Issue 18: The School Problem
07.18.20 | They can't stay closed. They can't necessarily open, either.
Hello,
Usually about this time in the summer I see the first back-to-school-sale ads and get that little pit in my stomach: the first foretaste of fall. This week I got that pit again. It had nothing to do with the ads.
The Covid resurgence shows no signs of peaking yet — the U.S. cleared 70,000 new infections on Friday alone, nearly four times the daily average from June. A surge of deaths from the virus is slowly building across the South and West.
Heading into this rising challenge, the Federal response has fallen further into disarray and self-sabotage. This week White House staff and advisors staged a short campaign to undermine Anthony Fauci’s credibility, and blocked the CDC director from testifying to Congress about reopening schools; four former directors of the CDC issued an op-ed condemning the President’s undercutting of the agency’s guidelines last week on school reopening; a destructive turf battle between the CDC and Department of Health and Human Services erupted into the open over how to aggregate national data on Covid hospitalizations. All of this amid the announcement that the U.S. is set to pull out of the World Health Organization, which is undermining our ability to get information critical for preparing vaccines for the impending flu season — especially alarming since the worst predictions of the fall center around overlapping waves of Influenza and Covid.
So on the public health front, the outlook is steadily darkening for August into September. Just in time for schools and universities to reopen. Well, some of them, maybe. Several major school districts, notably Los Angeles and San Diego, have already decided to delay or cancel in-person education for the fall.
It’s an impossible situation: schools can’t stay closed, for the sake of children’s development and education, and because tens of millions of parents can’t do their jobs if their kids are stuck at home. But they can’t necessarily open, either. Not in this environment. Yes it’s true, other countries have reopened schools safely without their becoming major vectors of spread. What can these countries teach us about opening schools in the U.S.? Not much, frankly, because none of these countries tried to reopen their schools with anywhere near the amount of community viral transmission some places in the U.S. may be facing in the fall.
As I noted last week, schools don’t operate in a vacuum. They’re entangled in the social networks of every student’s parents, siblings, and relatives, the people those family members work with or encounter at work or at play; the families and other extracurricular contacts of every teacher, administrator, bus driver, lunchroom worker, custodian, and DARE officer (are those still a thing?) in the building. Infections will travel into and out of classrooms through all of those interpersonal connections, and the risk is proportionate to the amount of virus already circulating in the broader community. So reopening strategies that might be safe for Connecticut (where the test positivity rate today is 0.8%) could be courting disaster in Florida (where 18.1% of Covid tests are coming back positive).
I’m a parent to two young kids. I’ve been struggling to figure this out myself. This issue of the newsletter is about how I’ve been thinking through the school problem.
I’d like to take a moment of silence here for Rep. John Lewis, who passed away today at age 80.
[Kids “remote learning” with their parents. Haiyun Jiang for The New York Times.]
// In This Issue
Link Roundup
The School Problem
// Link Roundup
Vaccine progress: Good news on the vaccine front. Researchers led by the National Institute of Allergy and Infectious Diseases, with support from a biotech company, have developed a vaccine candidate (unromantically named mRNA-1273) that in a trial of 45 adults produced high levels of antibodies protective against SARS-CoV-2, with no severe side effects. A Phase III trial of the vaccine, which will involve 30,000 participants, is set to begin July 27th. If successful, the vaccine could be ready for distribution by the beginning of 2021.
— “An mRNA Vaccine Against SARS-CoV-2 — Preliminary Report.” Lisa A. Jackson et al., New England Journal of Medicine.Can you get it twice? A lingering open question about Covid surrounds the risk of reinfection. How long does immunity last? What happens if people contract it twice? The virus has now been circulating for long enough, and widely enough, that we’re starting to see scattered reports of reinfection. Here, one doctor describes his experience with a patient who he thinks was infected twice — the first time suffering only mild symptoms, and the second time suffering severely enough to require hospitalization: “the trajectory of a moderate initial infection followed by a severe reinfection suggests that this novel coronavirus might share some tendencies of other viruses such as dengue fever, where you can suffer more severe illness each time you contract the disease.”
— “My Patient Caught Covid-19 Twice. So Long To Herd Immunity Hopes?” D. Clay Ackerly, Vox.The scene in Houston: Covid-related hospitalizations have more than quadrupled in Houston, TX since Memorial Day. A recent note to staff at Lyndon B. Johnson Hospital, obtained by reporters, “said that the hospital had reached maximum occupancy in its Covid-19 units. That day, nearly 50 percent of the patients tested for the virus had it, more than double the rate from a week before. The hospital had run out of remdesivir, an antiviral drug that’s shown some effectiveness in treating Covid-19. And for now, all elective surgeries were being canceled to preserve bed and staffing capacity. There appeared to be no letup in sight; the note to the staff warned that the following day would likely be worse.”
