COVID-19

If I Can Be Safe Working as An ER Doctor Caring for COVID Patients, We Can Make Schools Safe for Children, Teachers, and Families

By AMY CHO

We need to stop arguing about whether schools should reopen and instead do the work to reopen schools safely. Community prevalence of COVID-19 infection helps to quantify risk, but reopening decisions should not be predicated on this alone. Instead of deciding reopening has failed when an infected student or teacher comes to school, we should judge efforts by our success in breaking transmission chains between those who come to school infected and those who don’t. We should judge our success by when we prevent another outbreak. We should pursue risk and harm reduction by layering interventions to make overall risk of transmission in schools negligible. This CAN be done, as healthcare workers all over the United States have shown us. Unlike politics, we should avoid thinking this is a binary choice between two polarized options. At the heart of these decisions about tradeoffs should be the assumption that the education of our children is an essential, public good.

I advocated for school closures in March. We had little understanding of the risks and transmission of COVID-19 and faced massive shortages of personal protective equipment (PPE). The closures were a blunt force instrument but bought precious time to learn and prepare. Pandemic control, by flattening the curve and buying time for discovery of more effective therapeutics, care and a vaccine, remains a critical tool to save lives. But COVID-19 will not be eradicated. We must come to terms with the reality that COVID-19 will circulate among us, likely indefinitely. Shutdowns slow spread but at a great cost, disproportionately paid by vulnerable groups including children, women, minorities, and those with the least financial resources. Getting children safely back to in-person school should be among our highest priorities.

Hospitals never considered closing. As healthcare workers, we cannot physically distance from patients. We watched in horror as hot spots like Bergamo suffered high nosocomial and staff infection rates as they were quickly overwhelmed. In response, we worked tirelessly and collaboratively to protect one another while continuing to provide care.

The good news is that we seem to have learned how to prevent in-hospital transmission of COVID-19. A recent study showed that at a large US academic medical center, after implementation of a comprehensive infection control policy, 697 of 9,149 admitted patients were diagnosed with COVID-19. But only TWO hospital-acquired patient infections were detected. COVID-19 is not “just the flu,” but it isn’t Ebola either. I no longer worry that I will become infected with COVID while working in my emergency department. It is not easy, comfortable nor cheap, but a bundle of universal masking and eye protection, appropriate PPE use, sanitation, improved room ventilation, and protective policies have proven effective at preventing in-hospital outbreaks. 

While necessary in the spring, school closures were devastating. As a mom of four young children, I can tell you that education cannot be replicated in a virtual format for most young children. Stable high-speed internet and devices are minimum requirements, but far from sufficient. Parents, disproportionately women, spend entire days helping children navigate clunky technology. We spend maddening hours badgering our young learners to join up and engage while we struggle to keep younger siblings from distracting them. Getting our own work done at the same time is impossible. And these are challenges faced by parents who are able to telecommute. It is telling that, even with the best resources to meet the challenges of virtual school, the most privileged families are forming pods and hiring private tutors or enrolling in private schools.

The challenges faced by those without financial means and other advantages must be overwhelming. Can you imagine being a single parent, unable to work virtually, and trying to get your 2nd grader to do their online school while you are at work? Without reliable internet or devices? Without the benefit of English as your first language? There are data showing that 90% of high income students accessed online learning versus just 60% of low-income students. Low-income families are not lazy. They do not value education less. But they lack the privilege to demand better or to pay for something better. We are failing these children by not reopening the schools.

The harm caused by the continuing loss of in-person instruction will be, like many aspects of the pandemic, hugely disparate. We absolutely need to offer high quality virtual options for families at the greatest risk from COVID-19. But, for many children, virtual learning will mean a year without learning — a lost year that will widen the enormous gap between the privileged and the disadvantaged. The impact of the loss of education may follow these children for a lifetime as the cost of these inequities could compound over the years. 

Six months into the pandemic, we know a lot more about COVID-19, and we should know better than to sacrifice in-person school simply because it is the easiest solution for pandemic control. We now understand that there is heterogeneity of risk for transmission and serious illness. Instead of using community spread as a trigger to close schools, communities should identify the threshold at which other high-risk, non-essential adult recreational activities and venues, like indoor bars, should be closed. Measures should protect the most vulnerable and be layered on to reduce cumulative risk. Schools can adopt much of what was done in hospitals. Cohorting and encouraging employees to take sick leave has helped. This can be done with students and teachers too. Adherence to universal masking, even of people without symptoms, has proven critical to interrupt transmission chains among workers and between patients and workers. Eye protection adds another layer of defense. Negative pressure ventilation allows us to safely perform high-risk aerosol-generating procedures without becoming ill ourselves. Negative pressure would be difficult to implement in schools, but improved ventilation and air filtration in schools could provide similar protections. Identification of an effective, protective bundle of measures that reliably prevents outbreaks will enable kids to stay in school rather than suffering a disruptive revolving door of quarantines.

