More False Prophets of Science

At the 6/12/2020 meeting of the San Mateo High School District school board, Dr. Suneil Koliwad, a professor of medicine at UCSF, argued that it is “exceedingly unlikely that schools will be a vector for virus transmission.” He further argued that masks, social distancing and good hygiene were sufficient to keep the R₀ below 1.

So, are his claims credible or valid?

If the goal is to keep the rate of community infection low enough to not overwhelm hospitals, AND if he is right about masks, social distancing and hygiene being sufficient to keep the R₀ below 1, then the answer is maybe. We don’t really know what the R₀ is when the shelter-in-place (SIP) has been lifted and schools reopen. And there are very few localities that ever got their R₀ below 1, even with social distancing, so this question hasn’t really been answered. However, sending teachers and students back to school will bring a lot more people into close, indoor proximity than was occurring during the SIP and, even with masks, distancing and hygiene, this could bring the R₀ back up well above 1, creating a surge that overwhelms hospitals, as is currently happening in Houston, parts of Southern California, and many other regions of the country.

If, on the other hand, we’re talking about preventing children from getting sick, potentially developing the deadly Kawasaki-like syndrome, or spreading it to vulnerable teachers, staff and family members, then the answer is NO—it is NOT safe. If our goal is to keep the R₀ below 1 and prevent an explosion of new cases, as occurred in New York, Italy and Spain, then the answer is NO—it is NOT safe.

Dr. Koliwad seems to think that teachers’ resistance to reopening the schools is entirely about their own delusional fears of death, or that of their students.

It would be tragic for any students or teachers to die (and mostly preventable if we kept the schools closed), and not unlikely, considering one-third of all teachers are at elevated risk for severe covid-19 complications or death due to age and/or underlying health conditions. However, there are far bigger issues to worry about, like the estimated 1.2 million deaths we could see by the end of the year, even with mitigation, or the 6-7 million deaths we could see without mitigation (e.g., sending people back to work and school) if 60-70% of all Americans get infected and the mortality rate holds at 3.8%. Or the famine that we could all suffer because so many farm workers, grocery store workers, meat packers, and fish processors are becoming ill.

While there may not yet be any controlled scientific studies proving transmission between students and staff, there is considerable anecdotal evidence, including numerous school outbreaks that have prompted schools to reclose. Two weeks after reopening their schools, Israel was prompted to reclose them because of Covid outbreaks, including 130 cases at a single school. France had a similar experience when they reopened their schools. In the town of Skellefteå, Sweden, a teacher died and 18 of 76 staff tested positive at a school with only 500 students. Preliminary results from an antibody study in Sweden showing high rates of infection among children, suggest there was significant spread in the schools. And in Montreal, nearly an entire class tested positive after one student fell ill, despite social distancing. Health authorities believe this was a case of classroom transmission.

It should be obvious that in-person learning will be more risky than distance learning. Indoor environments are the riskiest places to be during a pandemic. The longer you spend indoors with people outside your immediate family, the greater the exposure to germs and the greater your chances of becoming infected. This is true for students and even more so for teachers, who will be expected to spend hours inside a potentially infectious room. Studies show that Keeping Schools Closed Significantly Reduces Transmission rates. Closing schools early and keeping them closed is one of the best ways to curtail a pandemic. Keeping them closed reduces infection rates by 40-60%.

Dr. Koliwad argues that schools are like hospitals, but safer, directing us to the article by Atul Gawande, in the New Yorker on how employees at Boston’s Mass General Brigham Hospital have kept their workplace infection rates low. However, despite arguing for the efficacy of face masks, hygiene and following the “six-foot rule,” Gawande concedes that in some cases, infectious droplets can travel at least twenty feet, and that loud talking, as is typical in a classroom, generates significantly more droplets than quiet talking. He also concedes that some activities, like performing in a choir, can be extremely dangerous, like the outbreak in Washington, where 52 out of 60 members of a choir were infected by one infectious person during a single 90-minute practice session. Choir, by the way, is a common course offering at K-12 schools.

Another fallacy in Dr. Koliwad’s argument that schools are like hospitals, but safer, lies in the assumption that in-person learning is an essential service, like hospitals. But a doctor cannot perform surgery remotely on a patient, whereas teachers can teach remotely. Furthermore, while the best examples of distance learning are likely inferior to the best examples of in-person learning, the health of our children, their families and their teachers, is far more important. Even if they missed school entirely for a year or two, it would be preferable to losing one or both parents, or allowing the pandemic to spin so out of control that our food supply was threatened.

Another problem with Dr. Koliwad’s argument is that educators have even less access to effective PPE than medical workers. In hospitals, employees have surgical masks, which Gawande explains are far more effective than the typical two-layer cotton mask worn by most people. The surgical masks create a tighter seal around the face and they breath more easily, making it less likely that wearers will pull them down and expose themselves, or that droplets leak in or out through the gaps. Furthermore, the surgical masks have an electrostatic charge applied to them that helps trap viral particles. Cloth masks lack this feature.

Gawande also talks about how they’ve brought the “stringent antiseptic standards of the operating room into…other parts of our institutions.” Problem is, hospitals are operated by health professionals who are trained in these antiseptic standards and who’ve had years to practice them and make them part of their professional culture. Educators have not had this training, nor this practice. Worse, what about students, particularly K-5 students? It is completely absurd to think that kindergartners are going to not touch their faces, let alone those of their peers and teachers. It’s also hard to imagine the teacher remaining six feet away from a sobbing child who has fallen down and hurt herself, while gently admonishing her, through his mask, to suck it up and get back to work because there can be no touching during a pandemic.

Part of this change of culture, according to Gawande, includes calling out colleagues when they have lapses in protocols. That might work in a hospital setting, with the common training and understanding employees share regarding hygiene, but not in a school, where students regularly defy teachers, refuse to follow rules, and sometimes get loud and belligerent when called out for misbehavior. And we’ve all experienced moments in public where someone has called out a neighbor or stranger for walking too close, spitting or committing some other violation of the rules of hygiene.

Like so many other scientists and doctors who are jumping on the back-to-work bandwagon, Dr. Koliwad is allowing the confirmation bias to direct his thinking, even at the expense of violating his commitment to do no harm. He repeatedly referred to evidence that supported his desire to have students return to in-person learning, while providing no examples of this evidence (the Gawande article, didn’t actually support his claims). And while one could argue that distance learning is also doing harm to students, I don’t see how anyone could argue that it’s doing more harm than 116,000 deaths so far, particularly when in-person learning under the conditions of social distancing, mask wearing, health screenings, etc., will not come close to approximating the conditions of school prior to the pandemic. Particularly when you consider that students will not be able to see the smiling faces of their teachers or peers, or sit together at lunch, or hug or high-five each other, or even work collaboratively in teams and at lab benches.