Tag: other covid-19

“TJ Webb, nice to meet you”

I’ve actually been thinking about this particular blog post for a while. Ever since I took on the role of being a clinic lead for our system’s very busy outdoor COVID-19 clinic about 6 months ago, I’ve been seeing multiple COVID-19 positive patients, face to face, 3 to 5 (sometimes 6) days a week. Unlike the very high volume, rapid turnover testing-only strategy that is so important from an epidemiology standpoint, these were real medical visits; I heard about my patients’ symptoms and exposure history, we discussed risk factors, we checked vital signs, and I listened to their hearts and lungs. When we needed them, we got blood work or EKG’s, or if the patient was pregnant, listened to the baby’s heartbeat.

COVID-19 is a stressful thing to be seen for, and patients very frequently need more than just a targeted physical exam and a test result. At each visit I provided reassurance, and careful instructions for quarantine or isolation as their clinical situation demanded. I told my patients not to be afraid, and then we discussed what vigilance demanded and a detailed discussion of the signs and symptoms that should lead them to seek further care or go to the emergency department. Sometimes these visits really only lasted 5 or 6 minutes; sometimes they lasted 15-20.

I don’t have an exact count, but I’ve done around 1,500 of these visits since the pandemic started.

Masks are very, very good at preventing COVID-19 transmission, and my N-95 and faceshield are a powerful combination; but they are not perfect. Besides, we know that masks are better at protecting against lower velocity respiratory droplets and work best when worn by both parties. Many times my patients were coughing and sneezing, and some simply couldn’t tolerate wearing their mask for our entire visit because of their shortness of breath or other reasons, so we relied entirely on my own PPE, and the outdoor setting, to mitigate the risk of that face-to-face visit. I knew this would be the case sometimes; it’s the nature of the job.

Because of this, my wife and I have more or less treated my getting COVID-19 as an inevitability (it wasn’t actually inevitable, but it definitely felt that way). So when I recently joked darkly on facebook how nice it was knowing that “if I join the 1,700+ American healthcare workers that have died from the pandemic so far, my $300,000 of med school student loans are non-transferrable to my wife and 4 children,” and then in a blog post on not going home for the holidays said, “My PPE game is strong” and “I’m really, really good at being cognizant of fomites and at personal transmission control,” anybody with even a small amount of Genre Savviness could have told you what would happen next.

Sure enough, following a night of fever and chills and a morning of coughing, sneezing, sore throat, and headaches, I finally tested positive for COVID-19 yesterday afternoon. As someone who diagnoses and treats COVID-19, who writes about COVID-19, and now who has COVID-19, I thought my perspective might be helpful to others, and today I’d like to write about what I will and won’t be doing over the coming days and weeks (specifically as it relates to my diagnosis; nobody wants to read about my Mandalorian costume 3d printing).

5 things I’m not going to do now that I have COVID-19.

1. I am not going to Panic.

One of the biggest communication challenges I face on a daily basis is helping patients understand that a virus like COVID-19 or seasonal influenza can be extremely deadly and devastating in aggregate, but not necessarily dangerous for a particular individual. There are pitfalls on either side; if my patient erroneously believes that there is a 100% chance the virus is going to make them so ill that they end up in the ICU, they will spend the following days and weeks in fear and anxiety, less capable of navigating their symptoms and more likely to over-utilize an already strained emergency medicine system, and easier prey to those profiteering off of the pandemic by selling unproven pharmaceutical and wholistic ‘cures’ (including, sadly, at least a few doctors out there).

But if my reassurances cause them to believe that the virus isn’t dangerous, as many people do despite a now insurmountable accumulation of evidence to the contrary, not to mention the lived experiences of our friends and neighbors, there is a risk that the rest of my cautions and teaching about transmission control will go unheeded.

We will look at the numbers in a moment, but this is the most dangerous virus in our lifetimes. The risk an illness presents to a community is based both on how dangerous each individual case is and on how many people contract it. So while any particular COVID-19 case is more dangerous than the flu but far less likely to lead to serious disability, life-long suffering, or death than a case of say Ebola, it is much, much more contagious and will therefore make up the ground easily. And we do not share the burden of risk equitably. We know that the risk of a serious illness and death is greater for those above 50 and far greater for those 65 and older. We know it is greater for those with chronic medical problems, especially those affecting the heart and lungs, multiple medical conditions, and compromised immune systems. But these biological factors are not the only ones at play; people are also more vulnerable if they are part of a marginalized community, and have worse access to healthcare, preventative health, and affordable nutrition. We know they are more vulnerable if they are non-English fluent and therefore have a harder time navigating intricate healthcare systems or having their symptoms and questions understood in a busy clinic or emergency room. We know the poor, especially, bear a greater burden of illness in all diseases, and despite talk of COVID-19 being ‘the great equalizer’, equality just isn’t something American healthcare has been setup to deliver.

