Reopening Primary Schools during the Pandemic
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The n e w e ng l a n d j o u r na l of m e dic i n e
Medicine a nd So cie t y
Debra Malina, Ph.D., Editor
Reopening Primary Schools during the Pandemic
Meira Levinson, D.Phil., Muge Cevik, M.D., and Marc Lipsitch, D.Phil.
For the past 6 months, policymakers and the however, we believe that primary schools should
U.S. public have weighed economic against pub- be recognized as essential services — and school
lic health considerations in debating what limits personnel as essential workers — and that school
to set on individual and collective behaviors in reopening plans should be developed and fi-
attempting to control the Covid-19 pandemic. As nanced accordingly. (We also believe that fully
fall approaches, attention has turned to a third reopening schools for middle and high school
pillar of a pandemic-resilient society: schools.1 students should be a national priority, but given
Under ordinary circumstances, about 40 million the more challenging transmission dynamics at
children would be entering prekindergarten older ages, we confine ourselves here to elemen-
through 8th-grade classrooms this year, includ- tary schools.)
ing nearly 27 million students in grades pre-K
through 5.2,3 Until these children physically re- Why In - Per son Scho oling Mat ter s
turn to school full time, many will lose out on
essential educational, social, and developmental Children miss out on essential academic and so-
benefits; neither the economy nor the health cial–emotional learning, formative relationships
care system will be able to return to full strength with peers and adults, opportunities for play, and
given parents’ caretaking responsibilities4; and other developmental necessities when they are
profound racial and socioeconomic injustices will kept at home. Children living in poverty, children
be further exacerbated.5 We believe that safely of color, English language learners, children with
reopening schools full-time for all elementary diagnosed disabilities, and young children face
school children should therefore be a top na- especially severe losses.1,13
tional priority. Moreover, schools provide numerous addi-
Many parents and educators are reasonably tional in-person benefits. School-provided social
concerned, however, about whether any large- welfare services support the health of U.S. com-
scale reopening plan can ensure safety for stu- munities made vulnerable by systemic racism,
dents, school staff, and household members, inadequate insurance, family instability, environ-
given high levels of community transmission in mental toxicity, and poorly paid jobs.1 More than
many U.S. regions.6 Contagion is a particular 50% of all U.S. school-age children rely on their
concern in schools that serve predominantly low- schools for free or reduced-price daily meals. De-
income communities of color, given that such spite efforts by school districts to maintain these
schools are often overcrowded and understaffed services even when school was conducted re-
and that the families whose children attend them motely, a majority of children have been unable to
are at especially high risk from Covid-19.7-10 It access the full nutritional benefits to which
would be best — and evidence from many coun- they’re entitled.5 Schools also provide physical,
tries demonstrates that it’s possible — to lower mental health, and therapeutic services to mil-
community transmission rates by means of lions of students per year. Many of these services
stringent control measures this summer so that have proved inaccessible to children — particu-
schools can reopen this fall with an acceptable larly low-income children of color and children
level of safety.11 Even under conditions of moder- with noncitizen family members — when schools
ate transmission (The n e w e ng l a n d j o u r na l of m e dic i n e
tently open schools are essential for many par- Covid-19 and are much less likely than adults to
ents and guardians (particularly women) to be face severe consequences from the infection.18
able to reenter the workforce — including the Although a small number of children worldwide
health care sector.4,14 have been hospitalized with multisystem in-
In light of these concerns, some school dis- flammatory syndrome in children (MIS-C) after
tricts are developing hybrid learning plans for SARS-CoV-2 infection, so far this appears to be
the fall that would bring alternating groups of a rare syndrome (affecting a reported 2 per
students back into school buildings under condi- 100,000 people under 21 years of age between
tions of strict social distancing.15 Although some March 1 and May 10, 202019), and with early
in-person schooling is preferable to none, for recognition and treatment, clinical outcomes in
primary schools in particular these plans may the short term have been good.19-21 In contrast,
achieve few gains over completely remote learn- adults, especially those who are over 60 or have
ing. Millions of children will remain excluded underlying health conditions, are at higher risk
from learning on the days when they’re assigned for severe illness, hospitalization, and poor out-
