Dr. Sanjay Gupta: Back to school or back to square one?

Even though the heat of mid-summer is still upon us and the coronvirus pandemic continues, back-to-school season is right around the corner. With the possible exception of mask-wearing, no topic is generating as much debate as the reopening of schools.

Everyone — leaders at all levels of government, public health experts, child welfare advocates, pediatricians, parents and teachers — has an opinion. As a doctor, a journalist and, perhaps most importantly, as a parent to three school-age children, it may come as no surprise that I’ve been thinking about this, too.

School reopening has become politicized. It’s a source of tension within this administration, pitting those who want society to get back to normal routines as soon as possible against its own public health experts, who want to take steps incrementally.

Children as ‘political footballs’

President Trump has been pushing strongly for schools to reopen, even insisting that the US Centers for Disease Control and Prevention revise its comprehensive guidance for schools because they are too “tough and expensive.” But CDC Director Dr. Robert Redfield pushed back, saying the agency would not water them down, although Redfield said additional guidance documents would be provided.

Both Trump and US Department of Education Secretary Betsy DeVos threatened to withhold federal funding for school districts that didn’t reopen, and White House economic adviser Larry Kudlow dismissed concerns about reopening schools by saying, “It’s not that hard.”

At the same time, Dr. Anthony Fauci, the nation’s top infectious disease expert and a member of the White House Coronavirus Task Force, said reopening is complicated and he grown increasingly vocal about his concerns on the matter.

Even the World Health Organization weighed in, with one official warning countries not to use the reopening of schools as “political footballs,” calling the politicization “not fair on our children.”

Education is essential on many levels

Politics aside, it is important for schools to reopen because there are many benefits. Not only do they provide kids with an education and structure (and parents with a place for kids to stay safe while they’re at work), schools also fill social and emotional needs, and for some kids, they play a protective role, keeping them fed through breakfast and lunch programs, and being on the front line against child abuse.

The American Academy of Pediatrics, which represents pediatricians across the country, updated its back-to-school recommendations and “strongly advocates that all policy considerations for the coming school year should start with a goal of having students physically present in school.”

The organization says the evidence shows that children are probably not greatly amplifying the spread of coronavirus and that many schools should reopen, provided they follow appropriate guidelines — like wearing masks and practicing social distancing and proper hand hygiene– and take into account rates of transmission in their community.

Former CDC Director Dr. Tom Frieden told CNN that education is essential and interruptions slow or stall progress for millions of children.

“Schools are also essential for the overall educational and social development of children, as well as in the functioning of the overall economy. It’s not, we think, a matter of whether to open schools but how to do it as safely as possible,” said Frieden, the president and CEO of the nonprofit Resolve to Save Lives.

But Frieden said we can’t just charge forward. “One step forward too fast, many steps backward, and for a long time,” he said, noting what happened when states tried to reopen other segments of society too quickly. “Trying to open schools without accounting for and protecting students and staff from Covid is going to backfire.”

Public health expert after public health expert says we have to look to science for answers. “It’s so critically important that all of the decisions that we do are based on the best public health science,” another former CDC leader, Dr. Richard Besser, told CNN. “You never want to get in a situation where the science and what goes into a guidance is politicized. It may be the policy decisions aren’t based solely on science, but the science itself needs to be separated from the political process.”

Besser, Frieden and two other former top CDC officials wrote an opinion piece that appeared in the Washington Post Tuesday in support of the CDC school guidance and criticizing those who have politicized the situation.

Said Besser, “I’m a pediatrician and a parent, and I think it’s critically important to get children back to school, but it has to be done in a way that’s safe — and not just for the children but for the staff, for the teachers, for the rest of the community. And that means following the science; that’s the blueprint, that’s the roadmap to get there.”

What does the science tell us?

If a community is experiencing high transmission rates, public health experts say reopening does not make sense. In countries where schools appear to have reopened successfully, such as Germany and Denmark, transmission rates and Covid-19 cases had already been brought down to low levels prior to reopening.

By contrast, the United States is nowhere near being under control. The United States saw a record number of new coronavirus cases in a single day Tuesday, with 67,417 new cases reported, according to Johns Hopkins University’s tally of cases, eclipsing the previous high of from last Friday by almost 800 new cases. The situation in a handful of areas in some states, including Texas, Florida and California, is teetering on dire.

“If you have such an aggressive level of transmission in certain states, it’s going to be very tough to open up those schools safely,” said Dr. Peter Hotez, dean of National School of Tropical Medicine at Baylor College of Medicine.

Former Baltimore Health Commissioner Dr. Leana Wen agreed. She told CNN, “The single most important thing that we can do to ensure that schools can open, if we’re interested in instruction in the fall, is to reduce the level of Covid-19 spread in the summer.” She said that may mean thinking carefully about our priorities, “so if the priority is to open schools in the fall, maybe we need to keep bars closed in summer.”

