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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