I am a white male doctor, 35 years old, in pretty good health, with excellent food access, living in a town with a dozen clinics and two hospitals where many staff know me by sight. I have all the advantages in the world when it comes to surviving this. With COVID-19, sometimes all of that isn’t enough, and we can’t predict and don’t really understand why some healthy young people develop incredibly severe symptoms and die despite our best efforts. But it is, relatively speaking, rare. So I’m not really afraid of this infection for my own sake, but I am taking it deadly seriously because among the many people I love and care about are those who have fewer or none of the privileges I do. And even among those few who are actually at lower risk that me- those who are younger, healthier, and whiter I guess- they are still at some risk, and those characteristics and the privilege they represent are not a perfect protection against this pandemic. So for all of those people, I will be staying home for the next 10 days at least.

2. I’m not going to take unproven medications (and I could get them if I wanted to).

One of the main reasons I have chosen to write about being diagnosed with the virus, instead of just quietly continuing to nitpick viral videos, is because this is really my first opportunity to put my money- or my health- where my mouth is. I’ve been writing about the dangers and sheer impracticability of physicians prescribing unproven treatments like hydroxychloroquine and budesonide since May. Now I have to put those reflections into action, and the outcome will affect myself and my family.

There is a tough kernel of suspicion in the minds of many people that when the doctor tells you there isn’t a specific medicine that will treat your illness, it really just means there’s not a medicine we are willing to give to you. Many people really do believe that there are special treatments reserved only for those who are ‘in the club’: doctors and their families, VIP’s, the wealthy, and those with excellent insurance. If you are a person of color in the US, or belong to any other group that has been marginalized and continues to experience systemic discrimination, there are even good historical reasons to struggle with this suspicion and to find it hard to trust the medical field in general; and not just the Tuskegee Syphilis Study, though it remains the most notorious example. For people with this shared cultural narrative, taking a quick look in my medicine cabinet at home, or those of any of the physicians I have treated for COVID-19 during this pandemic, to see that we are taking the exact same medications and treatments we are offering to our patients may be a good start to dispelling this particular myth; but rebuilding broken trust obviously takes a lot more than that.

I know literally hundreds of doctors; I’ve been learning with them, training with them, and working alongside them for the last decade and a half. This creates a great amount of potential for privileged healthcare access, which we have to be cognizant of and intentional not to abuse (and which is not fully cancelled out by the fact that we are, as a profession, notoriously bad at setting aside time for our own physical, mental, and emotional health). Most of those doctors believe exactly as I do about unproven treatments not supported by evidence; but not all. Even if it took a few phone calls, I could probably find a doctor willing to prescribe me budesonide, hydroxychloroquine, systemic steroids, azithromycin; any or all of the ‘silver bullet’ medicines (besides bleach) that have been touted by viral video doctors convinced by confirmation bias, selection bias, conspiracy theories, and negligible sample sizes.

Why am I not? For the same reasons I haven’t prescribed them (except when they are indicated, like my COPD patients who were experiencing an exacerbation and needed a course of prednisone) for those 1,500 or so patients who have entrusted me with their care during this crisis: Because there is no evidence that they work.

Instead I’m going to do three types of treatments, all of which I recommend for my patients.

• Medications I am already taking.
  • Unless specifically recommended by your doctor, you should not discontinue the medications you need for chronic medical conditions. Although it’s always a good idea to revisit your medicines with your PCP and make sure you still actually need them, especially if you are on many medications per day.
• Medications to alleviate my symptoms.
  • I take fluticasone and cetirizine for sinus congestion and allergies, and recommend them to my patients when they have similar symptoms. I like guaifenesin for chest congestion, and tylenol and/or ibuprofen for headaches, body aches, and fevers. I may call my doctor’s office and ask for some tessalon perles if this cough get’s any worse, though that medicine doesn’t work for everyone. None of these will cure the virus, but with any luck they will make the next week or two a lot less uncomfortable. Before starting any prescription or OTC medication, check to makes sure it doesn’t interact with your other meds and isn’t contraindicated because of a chronic health condition; your PCP is happy to help you with this.
• Non-pharmaceutical supportive care treatments.
  • One day I’ll get around to writing a blog post titled “Your Physician is also a naturopath.” Despite claims that doctors want you ‘locked inside your house’ for the entire pandemic, I encourage my patients to get plenty of sunlight and as much exercise as they can tolerate with their symptoms; just not to do it around people they could infect. We have the privilege of a backyard; for those who don’t we talk about how to be outside but safely distanced while you are under isolation or quarantine. We are also going to talk about the need for additional rest and fluids. If you have a sore throat, we touch on judicious use of chloraseptic spray; but I really emphasize hot water or tea with plenty of honey. I might recommend a nasal decongestant, but I also talk with my patients about safely using a Neti Pot or saline rinse, as long as they don’t have contraindications (and don’t use tap water). I take a multi-vitamin daily and eat a balanced diet, but as long as they aren’t taking amounts that could be toxic or being taken advantage of with expensive, high-profit-margin products, I don’t give my patients any pushback on taking additional vitamins or immune supplements. My recommendations regarding alternative health treatments that don’t have solid evidence are these; they should be safe, they should be affordable, they should not interfere with your evidence-based medical care, and if at all possible they should have a plausible mechanism of action that actually relates to your condition or symptoms. That covers an awful lot, and anybody who claims to be helping you but fails those criteria is probably, quite literally, trying to sell you something.

