Thursday, July 9, 2020

Reopening schools (or anything else) safely depends on first containing the virus

If you have young children, you probably breathed a huge sigh of relief when the school year ended. For my wife and me, working from home while taking turns keeping track of our kids' various Zoom meetings and their teachers' creative class assignments (including science projects involving neighborhood nature walks and open flames in the kitchen) was an exhausting ordeal. Yet in some ways we were lucky; unlike many children who lost educational ground, our kids adapted well to online learning, and the older ones were able to help the younger ones stay on task when their attention spans faltered.

Surely, we expected, by the start of the school year in the fall, the pandemic would be under control.

Unfortunately, with less than two months until Labor Day, COVID-19 still very much has the upper hand in the United States. Although pockets of the nation (including the Washington, DC area) have successfully reduced viral spread, two-thirds of states have seen increasing case numbers over the past two weeks, driving new national record highs each day. Belying President Trump's contention that the rising numbers are solely the result of increased testing, the number of infected patients hospitalized and in intensive care units are rising overall and skyrocketing in several states, and the number of daily deaths, which had been trending down since mid-April, is also on the rise.

If you want to read about how the U.S. became an international outlier in the fight against COVID-19 and who is to blame, check out James Fallows' story in The Atlantic, "The 3 Weeks That Changed Everything," and Jonathan Mahler's profile of Michigan governor Gretchen Whitmer's response to the crisis in The New York Times Magazine. A recent JAMA viewpoint also explored four types of cognitive bias that drove poor policy responses: identifiable victim effect (responding more aggressively to threats to identifiable lives than to projected statistical deaths), optimism bias (assuming that the best case scenario is most likely), present bias (preferring smaller immediate benefits to larger future benefits), and omission bias (preferring that a harm occur by failure to take action than as a direct consequence of actions taken). Regarding the latter, the authors wrote:

Policy makers who do not advocate for increasing the ventilator supply, and clinicians who follow triage guidelines, may perceive that they are responsible for the [COVID-19] deaths. In contrast, responsibility is more effortlessly evaded for causing greater numbers of deaths through failures to enact policies that effectively suppress viral spread.

Omission bias explains why federal and state leaders moved heaven and earth to increase supplies of mechanical ventilators and hospital capacity, but dragged their feet on recruiting public health contact tracers, mandating mask wearing, and keeping businesses and schools closed where community spread of the infection remained high.

The American Academy of Pediatrics (AAP) published guidance for school re-entry that "strongly advocates that all policy considerations for the coming school year should start with a goal of having students physically present in school." On the surface, this guidance seems to support the Florida education commissioner's order that all public and charter schools open in the fall for in-person instruction and President Trump's recent declaration that schools will re-open nationally or forego federal funds. However, the AAP's president clarified that states should not force school districts to re-open where transmission of the virus is clearly out of control.

There is much that we still don't know about the contribution of school-aged children to COVID-19 spread and the potential risks classroom exposures to adult teachers, administrators, cafeteria workers, and janitorial staff (who will likely shoulder the additional burden of frequently sanitizing shared spaces). Guidance from the Centers for Disease Control and Prevention (CDC) and the public health organization Resolve to Save Lives combines the best science and common sense to provide schools with strategies to minimize risk when and if they hold in-person instruction. But as former CDC Director Tom Frieden and the Education Secretaries under Presidents Obama and George W. Bush wrote in an editorial today:

The single most important thing we can do to keep our schools safe has nothing to do with what happens in schools. It’s how well communities control the coronavirus throughout the community. Such control of COVID-19 requires adhering to the three W’s—wear a mask, wash your hands, watch your distance—and boxing in the virus with strategic testing, effective isolation, complete contact tracing, and supportive quarantine—providing services and, if necessary, alternative temporary housing so patients and contacts don’t spread disease to others.

I hope that all of my children can return to school in person in the fall. But if they do, I want it to be because elected representatives and public health leaders have taken appropriate steps to contain COVID-19 and make school environments as safe as humanly possible, not due to political pressure or reckless executive orders.