School staff, like health care workers, are essential. We must provide them with money, expertise, and resources to optimize air quality in buildings, make space for distancing and provide adequate PPE and sanitation. They deserve maximum protections. It is possible to make in-person school safe again, and we should neither deny the risks nor descend into nihilism. Our communities should come together to do what it takes to prevent the collapse of education. Failure should not be an option. 

Dr. Amy Cho, MD MBA is a practicing emergency physician, policy and legislative advocate, and mom of four young children. This post originally appeared on LinkedIn here.

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5 replies »

  1. “So things are much different now, but then I also have massive amounts of staff support and our network is willing to spend the money to make us safer.”

    That’s what’s different about schools that can’t be compared to Hospitals. Hospitals were already geared for infection control in a controlled, closed work place before covid and they have way more money than our defunded public schools. I’m not so worried about the younger students, it’s all students with the potential to take covid home to their families and the teachers who have no control.

    As for risk, no one knows the risk as there is no wide spread contact tracing and testing with varying community adherence to compliance.

  2. I do OR and ICU. We did a couple of tracks on Covid puts in th last week, and while these are considered high risk procedures I felt pretty safe. But then I had a lot of Hazmat training and did some teaching in the military. Like a lo to fuss I was worried since I didn’t know what we were facing when this started in March. Now we know what to expect. At first we weren’t sure we would have enough PPE and equipment was always tight. Now we mostly are OK.

    So things are much different now, but then I also have massive amounts of staff support and our network is willing to spend the money to make us safer. Schools don’t have that support, they don’t have the training and i have ni idea where the money is coming from. The wife and I have helped with our speech and debate team for years. When we go to the poorer, rural schools a lot of them are in poor condition. Where are schools going to get all of the personnel to help when teachers need to stay out? Are teachers going to be pressured to not wear masks? That is my bet.

    Going back to school is important for our kids. Agree on that. It could be done safely, if we had schools take it as seriously as they should, but they won’t.

    Steve

  3. Peter — Nationwide, Catholic school enrollment declined from 5.2 million in the 1960’s to 1.7 million today. The reasons include: families having fewer children than 50 years ago, the drastic decline in the number of nuns which necessitated a steady increase in tuition as they were replaced by lay teachers, which, in turn, meant more parents could no longer afford to send their kids to Catholic school and middle class families moving out of cities to suburbs with decent public school systems. None of that has anything to do with COVID-19. The vast majority of Catholic schools that existed last year still exist this year while a few have closed. I repeat that around here, the Catholic schools are open for in-person learning while many public schools are not.

    As for air filtration, better air filters are not that expensive. I could upgrade the air filter in my house for less than $100. It doesn’t involve completely revamping or replacing the HVAC system.

    We can’t expect to reduce COVID-19 risk to zero before determining that it’s safe to reopen schools. In a bad flu year, we’ve had up to 61,000 deaths including many children but we don’t shut everything down.

  4. It’s interesting to note that here in NJ the Catholic schools, which must satisfy customers who pay tuition, are largely open for full time in person learning and doing fine so far. The public schools are mostly using hybrid systems meaning open a couple of days a week and virtual on other days or they are completely virtual. The teachers unions don’t seem to want their members to return to work unless the perceived risk of getting COVID-19 is at or near zero. In the meantime, besides hospital workers, police, fire, and sanitation workers along with bus drivers and subway employees plus grocery clerks, truck drivers and others continue to show up for work every day.

    Virtual learning is not a very good substitute for in person learning even for kids from relatively prosperous families. For low income kids, it’s a disaster. We need to make accommodations for teachers who are older or have diseases and conditions that make them especially vulnerable to contracting COVID-19 but the vast majority of teachers and other school employees need to return to work. In school buildings, ensuring that the air filtration system is rated at least MERV-13 or higher would be helpful and reassuring to both employees and students.

  5. “As a mom of four young children,” “the most privileged families are forming pods and hiring private tutors or enrolling in private schools.”

    Were your kids enrolled in private or public school? Are you one of the “most privileged families” above? Would you send your kids back to public school?

    I think you’d be right if Trump had done what was needed back in March, even February, as we now know he knew the truth about Covid then. But the administration has failed to contain the virus sufficiently to make schools safe, let alone any other gathering of people. Why would we trust the safety of kids wearing masks when it’s possible their Republican parents don’t wear masks. Many universities tried opening, but shut quickly after their students could not resist a party atmosphere to spread covid. I don’t think it will be any different with other schools.

    And who’s going to pay for all of your ideas, especially in defunded public schools?

    I agree with your measures for schools, but only if those measures are being used by the entire community.

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