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Reopening schools must balance benefits, risks

The topic of return to in-person learning has been vigorously debated since the beginning of lockdowns last spring. As a physician, the spouse of a teacher and parent of children in public schools, I have the opportunity to view the current remote learning process from multiple angles. As I discuss school with patients and their parents in the clinic, see my wife struggle to connect with students in her online Spanish classes, and help my own kids navigate technology, I realize the data on distance learning don’t look positive.

Students are falling behind. The education gap is widening. Vital social services are lacking for vulnerable children. Students need more than academics — they need nutritious meals, access to health care, a stable and competent adult who can screen them for abuse and neglect, and role models to whom they can look for guidance. For the majority of our students, this occurs only at school.

Risk assessment is key to pandemic decisions. Public health officials, government leaders, education system leaders and front-line health care workers must consider risk outside our respective domains. Measurement of risk across domains is key to good medicine. If a treatment reduces risk of a heart attack but increases risk of liver failure, we use tests to screen for liver damage or employ an alternative treatment strategy.

Relative risk assessment should be applied in the context of pandemic policy. Early decisions were made with limited preparation, foundational data or prior experience. When businesses and schools closed in March, we were beginning to learn about the behavior of SARS-CoV2, the virus responsible for COVID-19 illness. The news from Northern Italy, New York City, Spain, and other large population centers was terrifying. The experience in these centers was initially applied to policy-making in disparate groups.

Seven months into our response in this country, we know more.

1. Children are less likely to become infected than adults, and infection is almost uniformly mild or asymptomatic in children and adolescents.

2. Children and adolescents are less likely to transmit the virus to adults outside their own home.

3. Super-spreader events account for most large outbreaks, and such events tend to be large gatherings, indoors, without masks, involving high minute ventilation activities (singing, yelling, exercise) in close proximity. Examples of such events include concerts, indoor sporting events and bars or dance clubs involving large crowds without physical distancing.

4. Testing, isolation and contact tracing are effective strategies to control outbreaks in micropopulations such as manufacturing facilities, universities, care homes and health care facilities.

5. Physical spacing, masks and sanitation strategies are effective means of reducing transmission in the indoor environment, including schools.

An educated analysis of current data does not suggest that children cannot infect adults — they can. The data do not suggest that reopening schools for in-person learning will have no effect on community transmission. However, results from Europe and several U.S. states are reassuring. Transmission in schools is manageable with modifications in attendance guidelines; good testing, isolation and contact tracing; and continuous data analysis with nimble policy changes. Jackson County Health and Human Services and our two hospital systems have made tremendous progress in this area over the past three months.

SARS-CoV2 vaccine development is progressing at an unprecedented pace, a truly remarkable collaboration in drug development aided by the National Institute for Allergy and Infectious Diseases. Like most new vaccines, initial data suggest significant barriers to broad community vaccination efforts. Most experts estimate that about 60% natural plus vaccine-generated immunity is needed to achieve “herd effect.” In typical years, less than 50% of Americans receive the influenza vaccine despite demonstrable safety, low cost and widespread availability. We cannot assume that the necessary portion of the population will be willing or able to receive a coronavirus vaccine before resuming in-person learning for students. If we wait, we will lose a generation of vulnerable children.

In a recent article from the nonpartisan Economist magazine, “Let Them Learn: the risks of keeping schools closed far outweighs the benefits,” editors offer a clear warning:

“Education is the surest path out of poverty. Depriving children of it will doom them to poorer, shorter, less fulfilling lives. The World Bank estimates that five months of school closures would cut lifetime earnings for the children who are affected by $10 trillion in today’s money, equivalent to 7% of current annual GDP.”

Good science points toward a policy change. The Oregon Health Authority’s metrics for return to in-person learning must be revised to weigh the relative risk of adverse outcomes for children against the risk of SARS-CoV2 transmission.

Kevin Parks, M.D., is a physician at the Allergy and Asthma Center of Southern Oregon.