to virtual school, owing to digital access chal- comes.18
lenges, developmental inappropriateness, or lack Limited emerging evidence suggests that sus-
of real-time adult support.16 Such plans also fail ceptibility to infection also generally increases
to solve child-care challenges, since children with age.22 Given the same exposure to infected
will still be out of school for substantial periods. household members, children under the age of
These challenges may be particularly acute for 10 seem to become infected less frequently than
educators who are parents themselves, for other adults and older adolescents; studies of both
workers who lack flexibility in determining when household and community transmission find that
or where they work, and for parents with multiple children 9 or younger are also less susceptible
children on misaligned attendance schedules. than 10-to-14-year-olds.22, At the other end of the
Furthermore, even when they are in the build- spectrum, adults over 60 have higher susceptibil-
ing, teachers may struggle to teach and students ity to infection even than middle-aged adults.22
may struggle to learn under rigorous social dis- Age-related differences in infectivity are less
tancing conditions. Young children cannot reli- clear. Findings from a few contact-tracing stud-
ably maintain physical distance, and teachers ies suggest that children may be less infectious
cannot simultaneously enforce distancing and than adults,22 but the strength of this evidence is
teach. In-person classes that require students to weak and some of the relevant studies were con-
look straight ahead and work independently (as ducted when schools were closed. A recent study
many proposals for distanced classrooms rec- from South Korea of both household and non-
ommend) violate evidence-based good teaching household contacts suggests that infected children
practices.17 High-quality learning is inherently under 10 years of age are less contagious than in-
relational and social, not individual and teacher- fected adults.23 The direction of transmission was
centered. Teachers also rely on physical proxim- not rigorously documented in the study, however,
ity to build positive relationships with students and even young children can probably still trans-
and manage their classrooms; such tasks may be mit the virus to others.
impossible if teachers are rigidly separated from
students. E vidence fr om the Field
We therefore need to prioritize both the com-
plete physical reopening of schools and safety These findings align with data on school and
protocols that are aligned with children’s devel-
community transmission from countries that
opmental needs and teachers’ pedagogical and have reopened schools (or never closed them).
supervisory capacities. Covid-19 outbreaks in high schools in France,
Israel, and New Zealand did not extend to
nearby elementary schools, which suggests that
Clinic al and Epidemiolo gic
Per spec tive s susceptibility, infectiousness, or both are lower
among younger children. When schools in the
From a clinical standpoint, most children 1 to Netherlands opened in April, they cut class sizes
18 years old experience mild or no illness from in half but did not enforce distancing among
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students younger than 12 — a loosening of re- sonal protective equipment (PPE), closing school
strictions that has now been extended to every- buildings to all nonstaff adults, and holding
one under 17.11 Primary schools in the Nether- digital faculty meetings. These precautions are
lands returned to full capacity and full-day teaching especially important insofar as 17.5% of teachers
in early June. Though both staff and children are 55 or older.25 But we believe that schools in
who are high-risk or have high-risk family mem- low-transmission settings could probably pro-
bers have been exempted from returning to vide pedagogically sound and socioemotionally
school in person, most children and educators appropriate instruction to all students, in per-
have returned and the case rate has thus far son, in ways that do not put educators or fami-
remained flat. lies at undue risk.26
Case numbers have continued to decrease in Any region experiencing moderate, high, or
Denmark, which reopened elementary schools increasing levels of community transmission
in April and middle and high schools in May, should do everything possible to lower transmis-
albeit under strict social distancing rules. Nor sion. The path to low transmission in other coun-
have school reopenings led to increased case tries has included adherence to stringent com-
counts in Finland, Belgium, Austria, Taiwan, or munity control measures — including closure of
Singapore, although, again, schools in these nonessential indoor work and recreational spac-
countries have taken substantial extra precau- es.11 Such measures along with universal mask
tions and are only slowly lifting restrictions on wearing must be implemented now in the United
activities and group size. Israel offers a caution- States if we are to bring case numbers down to
ary counterexample, since a recent case resur- safe levels for elementary schools to reopen this
gence there may be linked to early high school fall nationwide.