3. I’m not going to get bored of isolation and decide it’s ok for me to stop early.

That first part is a lie; I’m definitely going to get bored of isolation. I’m strongly extroverted and I’ve been terribly bored of socially distancing for months now. I absolutely love being at home with my wife and four children, it’s my favorite place to be in this present world (besides the Bua Thong “Sticky” Waterfall near Chiang Mai, Thailand); but after 10 days I’m going to be dying (Editor: probably a poor choice of words) to spend an afternoon sitting outside at a coffee shop, or go for a trail run in the park instead of doing laps in our small back yard.

Nevertheless, I’ve heard too many stories of people who decided that since they were asymptomatic or minimally symptomatic, or because they had reached day 6 or 7 and felt better, that their COVID-19 infection didn’t count and they were the exception to those pesky CDC guidelines. Who did I hear these stories from? Mostly from the people they had infected. As much as certain people make ‘freedom’ their rallying cry and rail against so-called draconian restrictions meant to decrease transmission of the virus, the truth is we are pretty much free to follow the guidelines given to us by our doctors and by public health experts, or not, to whatever degree we choose. As much as people talk about the specter of government tyranny related to fighting the pandemic, there really isn’t much we can’t do. I got diagnosed with COVID-19 yesterday, and I could have sat inside at a restaurant or a bar last night; nobody would arrest me. I could sit inside at my favorite coffee shop all day today, and publish this blog entry about me having COVID-19 while sitting there, coughing and sweating and with a hoarse voice, and it’s still extremely unlikely that anyone would say anything to me. Why don’t I? Because of this:

Because with all of that freedom comes responsibility, and because the number of family, loved ones, friends, and neighbors, co-workers, and patients we each lose during this pandemic, which is now in it’s darkest hour, depends on how seriously we each take that responsibility; how deeply we feel the true gravity of our own actions. We are living right now in the failures of our society to do just that. I don’t claim to have been perfect over the past 9 months; but every single one of us needs to stop and honestly consider if there is any area of our lives where we can make different choices in the coming weeks and months to try to prevent even more loss of life.

4. I’m not going to Church.

Our church, Mosaic Waco, has done an amazing job of meeting safely throughout the pandemic. We have “Drive-In Church” in-person but outside and socially distanced every other week, and staff members, volunteers, and congregants consistently wear masks. Our pastors and other leaders have sought out and listened to the wisdom of epidemiologists, physicians, and other experts, especially those who are brothers and sisters in Christ, and understand acutely the difficult balance of goods in deciding how best to gather as believers. They have rightly considered responsible transmission control measures as an essential part of our responsibility to love our neighbors during a pandemic.

All that said, I skipped last week. We were having Drive-In Church and I had signed up to serve, but we were beginning to see signs of illness in our family, and our policy has been to exercise an abundance of caution when it comes to the health of those around us. I’m skipping this week too, obviously, though we are going to continue to attend online. The worship band probably can’t manage without me running the slides, poor things, but the pandemic demands sacrifices of us all.

I bring it up because there has been a popular and persistent narrative that has invaded the Church in America that choosing not to meet in person, or humbly following expert and even pastoral advice for social distancing and masking, is somehow a betrayal of Christian values; even when failing to do so is potentially dangerous for those we name as brothers and sisters and claim to love. We are commanded in Matthew 10:16 to be as wise as serpents and as harmless as doves, and seldom has the interrelationship between these two concepts been as obvious as during a viral pandemic, when our ability to be do no harm to those around us is predicated so strongly on the amount of wisdom we practice, and the amount of wisdom we are willing to receive from experts. Attending your local church in-person, and particularly indoors, when you are ill, under quarantine, or have other reasons to believe you might be at risk of transmitting the virus is as unwise and harmful as it is unloving.

5. I’m not going to make my experience normative.

We’ve talked already about all of the privileges I personally have facing this illness. Except for my age and a minor medical problem or two, it would be hard for me to be at lower risk from this virus. And even though I can’t perfectly predict what will happen, statistically I’m probably going to be fine.

And that’s great, but it does leave me open to a big temptation that I have seen so many people fall into; taking the anecdotal experience of one or a handful of people and using it to dismiss the suffering of millions, including 290,000 of our neighbors who have died in the last 10 months. After each warning, each exhortation to take action now to prevent more disease and death, you will inevitably see someone comment “I had COVID and I was fine.” And we are glad for that, but me or you feeling well and having a mild course of illness says absolutely nothing about the experiences of others. Even deeper than the flawed logic at play here and the willful disbelief and disregard of physicians, nurses, EMS workers, respiratory therapists, and all the others who have shared their own and their patients’ experiences with this crisis, this view betrays a deeply seated arrogance; believing that our own personal experiences are somehow more real than the suffering of our fellow human beings, or the grief of their loved ones.

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5 things I am going to do.

