As school districts figure out what they’ll do come fall, Alex Navarro has a sense of what, exactly, the planning discussions between administrators and public health officials might look like.
Navarro, a medical historian at the University of Michigan, has studied how school closures affected previous pandemics in the U.S. When looking back at the 1918 influenza pandemic, he and his colleagues found that mass school closures were one of the most helpful strategies for reducing local caseloads.
Navarro also spent part of the 2009 H1N1 pandemic learning how communities coped with CDC school closure guidance. The health authority vacillated between recommending schools close for seven, then 14, and then back to seven days if they diagnosed a student with H1N1. In the spring of 2009, more than 1,300 schools closed temporarily because of these guidelines. The back and forth in CDC closure advice had some parents, officials and media questioning the recommendations.
Some of those same factors Navarro has seen play out before are cropping up again with the coronavirus. To understand where current uncertainties came from — and what might happen if school districts are divided on the best way to educate kids this fall — Discover spoke with Navarro.
Q: What inspired you to research the response to school closings during the H1N1 outbreak?
A: We were actually commissioned to do that study for the CDC. When the 2009 H1N1 pandemic hit, we had started gathering as much of the real-time media coverage of the pandemic as we could. Then the CDC came and asked us if we could basically take a historical approach to look at issues of decision-making. In 2009, there were very quick changes in CDC guidance rolled out on the issue of school closures to state and local health departments. There were a lot of issues about whether schools should close and for how long they should close. That guidance changed in a way where there was sort of a whipsaw effect, and it led to some issues. So they wanted us to look at the decision making process over school closures.
Q: When you look at the circumstances that some schools were dealing with back then, how does that compare to what schools are considering now?
A: It’s hard to say, because the pandemics are so dramatically different. In 2009, with H1N1, we knew from the get-go that children were most heavily impacted. There was a lot of emphasis placed on school closures there. With COVID, you know, it's kind of the opposite. You have a lot of people arguing kids aren't affected. It’s not true, but certainly, it seems that younger children are not as heavily impacted by COVID as older adults.
That being said, there were still lots of issues that cropped up in 2009 with implementing school closures that are familiar now. One of the things we didn't really fully appreciate going into the research is how many schools have underprivileged students. It's a place where students, especially in urban areas, get meals. We were finding schools where over 90 percent of the student body was eligible for free or reduced-price lunches.
I think a lot of Public Health Officers that we interviewed also realized that when they were recommending that these schools close, schools were pushing back and saying, "Look, we want to do the best thing for our students, but you have to keep in mind that this is coming at a cost." Schools in certain areas are safe havens when students might face domestic violence. All those issues that were present since 2009 are still present today.
Q: You recommended in your H1N1 research that there be better communication between public health and school officials. How has that panned out, do you think, since then?
A: I haven't followed this since and so honestly, I couldn't say. I think the fact that we're having this debate [about reopening schools], and that it's in the national discourse, is definitely a positive in that at least people are aware of these issues. Now, of course, what will be done? That remains to be seen. That's the work of good policy, but at least we're discussing it nationally.
Q: You also had a pretty clear recommendation that civic leaders talk to the public about pandemics ahead of time. How has that played out?
A: That's a kind of a charged question in some ways, unfortunately. It shouldn't be. I think that time after time, we see that public health officials tend to be — especially in times of public health crises — among the most trusted officials. Generally speaking, in 2009, it really came down to: What is safest for you? What we found, at least in a relatively limited sample of people that we interviewed, is that people just wanted to know what was the best guidance. What school officials said was, tell us what the best health responses are, and we will tell you how we can translate that into the best response in terms of the issues that surround closing and reopening schools.
Today, we're seeing governors and the president saying "schools have to reopen" when you have public health officials saying "let's slow this down a little bit." It wasn't as politicized in 2009, so it's kind of a hard question to answer. I think in 2009, we sort of had a response that was "normal," you know? It was, "what does the science say and how can we best to use that to make good policy?" And today, it's kind of, in some states, "Science be damned. We're opening the schools, no matter what."
