Glossary

• Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses, and on it goes.
• Coronavirus– a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes that form a crown, halo, or corona of spikes
• SARS-CoV-2– the specific name of the new coronavirus
• COVID-19-the name of the illness that the new coronavirus is causing
• Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
• Epidemic– a sudden burst of an illness that comes and goes over a limited time
• Pandemic– an epidemic that bursts across the world not just one region
• Spreadability– how contagious is the disease, how many people will end up infected
• Symptoms- the experience of being ill, for example- fever, cough, headaches, loss of smell etc.
  • Asymptomatic– literally means “without symptoms”.  For COVID-19 it refers a person infected with the virus but has no and will have not symptoms
  • Presymptomatic– This is a person who was infected with SARS-CoV-2, and will feel sick, but hasn’t yet
• Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
• Mask- a mask is a loose-fitting cloth or textile that covers the mouth and nose loosely.  A surgical mask is a mask used in surgery
• Respirator-  for the purposes of the COVID-19 pandemic and other respiratory illnesses, a respirator is a mask that fits very snugly or tightly to the user’s face.  An N95 mask is a respirator.
• Personal Protective Equipment (PPE)- PPE are any item that covers any part of the body with the design and intent of keeping viruses in the environment from infecting the wearer of the PPE. PPE’s include all masks (which includes respirators), face shields, eye shields, gloves, gowns.
• Ventilator- a ventilator is a machine that can force a person unable to breathe to inhale and exhale and control both effectively.  They are sometimes called respirators, but during this pandemic the word respirator is now reserved for reference to a tightly fit mask.
• Live Virus Swab– this is the swab which attempts to swipe live virus from one’s nose or throat to see if you are currently infected.
• Antibody Test- (aka serology test) this is the blood test which looks for antibody to the SARS-CoV-2 virus to see if you have been infected in the past.

Spreadability

As we know from many posts on Real Answers, including our recent interview with Dr. Michael Osterholm, the SARS-CoV-2 virus is very contagious, and can cause grave damage including loss of life and of function.  And so, as we move closer to one month away from when schools normally re-open, this basic fact is our starting point for this urgent question:

When it comes to opening schools, what is even the right question to ask?

Some Basic Facts

To come up with a good frame for this discussion, it makes sense to list a few other facts as they are understood at this time:

1. As noted, the virus that causes COVID-19 is highly contagious, and can be and is deadly and dangerous.
2. Osterholm, on July 8, 2020 was asked by me if we know– Do children catch and spread the SARS-CoV-2 more or less likely than adults.  His answer was firm and clear- NO
3. We have had some experience of groups of kids gathering, mostly outdoors, and have seen outbreaks in these settings. Those settings have been summer camps, and at least 3 have reported outbreaks with dozens of campers infected with the SARS-CoV-2 virus, leading to camp closures.  This hints that kids can transmit the virus.
4. Schools have always been hotbeds of viral transmission.  Everyone with children knows what I have seen every year of my professional life: within several weeks of schools opening, great waves of viral illness wash over the community and our office begins to see hundreds of children with fevers, colds, stomach flus.  Every year.  We know that if a virus can be spread by children, school is a place to spread it far and wide.

Now, What is the Right Question?

For the last few weeks our community and our nation has been gripped by a question that seems to be pressing down on us with tremendous pressure:

Should we re-open the schools?

This is, I strongly believe, not the first question to ask.  It is definitely a question that has to have an answer.  From that point of view we need to answer this question, and of course will be forced to answer it soon.

But if we start with the question of opening schools, we are trapped in deciding a terrible decision- should we offer our children in classroom education?  should parents have to stay home one more semester?  should we send our kids into danger?  should we send teachers and staff into danger?

Starting with the opening the doors question cannot be answered before we answer the first question:

Has Cuyahoga County, has Ohio, has the United States achieved control over this deadly pandemic?