— “Internal Messages Show Houston Hospitals in Covid-19 Crisis.” Charles Ornstein and Mike Hixenbaugh, Undark.Why we weren’t ready for Covid: This deep and worthwhile profile of the health response in Texas highlights a more general problem across the country — our chronic underinvestment in public health. Jeneen Interlandi at The New York Times notes that by the time Covid started surging in Texas…
Harris County as a whole was still reeling from a brutal few years: Zika in 2016, Hurricane Harvey in 2017 and a string of floods and petrochemical fires in the years since, including one so relentless that for a full week in 2019 you could see thick black plumes stretching across the horizon from almost anywhere in the county. [Umair] Shah and his colleagues were still grappling with the fallout from each of those catastrophes, plus endemic chronic illness in the county’s lower-income communities, a shortage of treatment for the seriously mentally ill (the county jail was the largest psychiatric facility in the entire state) and an uninsured rate of 20 percent that overlapped with and exacerbated everything else.
Shah and his team had not been particularly well armed for any of these fights. Decades of research shows that a robust national public-health system could save billions of dollars annually by reducing the burden of preventable illnesses and keeping the population healthier over all. But like most public-health departments across the country, Harris County’s was grossly underfunded. Shah likes to think of his fellow public-health practitioners as the offensive line of a football team whose fans know only the quarterback: clinical medicine. Except that when a football team has a great season, the owners continue to invest in the offensive line, recognizing that it is crucial to the quarterback’s success. “In public health we do the opposite,” he told me recently. “When tuberculosis rates decline or tobacco use goes down, we cut those programs.”
— “Why We’re Losing the Battle With Covid-19.” Jeneen Interlandi, The New York Times.
How the CDC got played: The Centers for Disease Control and Prevention carefully built a reputation for political neutrality. That left the agency defenseless against political manipulation and attack from within the government. Its advantage-turned-vulnerability is represented by the fact that the agency’s headquarters is in Atlanta, GA, not Washington, D.C.: “In a city that runs on handshakes, face time, favors, and gossip, the CDC’s absence puts it at a distinct disadvantage, former CDC and HHS officials acknowledged to STAT.”
— “The CDC Has Always Been An Apolitical Island. That’s Left It Defenseless Against Trump.” Nicholas Florko, STAT News.A double pandemic: The longer the Covid pandemic lasts, the greater risk we run of one or more other infectious diseases spreading out of control alongside, whether it’s an existing problem like measles or polio, or another novel virus. At The Atlantic, Ed Yong writes: “Covid-19 has made clear what happens when even powerful, wealthy countries are inadequately prepared for rare but ruinous events. Months into the pandemic, international alliances are strained, resources are diminished, and experts are demoralized. The longer this fiasco drags on, the more vulnerable America becomes to further disasters: inbound hurricanes, wildfires, and many other viruses that lie in wait.”
— “America Should Prepare for a Double Pandemic.” Ed Yong, The Atlantic.An opening for West Nile, Dengue: The fight against Covid has left health departments around the country unable to carry out their usual mosquito control efforts, leaving an opening for mosquito-borne illnesses like West Nile and Dengue.
— “Mosquitoes Flying Free As Health Departments Focus On Virus.” Anna Maria Barry-Jester and Lauren Weber, The Associated Press.A crisis of self-harm: The mental health challenges of this period have been hitting Black people especially hard, Sophia Tareen reports for The Associated Press, compounded by “a combination of stressors hitting simultaneously: isolation during the pandemic, a shortage of mental health care providers and racial trauma inflicted by repeated police killings of Black people.”
— “Pandemic, Racism Compound Worries About Black Suicide Rate.” Sophia Tareen, The Associated Press.Universal Basic Income: The Spanish government has launched the first-ever national experiment in Universal Basic Income, sending monthly payments of up to €1,015 (US$1,145) to 850,000 households. The policy was in the works before the pandemic, but the virus and the lockdowns accelerated the rollout.
— “Pandemic Speeds Largest Test Yet Of Universal Basic Income.” Carrie Arnold, Nature.Reading the Pandemic: Check out this fascinating 11-week syllabus for understanding society and disease, assembled by a team of public health historians and sociologists.
— “Pandemic Syllabus.” David Barnes, Merlin Chowkwanyun, & Kavita Sivaramakrishnan, Public Books.Seeing through the eyes of medical workers: I’ll close the link roundup this week with two remarkable collections of interviews with medical workers that I highly recommend. The first appeared late last month, summarizing a project by 40 physicians to interview each other in short bursts about their experiences of the pandemic. It includes a heart-stopping excerpt of a video interview between two doctors about the emotional strain. The second, which you can watch below, is a “documentary play” built from re-enactments of interviews with paramedics, nurses, doctors and other medical workers. It’s a stunning look into the lived experience of medical workers in New York around the peak of the pandemic here.