1. I am going to take precautions in my own home.

The very first question I get from almost every parent when they are diagnosed with or even tested for COVID-19 is, “what about my children.” I’ve had the opportunity to talk with hundreds of patients about what is an extremely personal and complex decision; how much to isolate and distance from their own children if they have the virus. Thankfully, this conversation gets to start off with one piece of very reassuring data; while children have become very ill and died from this virus, it has been rare, and children and adolescents seem to be the people in our society least likely to experience a severe course of COVID-19.

Nevertheless, the risk is not negligible and it should not be ignored. The degree of caution each of us needs to follow in our own homes when diagnosed with COVID-19 depends on many factors; the ages and developmental ages of our children, how much they depend on us for their daily needs, their individual personalities and the ways they experience love and closeness, the available space in our homes, and the amount of support we have, among others. I have a lot of privilege in a lot of these areas, particularly in having a spouse who takes care of everything with the kids by herself for 50+ hours a week at baseline. If we chose to go the route of many doctors and other healthcare workers early in the pandemic and I moved out for 2 weeks, she would make sure that they didn’t lack for anything except actual time spent with their father.

We have decided not to go this route. Instead, we’ve taken these precautions:

• I am wearing a mask when I’m in close proximity to my family.
• I am washing my hands obsessively.
• I am not letting anyone drink after me (if you have kids, you know exactly how difficult that can be).
• I am not kissing anybody (if you have kids, you know exactly how difficult that can be).
• I am not preparing food (much to everyone’s relief).
• They are strictly quarantining; groceries delivered, no visitors, no birthday parties, no trips to the store or quick stops for coffee.

These decisions become even more challenging when you are caring not for a healthy child, but for an aged parent or a chronically ill or immunocompromised loved one. Again, these are difficult decisions, and we each have to decide for our own families what is the right balance between the need to protect them from the virus and their need to be near us and receive our love, affection, and care in person.

2. I am going to keep fighting for my patients.

Most (though not all) of the misinformation I write about here on the blog contains at least a nugget of truth. Those who have said for the past 10 months that the measures we have adopted to fight the virus are worse than the virus itself couldn’t be more wrong; but they are right about the added dangers of interruptions to care, decreased access, and postponing medical visits, which have all been secondary effects of the pandemic. We’ve been working hard for months (and in the early days of the pandemic were literally working around the clock) to make sure our patients could still get the access to care they need. Even so, it continues to be a struggle.

Having your primary care physician out for 10 days, isolating due to COVID-19, is a huge barrier to care; and it would be even if we had primary care doctors to spare, which we definitely don’t. There are some services or interventions I provide that only a handful of our doctors are trained to, and there are patients whose situations and histories I know all the details of, and even with good medical documentation it would take another clinician a lot of additional work to be brought up to speed with them. There are also patients who simply prefer their doctor and are slow to seek help or accept guidance from any other, which says very little about me personally as a physician but an awful lot about the inestimable value of carefully built, mutual trust and respect at the core of the doctor-patient relationship.

So I’m doing what every other doctor I know does when they are sick: in between naps and bowls of chicken noodle soup, I’m making myself a nice hot cup of tea and logging onto our computer system remotely, responding to telephone calls, refilling medications, and following up on lab results, all trying to make sure my patients have access to equitable care and that the interruptions in that care because of my illness are as few, and as mitigated, as possible. I realize that sounds super braggy, but that’s not my point at all. My efforts are hardly heroic (I once watched a pregnant 2nd year resident in charge of the OB unit receive IV fluids for her hyperemesis gravidarum in between helping other women deliver their babies. I’ve got nothing on that); but I think it’s important that anyone reading this knows how deeply their doctor cares about them and how hard they are working on your behalf, even when you can’t see it.

3. I am going to notify my close contacts.

Done. Unless those close contacts don’t read this blog, of course, in which case they are on their own.

Actually, I’m incredibly thankful that I don’t have anyone to notify. I’ve alerted my teams both at my usual clinic and at our COVID-19 outdoor clinic, since we work together every day. We wear our PPE continuously in clinic, are seldom within 6 feet of each other and never for prolonged periods, and if we have lunch it’s outdoors and very physically distanced; I actually don’t count as a close contact for anyone I work with. We are watching my children and wife for symptoms, and have notified a few people that she has been around out of an abundance of caution even though they also don’t count as ‘close contacts’ by the CDC guidelines. Other than that we don’t have any phone calls to make. It’s a good feeling and I highly recommend it.

4. I am going to finally replace the HVAC ductwork under the house.

Not COVID-19 related, but I’ve been promising to get it done for weeks. Check back with me after isolation and I’ll let you know how it went. #fakenews #misinformation

5. I am going to makes plans in case things go bad, and go to the hospital if my symptoms get severe.

I know this is a two parter, but it’s short and I really wanted to keep the symmetry of ‘5 things I won’t do/5 things I will do’. Back in March when videos began to circulate from overwhelmed hospitals in Italy and France and Katie and I first began to grasp the gravity of the situation, we made a few arrangements. We knew I would be on the front lines one way or another. I made sure she had all of the account numbers for retirement accounts (she handles most of our finances anyway, so bank accounts weren’t an issue), the password to access my life insurance policy, etc. We talked carefully about those non-transferable medical school loans that would be discharged in the event of my death, and about being on guard against predatory offers to “refinance” loans which should, in fact, simply disappear. We talked about burial arrangements and funeral wishes, and how we would want to be remembered to our four young children if we passed. I gave her my list of top 10 guys she was allowed to marry after an appropriate mourning period. We finally got around to making a will.