Q: So the CDC asked for your H1N1 investigation because changing guidance had caused whiplash. Today, the agency is under pressure to adjust guidance about schools opening mid-pandemic again, so do you see the same problems playing out?
A: So the short answer is yes, I think there are some similarities between then and now. The longer answer is, though, that the reason for the shift in guidance in 2009 was because of evolving science and understanding of the pandemic and the novel strain of the influenza virus, as well as some differences within various CDC groups working on the issue over how to best interpret the science. The change from that seven day, to 14 day, back to a seven day closure issue? That was based on different interpretations of the unfolding science and knowledge of the incubation period and the duration of course of illnesses. So yes, the effect was a rapid whipsaw effect of the recommendations, but the basis was still science.
We always have to understand when you have a novel [disease-causing pathogen], there's always going to be this change of guidance. Look at face masks, for example: Mounting evidence says face masks work. We didn't know that a couple months ago. We should always take the latest [findings] and understand that the latest guidance might change.
Today, the initial CDC guidance that we saw about reopening schools seems to be based on science. The fear is that [any changes to the guidelines] are because the White House is basically saying, this is going to be too costly. And schools are going to use this guidance as an excuse not to reopen.
One of the problems that the CDC always runs into, and we saw this in 2009, is the “kick it upstairs” mentality. Nobody wants to be the person or the agency responsible for making the decision for, in this case, potentially children dying. School officials are always going to ask local health officials what's the best recommendation. And rightfully so — they're not scientists or public health officers. Local health officers always going to kick it up to the state officials and the state is always going to look to CDC. And at the same time, from the CDC people we've spoken to, they're always very cautious about saying, "here is the guidance — however, do what is right for your local scenario."
The problem with this is that it creates these gaps where people can make decisions and potentially blame another agency or another official if necessary. And, you know, to some extent that’s appropriate because it is a national pandemic, but it's really a series of local epidemics. And especially when talking about schools, the decision of whether to open and close schools is almost always made at the local level. But a federalist system of public health becomes kind of clunky when these gaps in leadership or responsibility are exploited for political gain.
Q: In 2009, many school officials you spoke with kept their eyes on absentee numbers, and factored absentee rates into their decision to stay open or closed. For some schools, an absentee rate of 10 percent was large enough to justify closing the school. Can you tell me a little bit about why tracking absentee numbers are so important for these decision-making processes, and how those numbers can sway a school's behavior?
A: I think there are two issues. One is that obviously, if you have a large number of students who are absent, it affects the ability of the school to carry out its educational mission. That’s something we saw in 1918. Most places in 1918 closed their schools, but cities like New York and Chicago didn't. And in Chicago there were some schools that had 45 to 50 percent absenteeism. You don't have a fully-functioning school when you have that many students absent. The other issue is, why are these students absent? Are they absent because there are concerned parents who are keeping otherwise healthy children out of schools? Or are they absent because you have children who are who are ill?
Now, chances are, you're going to have more students who are absent because of fear than necessarily an illness. But it's important to note that we don't really know because schools closed in most places in March, as the epidemic was just starting. So we really don't know what it's going to look like when we have mass gatherings of students back in classrooms during the middle of a pandemic that is still increasing in a great number of states.
Q: Gotcha. So, we don’t know the difference between people pulling their kids out because they're afraid cases have gone up, and kids leaving because they're actually sick.
A: Exactly. We saw this in 2009.
Q: Another thing we've struggled with is cohesive messaging about public health protocols. How do you think that's going factor into schools not being able to be open simply because parents are keeping their kids home? Could a failure of communication cause so much uncertainty that in-person school can't happen anyway?
A: I'm curious to see if there is there an overlap between parents who refused to wear face masks, and parents who want to charge full steam ahead with open schools. I fear that the parents who take the public health measures of social distancing, face masks and hand-washing seriously are probably more likely to be the ones who, if they don't feel safe and secure sending their kids back to school because that school doesn’t have a good plan for reopening, are going to keep their kids home out of fear for safety.
