick to come to school. Yes, that trust will be taken advantage of by some families, nobody knows it better than me; but right now I have visits every single week where parents know their child just has a mild illness and shouldn’t be in school, but had to come to the doctor to get a note for school and work; in the eyes of the school and their employer, they are guilty of faking an illness until my note proves them innocent. In the midst of a viral pandemic is exactly the time to reevaluate the wisdom of such policies and return that trust back to parents; and then keep it that way, because even aside from COVID-19 this dynamic is already dangerous during every single flu season.

Also, let’s get rid of perfect attendance awards.

Lower Our Expectations

And the same is true for our expectations of our teachers and school administrators. Being a high school physics teacher was my first real grown up job, and being a doctor was my second. There are plenty of similarities between the two, but one of the most salient is the constant feeling of being asked to do increasingly more with an ever decreasing amount of time and resources. As a primary care doctor, this often means walking out of one patient room and into the next from 8:00 to 12:30 and then from 1:00 to 5:15, providing extensive evaluation, compassionate listening, diagnosis, treatment, and teaching to each patient within a 10-15 minute window, and being expected to complete the documentation and respond to phone messages and refill requests in the often non-existent minutes “between visits” (we often don’t have time to go to the bathroom or get a drink of water “between visits”). As a teacher, it meant trying to make it through more curriculum than could possibly be covered in a year, prepare students for standardized testing, regulate behavior in the classroom, navigate and manage the interpersonal dynamics and conflicts of 13 years old, and provide counseling and interpersonal support for young people in some of the most formative and challenging years of their lives. Oh, and submit grades, which is just… I think I’ve still got some ungraded quizzes in a manila folder somewhere, and I haven’t taught since 2009.

Add to all of that the expectation that teachers will now be fighting COVID-19 transmission on the front lines of the pandemic and, somehow, teaching both in-person and online classes simultaneously, and you’ll realize what a sick joke it is to say that any adjustments we make to our expectations would be “lowering” them. We are asking so much of our teachers, and this year we are asking even more; we need to be comfortable, as a society, with accepting that less can be expected in terms of our students’ educational progress between now and May 2021 compared to years past and years to come. Somehow, in all of these discussions about reopening schools, I’ve missed all of the articles calling for a hiatus on standardized testing (or at least eliminating punitive measures related to those test results), on colleges using alternative evaluation methods for graduating seniors, and on discussions of exactly what percentage of the standard curriculum we expect teachers to be able to cover this coming semester; 50%, or just 35%? Rather than lowering our expectations, what we would really be doing is finally valuing teachers’ time and acknowledging their efforts, and recognizing that since most teachers are already working at maximum capacity as-is, we have to be willing to let something go when we add something on. If we are saying that schools need to be reopened because it is necessary to keep kids safe, detect cases of domestic violence early, and keep children from regressing academically, we need to realize that those goals do not logically imply that we can also somehow expect teachers and students to maintain the same pace of academic attainment, and that that is no longer our primary goal in reopening schools.

Be ready to pump the brakes
I think this is the biggest one, and it’s going to take an awful lot of honesty when we look at the epidemiology data that emerges over the coming weeks and months. As schools reopen around the country, we have to fight stronger than ever against misinformation. We will hear that any increase in cases is due to increased testing, even if it is mirrored by an increasing test positivity rate and hospitalizations. We will be told that the overall mortality rate is dropping and it “isn’t as dangerous as we were told,” because the virus is less dangerous for children than older adults, and seeing a decrease in the overall infection mortality rate is a natural artifact of an increasing number of cases in children and adolescents- even as teachers, school staff, and family members of students are hospitalized and die due to those exposures. As flu season approaches, we will be told every possible version of doctors lying to diminish the flu and inflate the pandemic or misattributing flu deaths to COVID-19 to hurt the economy or this or that politician, as though it mattered which preventable deadly respiratory virus your family member died from.

We have to be willing to cut through the noise and look carefully at the trends in cases in our community and ask continuously whether the risk is still justified today. It would be great if I were completely wrong, if cases continued to decrease even when schools start back in earnest; but it’s hard to imagine that happening, and the decisions are likely to get even more difficult, not less, from here on out. We need to drop our agendas and our egos and our politically motivated methods of interpreting data and meet the emerging information with intellectual honesty. We need to consider school closures and audibles and readjustments as the necessary and humble work that the pandemic requires of us, and work together to keep our kids, our teachers, and our communities safe.

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