— “Doctors Are Covid’s First Historians.” Ron Suskind, The New York Times.
— The Line. Jessica Blank and Eric Jensen, for The Public Theater.
// The School Problem
My wife and I have two young kids, and both of us have been working full time from home without childcare since the start of March, so I especially appreciated this breezy in-house study conducted by two academics showing the impossibility of balancing work and family life under these conditions. The couple took shifts meticulously tracking their working hours and interruptions by their children, and found that while working, a parent could be expected to be interrupted “an average of 15 times per hour. The average length of an uninterrupted stretch of work time was three minutes, 24 seconds. The longest uninterrupted period was 19 minutes, 35 seconds. The shortest was mere seconds.” If you’ve ever wondered why this newsletter sometimes gets a little jumpy between paragraphs, well now you know.
It’s been stressful not to be able to focus on either work or on being with our kids, stressful to see them not being able to socialize much with kids their own age, and for nobody to have the space apart during the week to grow and explore and do their own thing. We recognize that we’re in a position of privilege to be able to work from home, and that many families are in far more difficult positions. But this is the vantage point I’m coming from when I’m thinking through school reopening.
As with so much in this pandemic, there isn’t a one-size-fits-all, binary solution here — there’s no reasonable universe in which all schools everywhere are either open or shut. But both the American Academy of Pediatrics and the National Academies of Sciences, Engineering, and Medicine have put out statements recommending that school reopening for in-person instruction be a priority, especially for younger children, and have provided guidelines on how to do so safely (read AAP’s here, and the National Academies’ here).
The immediate risk to younger kids (Pre-K to 5th grade) from Covid seems to be extremely low (though it’s still a risk), and the harm of keeping them out of school during prime years of socialization and learning is high — remote learning for young kids has been an abject failure. The balance starts to shift for older kids, with the Covid risk rising, and harm from missing a semester or even a full year of physical co-presence with their peers in the classroom is somewhat less (and risk of transmission to teachers is higher, too). And while it’s been pointed out that economically and socially disadvantaged students will be harder hit by schools going remote, it’s equally true that many of these same students and their families will be be harder hit by the virus if schools reopen.
The controlling factor is how much viral transmission is in the community around the school. The effectiveness of in-school precautions will be seriously undermined in a community with high rates of transmission. As a rule of thumb, New York State and California have set a threshold backed by epidemiologists: schools can reopen in communities where the test positivity rate is at or below 5 percent. Personally, I’ll be comfortable sending our kids back if the rate where we live is closer to 1 or 2 percent. Only two out of the country’s 10 biggest school districts are in cities at or below the 5 percent threshold. Nationwide, only 18 states currently meet this threshold, and given the rate of spread in the rest of the country it’s unclear how long even that will last.
The best single resource I’ve found for thinking through the school problem is this exhaustive research roundup from preventepidemics.org. They also have a more concise and extremely helpful FAQ here, including a resource on how to get kids to wear masks, and games to play with kids to help them keep 6 feet physically distanced (pdf).
There are some things we can feel pretty confident we know about Covid and kids, based on the research, and some very troubling unknowns. We know kids younger than 15 are much less likely to develop acute cases of Covid than are older children or adults. And kids seem to be considerably less likely to pass the virus on to adults, which is good news for teachers and parents both.
On the other hand we have no idea what the longer-term consequences of Covid infections are for young children, and given the virus’s propensity to damage organs all over the body, from the lungs, to the cardiovascular system, to the kidneys, to the brain, this isn’t an unknown that can be shrugged off. Exposing an entire generation of schoolchildren to a novel virus that could very well produce life-long disabilities is not a mistake you can undo.
On balance, then, in a community with low viral transmission (well below 5 percent positivity rate) schools should be able to reopen, and parents, students, and teachers should feel fairly confident returning to the classroom if the proper precautions are in place. The precautions tend to vary by age group, and I highly recommend checking out the AAP’s guidelines for specifics. In general, they include universal masking, physical distancing, spending as much time outdoors as possible, and breaking up cohorts to reduce the number of contacts between students and teachers. Oh, and no singing (yeah but seriously, no singing, indoors anyway).
But all of the talk about precautions is moot, because of course we’re nowhere near the 5 percent threshold in most of the country, and heading in the wrong direction, and the political leaders pushing hardest to reopen schools show the least commitment to either taking action to drive down community transmission or giving teachers and school districts the resources they need to open safely.
So, approaching the school year with uncontrolled viral spread across the country we’ve been driven into an impasse, thanks to “perhaps the greatest failure of presidential leadership in generations.” We can’t keep schools closed without inflicting an enormous amount of harm. It looks like we can’t open them without doing the same.
Thanks for reading as always, and if you’re just coming upon this newsletter for the first time, you can subscribe through the box below!