I also made e-mail addresses for each of our kids for when they are older, and began to send them the occasional note or letter, letting them know just how much I love them and delight in seeing who they are now and the wonderful people they are becoming.

Now that I actually have the virus, we are revisiting these items, I am writing to my kids again, and we are making sure everything legal and financial is hammered out just in case.

The fact is that we expect me to be fine, but we’d be extremely foolish not to take this illness seriously; many younger and healthier people than me have died from it already. I’ve been giving people guidance about what to watch for at home for almost a year now; chest pain, significant shortness of breath, confusion or altered mental status, severe fatigue and malaise, low oxygen levels (we’ve reclaimed my pulse oximeter from our 3 year old’s Doc McStuffins doctor bag), or any acute worsening in overall status. For once in my life as a doctor I’m going to follow my own advice and treat my health seriously, and I’ll be heading in to the ER for further evaluation if I experience any of these symptoms.

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Final Thoughts

Doctors and nurses know they are going to get sick; it’s practically in the job description. We have the incredible privilege of taking care of people on some of their best and some of their worst days, but that also means continuously getting coughed or sneezed on, being exposed to contagious illnesses, and occasionally, despite our best efforts, being exposed to a blood-borne pathogen. When it’s a known entity we are familiar with and have been fighting for years, the uncertainty following those experiences is less hard to bear; and honestly after 10 months of this pandemic, having COVID-19 doesn’t feel much different than any of those other old enemies, even if the ‘what if’ factor is a little higher.

I know this post will be met with sympathy, and I truly appreciate everyone’s thoughts and prayers; but I hope the main take away for anyone who reads this rather long-winded announcement of my illness is that what we are doing to care for our patients and asking of each and every person we diagnose with this terrible virus are the very same things we ask for, and demand of, ourselves. If you or a loved one gets diagnosed, I hope you will have symptoms as mild as the ones I am currently having- a little fatigue, a little cough and sore throat, a few chills- hopefully even milder, or none at all. But I also hope you will be just as cautious as we are trying to be; taking the risk of transmission very seriously, communicating with those whom you might have unintentionally exposed, and respecting isolation for you and quarantine for your close contacts as a measure that can absolutely save many, many lives. I hope you are not afraid, and I hope you have all the information and support you need from friends, neighbors, and especially your local doctor.

And to the 300,000 people in this country who have died of this awful virus, the tens or hundreds of millions who have lost loved ones, family, and friends to it, and the 15 million others who have suffered from it physically to one degree or another, I am incredibly grateful to have had the chance to fight it with you and to walk through it alongside so many of you, and wouldn’t change any of that just because of this admittedly mild illness I have now; whether it gets worse in the coming days or not. I’m looking forward to doing it again, as soon as I meet the CDC criteria to do so.

-TJ Webb, Patient

This is a short post because, frankly, I don’t have time to write it (clinic all day, D&D with the kids tonight). Those of you hoping for another 7,000 word in-depth discussion (read: nobody) will have to settle for just 3,000 or so today. Nevertheless, I want to start with a digression and show you this chart I use in my clinic:

This chart is for my diabetic patients who have a very particular treatment regimen; they are taking both a long-acting basal insulin once or twice daily, and they are taking a short or rapid acting insulin before each meal. Because of this, we need some blood sugar numbers; we need to know their fasting blood sugar in the morning so we can adjust their basal insulin, and we need to know their numbers 2 hours after breakfast, lunch, and dinner so we can adjust their meal coverage with the short acting insulin. They are not taking insulin on a sliding scale; those patients will need to check before meals in order to take the appropriate dose.

Now, I work extremely hard to empower my patients to adjust their insulin on their own, and a lot of our visit time is focused on teaching them about the various insulin length of action times, the logic behind basal/bolus insulin dosing, and especially what numbers to look for that should trigger them to increase or decrease their dose. But it’s challenging, and as much as I love it when a patient is on ‘auto-pilot’ with their insulin, we still do a lot of adjusting in clinic, which is where these charts come in. Fasting blood sugar high? We’ll go up on your long-acting Lantus insulin. Taking 5 units of novolog before every meal but the after-lunch numbers are still super-high? We can go up on your pre-lunch and keep the pre-breakfast and pre-dinner numbers the same. You get the idea.

So that’s the glucose log I print for my patients. Now let me show the one I actually hand to them:

You see, like all doctors my approach to any medical problem represents a balance between what my medical training tells me is the best possible treatment plan and the actual, lived experiences of my patients. Some of my patients will check their blood sugar 4 times a day, every day (some of them even if they don’t strictly need to; they just really, really like to know). But I don’t think I could manage to do that, and so I don’t ‘demand’ it of my patients. The reality is, we could get almost all the information that the patient and I need by checking their blood sugar half that much; fasting every day, then checking after a different meal each day. And most of my patients are much, much more likely to follow through with checking twice a day than four times a day (as I certainly would be).