I feel strongly this is the first question for a number of compelling reasons:

• The essential reality about COVID-19 is that we are in the midst of the most deadly epidemic of deadly infection in nearly everyone’s life.   Thisis the core problem we are facing.
• If our community- local or national- has stopped the spread of this deadly danger, then all sorts of questions can be asked in a radically different way than if we have not.
• Going about decisions like opening schools, before understanding if we have control over the danger of this epidemic means we act blindly. We know this because if we act blindly everyone will feel very queasy, that sense of jumping into a stream not knowing if there are rocks protruding from the bottom, hoping in mid-air that there are not, but wondering, what is going to happen?
• Going about decisions like opening schools, after we have control over the danger of this epidemic means we really have a pretty good idea that it is safe, and are in a position to notice when outbreaks happen here and there and contain them.

Now, what about this question?  The answer is not hard to know.  And the answer is no.  Our County, Cuyahoga, does not have the infection’s spread under control.  Our state, Ohio, does not have this infection’s spread under control.  And our nation, the United States, does not have the infection’s spread under control.

Maybe this will change, it can, it should, I profoundly hope it does.   As noted, 48 other nations have achieved excellent control, check out www.endcoronavirus.org to see which they are.  Some are big, some are small, some are rich, some are poor.  And when I asked Dr. Osterholm if this was true, he said my claim was, “spot on,” and observed our nation could achieve the same success, if we Identified the Infected, and had Isolation for the Infected.

But right now, the virus is raging.  The United States has more viral transmission active today than any nation in the world. If your nation has people getting infected with a virus than any other in the world, when so many have nearly stopped its spread all together, then we have to agree, it is not under control.

Ohio routinely is in the top 10 states in terms of spread, we are not under control anymore.

Cuyahoga County is in the top counties of Ohio in terms of spread, we are not under control.

If We Know We Are Not Under Control Now Let’s Ask, Should we Re-open our Schools?

As I have advised schools that ask for my advice, the answer today must be, we do not know.

Many are familiar with a recent AAP Interim Guidance that urged schools to re-open as a priority, citing the mental health issues involved.  Clearly there have been harms to our children’s mental health from being cut off from friends, educational progress has slowed not being in the classroom, some vulnerable children have seen harmful drops in access to food and safety.  Opening good schools is important to childhood.

But the above considerations have led the AAP, on July 10, 2020 to issue a News Release that makes very clear that before we talk about the benefits of school denied by closure, we must talk about safety of students, staff, and teachers.  https://services.aap.org/en/news-room/news-releases/aap/2020/pediatricians-educators-and-superintendents-urge-a-safe-return-to-school-this-fall/

Clearly a consensus has emerged, first secure the safety of our community, then talk about opening schools.

BOTTOM LINES

1. Schools are an essential part of life.  As crucial for kids as work is for adults, in fact, schools are the work of our children.  As such, like work, they should be open.
2. But in an emergency, we always take measures to first save lives.  That comes before work and before school.
3. So the first question must be- is this deadly infection sweeping across our country and world, under control?
4. The answer as of today in our community, local/state/national, is no.
5. At the same time, it has been true since January that our nation could have, and today can, control the spread.  The path to do so is known, it is not complicated, it has been achieved in 48 nations.  It can and should be done here.
6. I therefore urge us first to control the spread of this deadly infection before we reach a point Dr. Osterholm described, at which 60-70% of our nation gets infected and most of us will lose someone we care for.   Once the spread is really controlled and deaths drop close to zero a day, then I think opening schools becomes a vastly easier task, one I support, one that would cause little worry.
7. If we choose not to control the pandemic, then I cannot say what will happen if schools re-open.  All the steps being taken might help, I hope they do.  I anticipate any school opening while the pandemic rages will need to look at the decision to open every day, every week, every month, to see if the waves of infection enter their shores.

We close where we began, the essential reality we live in today is that we live in one of the most dangerous outbreaks in any of our lives.  It is a dangerous time.  I hope all remain well, safe, and we find our path forward to stem this tide.  Whatever our community decides, whatever the schools decide to do, we will remain here for the families we care for.

To your health,
Dr. Arthur Lavin