reopenings in May, with crowded classrooms Epidemiologic evidence suggests that death
and minimal precautions in place; a clear causal rates can be lowered by 90% within 9 to 11 weeks
role for schools in this resurgence, however, has after stringent control measures begin (see the
not been demonstrated.11 Supplementary Appendix, available with the full
Notably, most locations (except Israel) whose text of this article at NEJM.org). Given the lag
schools are open had already achieved low com- between new infections and deaths, an equiva-
munity transmission rates (The n e w e ng l a n d j o u r na l of m e dic i n e
risk to families’ and educators’ safety — but gartners will need easy access to appropriate bath-
their ongoing closure also imposes the greatest room facilities; and schedules may need to be
harms on children and families.14 redesigned to accommodate special-education
Many families — particularly those with providers and specialty teachers so they can access
medically vulnerable household members — will children and classrooms at appropriate times.
choose to keep their children home under these Even if schools can make creative short-term
circumstances regardless of whether schools are use of additional space, thousands of schools
physically open.29 We understand this risk calcu- — particularly those serving low-income students
lus. Remote teaching and other school services of color — will require significant federally
(including meal provision and medical and funded upgrades to improve ventilation, sanita-
therapeutic services) should be available to all tion, nurse’s offices, and hand-washing and bath-
families who choose this option, with designat- room facilities.33 These improvements have long
ed educators being responsible solely for remote been needed regardless of Covid-19; they are
teaching. essential investments in educational equity and
But educators and other school personnel opportunity.
cannot necessarily dictate the place or terms of
their employment, even (perhaps especially) when Conclusions
the social compact has broken down. It is tragic
that the United States has chosen a path neces- Whether (and how) to reopen primary schools is
sitating a trade-off between risks to educators not just a scientific and technocratic question. It
and harms to students, given other countries’ is also an emotional and moral one. Our sense
success in reducing transmission and opening of responsibility toward children — at the very
schools with routine control measures in place. least, to protect them from the vicissitudes of life,
This dilemma represents a social and policy fail- including the poor decision making of adults who
ure, not a medical or scientific necessity. allow deadly infections to spiral out of control
Nonetheless, we would argue that primary — is core to our humanity. Our expectations of
schools are essential — more like grocery stores, school personnel are equally emotionally and
doctors’ offices, and food manufacturers than morally fraught. It is not incidental that the ma-
like retail establishments, movie theaters, and jority of primary school teachers are undercom-
bars. Like all essential workers, teachers and other pensated women who are expected to sacrifice
school personnel deserve substantial protections, themselves “for the sake of the children.” School
as well as hazard pay. Remote working accom- closures have also brought social, economic, and
modations should be made if possible for staff racial injustice into sharp relief, with histori-
members who are over 60 or have underlying cally marginalized children and families — and
health conditions.5,18 Adults who work in school the educators who serve them — suffering the
buildings (or drive school buses) should be pro- most and being offered the least. For all these
vided with PPE, and both students and staff reasons, decisions about school reopenings will
should participate in routine pooled testing.30 remain complex and contested.
Schools’ social and physical infrastructure will But the fundamental argument that children,
also need to be modified. Students and teachers families, educators, and society deserve to have
may need to eat lunch in their classrooms, and safe and reliable primary schools should not be
staff rooms may need to be closed to discourage controversial. If we all agree on that principle,
adult congregation.31 Crowded buildings or then it is inexcusable to open nonessential ser-
open-plan layouts may make it impossible for vices for adults this summer if it forces students
adults to maintain distance from one another32; to remain at home even part-time this fall.
in such cases, schools may benefit from spread- Disclosure forms provided by the authors are available at
ing out or relocating to local middle or high NEJM.org.
We thank Benjamin Kesselman for efficient research assis-
schools, unused college classrooms, community tance and David Fisman, Rose Levine, and Jacob Fay for feed-
centers, houses of worship, or businesses whose back on an earlier draft.
employees are working remotely.11,12 Such shifts
From the Harvard Graduate School of Education, Cambridge
will not be easy. Spaces and furniture will need (M. Levinson), and the Center for Communicable Disease Dy-
to be retrofitted for younger children; kinder- namics, Department of Epidemiology, Harvard T.H. Chan School
4 n engl j med nejm.org
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Copyright © 2020 Massachusetts Medical Society. All rights reserved.Medicine and Society
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