“I think every single person wants schools to reopen … but we also cannot jeopardize the health and well-being of our children, and the staff and teachers and their surrounding communities,” she said.

It’s a concern the White House Coronavirus Task Force has as well. A source close to the group told me, “With regard to schools, each community will have to evaluate the status of the outbreak in their particular area. While there are no hard and fast rules, if a particular community has had a five-day sustained increase in community spread, they should not be opening schools until they pass through the basic gating criteria of a 14-day downward trajectory. That guidance has not changed.”

Are children likely to infect others?

So far, evidence suggests that young children do not contract the new coronavirus as frequently as adults do, nor do they get as sick with Covid-19. But we can’t be too cavalier: a small fraction of children clearly do get sick, and an even smaller portion suffers severe consequences, including developing multi-system inflammatory syndrome in children (MIS-C). And, then, there’s a population of vulnerable children who have chronic health conditions and who need to be protected.

“Children do seem to be less affected, but they can be infected. And that is important,” said Maria van Kerkhove, the WHO’s technical lead for coronavirus response, said at a briefing Monday.

The virus is less prevalent among young children, van Kerkhove said, while children about 10 and older appear to have about the same prevalence as young adults. “They can be infected, which we’ve said from the beginning, but they do tend to have more mild disease,” she said. “In terms of transmission, there’s quite a lot that we still need to understand about transmission in children.”

So how likely are children to infect others?

A commentary published last week in the journal Pediatrics, the journal of the American Academy of Pediatrics, concludes that children infrequently transmit Covid-19 to each other or to adults. The conclusion is based on five small studies that evaluated in several different countries.

In one French study, a 9-year-old boy who had been infected with Covid-19 exposed over 80 classmates at three schools. None of those children contracted it.

In New South Wales, nine infected students and nine infected staff members across 15 schools exposed a total of 735 students and 128 staff to Covid-19. Only two secondary infections resulted, one possibly transmitted by an adult to a child.

“Children when they do get infected, they appear to have such milder symptoms, or, or be completely asymptomatic,” Dr. Benjamin Lee told CNN. Lee, a pediatric infectious disease specialist on the faculty of the University of Vermont’s Larner College of Medicine, co-authored the commentary.

One study has found that children can carry the same amount of virus as adults — potentially making them just as infectious.

But Lee says having virus isn’t the same as transmitting it. He says, children may be much less efficient at expelling the virus and transmitting it to the environment around them. “So maybe they’re coughing less, they’re sneezing less. Their breaths aren’t as deep to begin with. So, it could be that even though they are capable of supporting similar amounts of virus, they still could be spreading it around them to a lesser extent,” he said.

However, both Lee and van Kerkhove say that they have heard of outbreaks associated with schools.

A complex calculus

When reopening schools, the health of students and their parents isn’t the only issue to consider. School reopenings also put teachers and school staff at risk. A new Kaiser Family Foundation report found nearly a quarter of all teachers — approximately 1.5 million individuals — are at higher risk of serious illness if they contract coronavirus because they are older than age 65 or they have health conditions such as diabetes, heart disease or obesity.

At this point, it appears there is no one-size-fits-all answer to whether, when and how to reopen schools. And we’re starting to see that as several large school districts announced their plans for the start of the school year.

“Returning to school is important for the healthy development and well-being of children, but we must pursue re-opening in a way that is safe for all students, teachers and staff,” read a joint statement released Friday by the American Academy of Pediatrics, American Federation of Teachers, National Education Association and AASA, The School Superintendents Association.

The statement said local school leaders, public health experts, educators and parents should be involved in the decision to open schools, and they must take into account factors including community spread of Covid-19 and the ability of schools to institute safety protocols.

“For instance, schools in areas with high levels of Covid-19 community spread should not be compelled to reopen against the judgment of local experts,” the statement continued. “A one-size-fits-all approach is not appropriate for return to school decisions.”

My own children’s private school is opening in a few weeks and so I asked our own headmaster, Keith Evans, about the considerations they made in reopening.

One of the things he told me surprised me. “We are really blessed with some great buildings and square footage here. That is the constraining factor, I think in every school, space. If you can, if you can get the social distancing right and fit your program into it, it feels more normal and it works better. But no school was designed to have students six feet apart, you know, everywhere,” he said.

But many schools lack that kind of space. And even if they have it, so many other things outside of their control may change.

“We’re moving toward a particular end,” Evans told me “But we’re also ‘eyes wide open, ears wide open,’ understanding how this is evolving and, and not getting into a rigid mindset of one thing has to happen or another. We understand [that] next week, everything could change.”