What does this have to do with the quarantine recommendations for COVID-19? Everything, because both the CDC’s new guidelines and my approach to blood sugar logging for my diabetic patients are based on an essential mediator of medical outcomes: Health Behavior.

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Where did the original 14 day guidelines come from?

The CDC began to recommend a 14-day quarantine for international travelers coming to the US as early as February, and the same for any household and close contacts of COVID-19 positive persons shortly thereafter. This was based on the incubation period of the virus; the range of time it typically takes an exposed person who becomes infected to develop symptoms. Initially this relied on the already known incubation periods of similar novel Coronaviruses, SARS and MERS, from epidemiology studies that were done following those epidemics in 2003 and 2012. As the COVID-19 pandemic progressed, studies began to emerge which showed similar incubation periods for the SARS-CoV-2 virus as well. A study from The Netherlands in February found the incubation period to be between 2 to 11 days based on a small number of patients in Wuhan, China; very similar to SARS and especially MERS. This was supported by multiple other studies that all showed an apparent incubation period somewhere in the range of 2-12 days.

This begs the question, “if most studies showed the incubation period to end at 10 to 12 days, why were we all told to quarantine for 14 days?” And this is where health behavior comes in. The first (and least important) reason, I think, is because 14 days is just a lot easier to remember. “Your last exposure was last Wednesday, so you can be done with Quarantine after next Wednesday” is easier to remember than 11 days or 12 days because we naturally think in weeks anyway. But much more importantly, the novel Coronavirus was novel and recommendations needed to be made based on very limited evidence. The two studies above had sample sizes of 88 and 158 respectively; enough to be going on with, but not nearly enough to be really confident. Those studies consistently showed that though we thought the average incubation period would be 5-6 days, there was still a possibility that once we had more data it would end up being much longer; and there was a very good chance that even if the average incubation period stayed less than a week, some people would still be contagious for much longer, maybe even greater than 2 weeks. With a virus this contagious, ignoring that uncertainty could be very, very dangerous.

Hence the recommendation to be released from quarantine only once you have been asymptomatic for 14 days since your last exposure; it was easy to remember, it was very likely, based on early evidence, to cover the vast majority of cases (although it does absolutely nothing for fully asymptomatic cases, of course), and it was unlikely to be expanded based on new evidence.

That last bit is really important, because even though epidemiologists, physicians, and other scientists know that it’s exactly how science is supposed to work, we’ve all seen how suspiciously our society looks on any changes in recommendations based on new evidence. If the CDC started with 14 days of quarantine and later decreased it to 12, some people would be a bit irritated and probably lose some confidence in them (we’ve seen this time and time again; the undeserved “they keep changing the guidelines!” and “They don’t know what they’re doing!”), but overall it would be a welcomed change. But if they had started with say 9 days and then, based on new evidence, expanded it to 16 days, how would that have gone down? It would have been pandemonium.

So they picked a timeframe that was 1. Supported by the data available and 2. Unlikely to be expanded later based on new data. But there was still a problem, and it was this: Health Behavior.

14 days of quarantine is hard. It’s hard psychologically, it’s hard physically, and it’s hard economically. I see COVID-19 positive and COVID-19 exposed patients every day and I have to tell you, I feel terrible every single time I have to recommend a 14 day quarantine to someone. I see the irritation or frustration or even despair as they try to figure out what plans they have to cancel, what friends and family they will have to miss, and how they are possibly going to make ends meet if they can’t work for that long. The results of quarantine so often touted by the anti-quarantine, COVID-19 is a hoax folks, like increased depression and anxiety, are real. No one ever denied this, it’s just that the pandemic is not a hoax and has, as of today, killed 1.5 million people worldwide and 271,000 in the US.

And because it’s hard, every single one of us knows somebody who didn’t quarantine when they were supposed to. Unsurprisingly, that’s one of the main factors I see at play in my outdoor COVID-19 clinic visits; people were exposed to friends or family who had not reached the end of their quarantine period but decided that enough time had passed that they wouldn’t be at risk of spreading the virus. Based on what? Gut feeling, mostly; and also reaching the point where their desire for experiences or people or options precluded by quarantine was simply greater than their will to continue quarantine. For most of us, that point will probably come sometime before those 14 days are up. I even know of doctors who couldn’t make it to 14 days, and drawing on exactly none of there clinical training or basic sciences knowledge decided that they must have ‘dodged a bullet’ when they remained asymptomatic less than a week from their exposure, and resumed life as normal. Who am I to judge. I’m a strong extrovert and even general social distancing has been hard enough on me; there but by the grace of God go I.

And sometimes the guidelines, while valid, seem nearly impossible to comply with. For instance, I have friends who diligently completed their ongoing household contact quarantine guidelines, which begin on the day the COVID-19 positive patient is diagnosed and end 14 days after that person’s 10-day isolation period. That’s 24 days total for their household contacts.