For the parents who don't want to wear face masks — are they the ones who are going to be willing to send their kids to school anyway? It's hard to say. But you may end up with kids in class who maybe have gone to a crowded beach, or whose parents have taken them to movie theaters or family gatherings. You'd have potentially a riskier group of people — who have been exposed — now going to school.
Q: You mentioned parents might not send their kids because they don’t think their school has a “good plan” for reopening. What's a “good plan” look like to parents?
A: You know, it's hard to say. I'm not a parent. I haven't done polling on this or questionnaires. But what we've seen from 2009, the number one thing would be clear, consistent, public health messaging that is based on an explanation of the best science and data of the day. So things like hand sanitizing, spacing out students, maybe having some kind of partitions, using a face mask, those sorts of things — if you have a clear plan based on all those things, when those are explained to parents, if a school has the means to do that, that that might help allay some fears.
There are still going to be parents who, if the pandemic is rolling on, [are] not going to send their kids to school. Those are parents who probably also have the means to educate their children in other ways. This is a socioeconomic issue, as well. If you're a service worker, and you have to go back to work and you need schools to reopen as sort of daycare for your child, there's going to be a lot more pressure to send your kids to school. So it's an equity issue, here. And then you get these people who are thinking that kids are safer in school because your kid is depressed because he or she hasn't gotten to play with friends. Those are all serious, real issues.
Q: Ultimately, how much do families have a say in what education looks like for their children in the fall?
A: In large enough numbers, families have a lot of power. If you have parents who refuse to send their kids to school because they just think that it's not safe, you're not going to have a school that's capable of carrying out its educational mission. That school is going to have to either close or meet whatever the demands of the parents are for a better plan. So, you know, I think that parents do have a great deal of power. If they refuse to send kids to school, then there's no school, basically.
Q: In your H1N1 work, you mentioned that people need a chance to be flexible with the guidelines — that a certain amount of decision making needs to happen at the local level. Do you still feel that way with what's going on now?
A: Yeah, I do. I think that if you have a community, for example, that has done and continues to do a really good job of keeping the epidemic under control, that community's plan for a school reopening is going to look is going to be drastically different than if schools in, say, Miami-Dade County were scheduled to open next week. That’s a community that has that widespread outbreak and cannot reopen schools.
Our whole public health response is built around this federalist idea that you have state and local control of public health. For the most part, that's appropriate. Certainly in 1918 it was all state and local response — there was very little federal involvement. The difference, of course, between 1918 and today is not only the science is better, but people look to the federal government. We now have the CDC, the Department of Health and Human Services and the NIH. People look to the federal government to be the clearinghouse, and to the CDC, in particular, in the case of a pandemic, to be the clearinghouse with the best data. And in the CDC, these are career people who could have made a lot more money working in the private sector. These are dedicated public servants who want to do the best thing. So their guidance is always going to include the best (or hopefully the best) science, but also that flexibility for state and local public health officials and educational officials to tailor that guidance to their specific needs.
That's good when people are acting in good faith for the best public health outcome. Where it runs into problems is when you have a politicized public health response and you have people who are pushing full steam ahead for a school reopening and using whatever little gaps might be in the federal guidance to suit their own needs.
Whether or not it's a local issue or a state issue or national issue, the most important thing is that we are making those decisions that will lead to the absolute best public health outcomes and not what we feel the economy should be doing or what's the best political outcome for the party. That’s what I'm afraid of now, given that this has been so politicized. There exists now a space for people to make the argument that schools opening or closing is a political decision and not a public health decision. And that's the problem. That's what I fear.
When we looked at 1918 and at 2009, it didn't even dawn on us that these could be political issues — that public health could become a political issue in that way. But now that 2019 and 2020 have rolled around, so much of our response has been political. It’s really scary. You look at what other countries are doing — they're reopening their schools or have plans to reopen their schools. They can do that because they didn't politicize the public health response. Everyone got together as a society and did the right thing, and they brought their pandemics way under control. We've not done that. We've done the exact opposite.