This is no small problem; studies from previous epidemics requiring self-quarantine measures have found incredibly variable rates of adherence, and often south of 50%. In many ways America was a set-up for poor compliance to these guidelines; highly individualistic culture, a pandemic occurring in the most contentious election year in recent memory, massive campaigns (organized and unorganized) of misinformation about the virus, and with no clear messaging or leadership on a national level. Those last two points are crucial, because the strongest predictor for adherence is not cultural or socio-economic factors, or even fear of the virus; it’s how knowledgeable people are about the virus and the way it spreads, and how well they understand the quarantine guidelines. Which is, uh, why folks like me are doing this sort of thing.

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12/2/20: The CDC will update quarantine guidelines.

Which brings us to today, and the new quarantine options from the CDC, which are these:

Following close contact or exposure to COVID-19, an individual may self-quarantine for:

• 10 days, as long as they remain asymptomatic,
  or
• 7 days, as long as they remain asymptomatic and have a negative COVID-19 test.

Why were these changes made? Because they were wrong back in February? Because the election is over (finally)? Not at all. There are two possible reasons: either because enough new evidence has emerged to convince the epidemiologists at the CDC that these timeframes are as safe and effective as the original 14-day recommendations, or because they are convinced that enough people will actually follow through with these less extreme guidelines that there will still be a net decrease in transmission.

Let’s look at the first one. There have been nearly 14 million cases in the US since February and over 64 million world wide; even without access to complete information of each of these individuals and their exposures to COVID-19, we should be able to muster more than the 88 cases that first study was based on. Have all of the newer, more robust analyses of this data changed the picture of COVID-19 incubation so drastically that the CDC was forced to update their guidelines?

Answer: Not really.
It’s important to note that when the CDC did finally release the updated guidelines late in the night, they clarified that the new guidelines were alternative options to the 14-day quarantine, which was still their strongest recommendation. I believe this is supported by the evidence.

Just like there was nothing magical about day 14 that caused the virus to go, “all righty I guess we’re done here, pack ‘er up boys!” back in March, there’s nothing magical about day 10 or day 7 now. A systematic review and meta-analysis of all the then available estimates of the COVID-19 incubation period, first published in The British Journal of Medicine in August, found an average (mean) incubation period of 5 to 7 days, and 95th percentile estimate between 10 and 14 days…. Remarkably similar to the earlier estimates. The figure below is from that paper and reflects the distribution in all of the studies they could get their hands on. Notice how there isn’t a steep drop off at day 10; in fact, the range of the possible incubation period stretches all the way out to about 3 weeks. Unlike the early observational studies, this meta-analysis involved multiple studies with hundreds of cases each, though that original data was still from early on in the pandemic.

Another meta-analysis from later in the year, first published in October in the online journal Current Therapeutic Research, included 18 studies representing 22,595 participants. That’s a lot more than 88. What did they find? The average incubation period was about 6 days. This paper was advocating for a much shorter quarantine, along with testing, similar to the new ‘7 days with a negative test’ recommendation from the CDC; tellingly, however, it only included analysis of the mean incubation period, not the range of incubation from those studies; it doesn’t address the impact of all of those cases that would cease quarantine on day 7 but become symptomatic within the next few days.

Finally, a relatively small but thoroughly analyzed study from Singapore including 164 cases from January to April and published in the journal Epidemiology and Infection in September shows some cases with an incubation period definitively longer than the 10 day mark set by the CDC, though they were relatively small in number. It also found that the incubation period does seem to be positively correlated with age, with the longest incubation periods among those in their 70’s and older.

To summarize, unless there is some big study that the CDC has access to and I can’t seem to find (and please send it to me if there is, so I can take this post down and not look like an idiot), the current evidence has not revised the known incubation period of COVID-19.

You can still develop COVID-19 symptoms
more than 10 days after your exposure.

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Q: So why the change?
A: Health Behavior

So if the CDC isn’t changing the quarantine guidelines because of some scientific breakthrough that has utterly overturned our understanding of the virus’s incubation period or the way it is transmitted, why make the change at all? Because the 14-day quarantine guidelines aren’t working; not because quarantine doesn’t work, but because people won’t do it. They are banking on the idea that enough people will be willing to comply with a less aggressive quarantine period that still covers the vast majority of cases (compared to a longer quarantine that very few people were willing to follow) to make up for the relatively few cases whose incubation period would have been longer.

I don’t know if they are right or not. Something’s gotta give, so I really hope they are. But overall I actually kind of like this new recommendation because it has the potential to change the behavior of one group of people that has probably been contributing to the pandemic numbers as much as anyone else; asymptomatic COVID-19 carriers who aren’t following quarantine at all. The biggest weakness with the 14-day quarantine was that there was no fail-safe built in for the people who just weren’t willing to quarantine. They might stay home from work or school for 14 days because they had to, but would use some of that time to shop, have parties, or engage in other activities that had a high likelihood of transmitting the virus. I don’t mean to imply it was all from selfish motivations; some people with much less natural laziness than myself probably just couldn’t cope with 14-days off, and have probably been using their quarantine to help others and do good deeds around the neighborhood, or volunteer more at their local church or community center. Good things in themselves, but still very, very dangerous when you have been exposed to a deadly and highly contagious virus. And like I said before, many others very understandably don’t have the margin to be out of work for that amount of time. The new guidelines are helpful because for people very motivated to stop quarantine after day 7, a test for COVID-19 now greatly increases the chances that we’ll catch their infection and modify behaviors that lead to transmission. Even if they weren’t following quarantine before that day 7 test, they might follow isolation guidelines if it’s positive.

We know that asymptomatic and pre-symptomatic people can still spread COVID-19, but asymptomatic testing has always been a double-edged sword. Very wide scale asymptomatic testing would be one of the best possible ways to catch and isolate cases early and really modify the course of the pandemic, and asymptomatic testing targeting people in essential services, like nursing home nurses and doctors, is the best way to prevent pre-symptomatic transmission among some of our most vulnerable populations. But in both of these situations, the test result always leads to either a neutral or a safer set of decisions; if asymptomatic people test positive, they isolate, while negative people continue their standard level of caution. If a nurse or doctor tests positive, she calls in; if negative, she continues to work.

But testing of asymptomatic people who have been exposed and are still under quarantine is completely different, because the test result now has two drastically diverging branches; not safer and neutral, but safer and less safe. If an exposed person does test positive, it is much easier for them to feel the weight of their responsibility to keep those around them safe from it; I’m sure anybody reading this who has tested positive remembers the moment they received that news, and remembers how real the need to isolate suddenly felt. But since they are already under quarantine, there is a very real chance that a negative test will give many people a false sense of security without actually guaranteeing that they won’t become contagious, and instead of continuing with the same degree of caution they are most likely to exercise far less. There are a hundred different cartoons online right now demonstrating this concept. I like this one because it feels like the person who wrote it really has a vendetta against somebody named Casey.

This is the reason my COVID-19 clinic has shied away from broadly testing asymptomatic close contacts; the value of that test can be a big positive or a big negative, and it entirely depends on what the person plans to do with that information. If they plan to quarantine well regardless of a negative and only want to know so they can alert their close contacts, that’s terrific; but I’ve talked with lots of people, patients of mine and otherwise, and even some healthcare workers, who were under quarantine due to close contact and planned to get tested so that they could go ahead and travel, throw a party, or go back to work early. A negative test, within the incubation period, cannot definitively make these actions safe, and depending on when in the incubation period, might be no help at all. That’s why I carefully counsel every patient about what to do with their test results, symptomatic or not, based on their clinical history. I’m not opposed to asymptomatic testing for exposed individuals; it just has to be accompanied by a very careful discussion of what the test can and can’t be used for.

With all of that in mind, if you are going to do asymptomatic testing for exposed close contacts, 7 days seems like a fair point to test. Again, it’s easy to remember; ‘1 week of quarantine and then get tested’. But more importantly, it’s past the mean incubation period; a test on day 7 covers the incubation period for most people who remain asymptomatic, and has a good chance of catching any pre-symptomatic patients with an incubation period up to day 8 or 9. Between that and of course testing the folks that do have symptoms as soon as they get them, that covers most people. And if that negative test does give a little false sense of security, it’s at a point in the timeline of their exposure where lots of folks are feeling ready to throw caution to the wind anyway.

It’s not perfect, but I wouldn’t call the new quarantine guidelines ‘misinformation’ either. It’s a calculated risk based on the expected health behavior of a population who is absolutely exhausted with this pandemic. I hope it pays off.

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So… What do I do then?

Adherence to quarantine is highest when people really have a firm understanding of the quarantine guidelines and the rationale behind them. The rationale behind this decision is that more people will comply with less extreme quarantine guidelines that are still, for the most part, safe. But it doesn’t mean I’ll be counseling my patients differently; I still want them to know that they could become contagious for a few days after that day 10, and that the negative test on day 7 is not a 100% guarantee. I want them to understand the incubation period of the virus and the extra caution they still need to take for those several days after their quarantine is technically over. When I’m writing school and work notes, if their quarantine period under the new guidelines has them going back on a Friday, we are going to push that back (with the patient’s permission) to Monday. When they test negative on day 7, I want them to know that they should still come back and get re-tested if they develop symptoms on day 11 or 12.

And that’s the advice I’m offering to you now. If you have a close contact and need to quarantine, try to make it to at least day 12, if not day 14, before releasing yourself if at all possible; or get tested on day 8 or 9 instead of day 7 if you can. Advocate for those around you by fighting for your right to ere on the side of caution, recognizing that the current guidelines are a compromise with the expected health behaviors of our society. A timely and hopefully effective compromise, but a compromise nonetheless. And just as you wouldn’t act like Casey and use a negative test on day 5 as an excuse to cast aside all precautions, so a negative test on day 7 should be treated as reassuring, but not foolproof.

But as for me and my house, we will quarantine for 14 days.

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.

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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.

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.

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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.

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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.

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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?

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?

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?

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.

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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.

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.