Benjamin P. Linas | Vox

I’m an epidemiologist and a father. Here’s why I’m losing patience with our teachers’ unions.

2021-02-16T19:41:09-05:00

A student does at-home learning in Orange, California, in December 2020. After months of at-home learning, school districts are grappling with bringing students back to campus for in-person teaching. | Paul Bersebach/MediaNews Group/Orange County Register via Getty Images

Millions of students across America have now been stuck in remote learning for nearly a year. This situation, which has hurt learning and widened gaping disparities, is in large part because many teachers fear returning to the classroom in person. But in this past year, we have also learned how we can keep schools open safely.

Educators’ anxiety is based on reasonable concerns. Covid-19 is a serious illness. And schools are an indoor group setting with the potential to spread infection. But schools, it turns out, with a few basic safety measures, including masks and reasonable distancing, are not a high-risk venue for Covid-19 transmission. In fact, they appear to have far lower rates of the virus than their surrounding communities. Still, some education union leaders are beginning to lay the foundation for schools remaining shuttered into the 2021-22 school year.

For the better part of the past year, I’ve been living inside the tempest that is Covid-19 and schools. I am a father of three girls, ages 11, 13, and 17, all of whom go to public school. I am also an infectious diseases physician and epidemiologist. I understand teachers’ fear — it is real and I have felt it myself as a front-line doctor. But I also know that America needs to have its schools open for in-person learning and there are safe, affordable ways to do this — right now.

And if educators and their unions don’t embrace the established science, they risk continuing to widen gaps in educational attainment — and losing the support of their many long-time allies, like me.

The agonizing choice between science and teachers didn’t have to exist

Since March 2020, I have been a front-line pandemic health care provider, adviser to my hospital, and consultant to my religious congregation and a local community college — all with the aim of preventing the spread of Covid-19. Toward that goal, I have also been a volunteer member of the public health and safety advisory panel to the Public Schools of Brookline, Massachusetts, where my family lives.

Unfortunately, our panel’s expertise — and that of national and international health groups — has been frequently dismissed by the local educators’ union in favor of their own judgments about best health practices and the safety of in-person learning. In the process, they have misinterpreted scientific guidance and transformed it into a series of litmus tests that keep our district in hybrid learning. These litmus tests are not based on science, they are grounded in anxiety, and they are a major component of the return-to-school quagmire in which we are stuck.

One sticking point, for example, has been the union’s early and continued insistence that desks remain at least 6 feet apart at all times. This requirement mathematically determines whether there is enough space for learners in the building. Distancing is absolutely critical to Covid-19 mitigation, but there is no magical threshold that makes 6 feet the “safe” distance and 5 feet “dangerous.”

In settings like school, where everyone is wearing a face covering, there really is no measurable difference in risk between being 3 feet and 6 feet apart. That is why there is no official guidance from any relevant public health body that mandates 6-foot distancing at all times. Even the new Centers for Disease Control and Prevention (CDC) school strategy, released February 12, doesn’t address the key problems in the existing guidance to move us forward.

The union also named a lack of asymptomatic testing for teachers as a major barrier to returning to in-person learning. To get kids back to school, we implemented such a routine testing plan, at great cost and logistical effort. We discovered that since testing began in January 2021, the positivity rate among teachers and staff has been approximately 0.15 percent — while cases were surging in the Boston metro area — and our contact tracing efforts have not identified any cases of in-building transmission.

Even so, the union continues to resist a return to full in-person learning. What’s more, the goalpost seems to have shifted again, now to universal vaccination of teachers.

All of this is frustrating, especially to me as an epidemiologist. Generally, union leaders tie their position to public health guidance from bodies like the CDC. But so far, the implementation of these recommendations by our district’s union — and by many others across the country — has been opportunistic, and their stance does not align with current guidance from the World Health Organization, CDC, Massachusetts Department of Public Health, or the Massachusetts Department of Education.

This tension has been agonizing. Because not only do I support organized labor, having previously stood with my town’s educator union in negotiations with the district, but also because union representatives are among our family’s most beloved teachers.

I want our teachers to be safe — and feel safe — at work. I also empathize strongly with the fear and anxiety that they feel. That fear is real. I felt it too when I entered the hospital for work last spring. That fear traumatized me and still makes me tearful when I recall those early, terrifying days of the pandemic.

But as we approach the one-year anniversary of remote education in America, I find that I am losing sympathy for the educators’ position and their myopic vision this far along into the pandemic. We can open schools safely, and we have the evidence in hand to prove it.

We have the science to safely reopen — and know the stakes

When Covid-19 began to spread in the US last year, teachers were right to be worried about schools. We knew almost nothing about the virus’s spread. Operating schools under business-as-usual conditions very well could have led to more infections among teachers, students, and people in the community.

But since then, we have accumulated a massive amount of data about how to keep schools open safely.

First, last spring, we observed the experiences of other countries like Scotland, Singapore, and France, where schools reopened and masks and social distancing seemed to prevent large-scale transmission.

In the US, epidemiologists compared the timing of school closures to changes in Covid-19 incidence. Some studies found that school closures might have reduced the spread of illness, but the findings are complicated because we were also making other major public health changes at the same time. And overall they failed to find a strong link.

Data and patterns also began to emerge about children’s Covid-19 test results and their exposures. Playdates with friends emerged as the common exposure among the infected; time in school did not.

Still, as reassuring as the data was, it was all indirect. The gold standard to learn if schools can open safely is fairly simple: Open schools, measure Covid-19 incidence, and see what happens. Many US school districts have now done this, and we have the data.

First, researchers in North Carolina published results from 11 school districts and more than 100,000 students and staff. Schools in those districts employed mandatory masking and 6-foot distancing where feasible, but no major capital improvement to HVAC systems or buildings. In the first quarter of this school year, they found the rate of transmission of Covid-19 in schools was dramatically lower (roughly 1/25) than the level of transmission in the community. Among all of the Covid-19 infections observed in schools, the state health department’s tracers found 96 percent were acquired in the community, and there were no documented cases of the virus passing from child to adult in schools — zero.

Second, a similar study followed 17 schools in Wisconsin. Like North Carolina, those schools required masks indoors, 3-foot distancing with an effort to distance farther whenever feasible, and no major capital improvements. Between August 31 and November 29, with more than 4,500 students and 650 staff, they found seven cases of coronavirus transmission to children and also found no cases of coronavirus transmission to educators in the buildings. Further, these schools eliminated transmission at the same time that the surrounding community saw a rapid rise in Covid-19 cases.

A third important preprint study analyzes data from two schools in Atlanta. This study is small, but it is important because the schools were conducting routine asymptomatic screening of students, teachers, and staff. In Atlanta, 72 percent of the limited number of transmission events in one school were known to be the result of noncompliance with masking. And again here, there were no cases transmitted from students to teachers.

Sadly, at the same time that we are learning definitively that we can open schools safely and essentially prevent Covid-19 transmission, data is emerging about the real damage being done to children by prolonged remote learning, including a rise in the use of pediatric emergency rooms for psychiatric illnesses, increasing anxiety and depression symptoms, losses in learning progress, and large racial disparities in the availability of in-person instruction and educational achievement.

Furthermore, most private and parochial schools across America have been successfully open for the school year — many having seen an increase in enrollment for this reason — while most public school districts have been either partially or fully remote. We cannot allow these repugnant inequities to fester any longer.

We don’t need to wait for universal vaccination — or more time — to reopen schools

I appreciate that returning to in-person learning carries some risk for educators. There is no immediately foreseeable scenario in which there will be truly no risk of Covid-19 infection in school settings.

However, insisting on a zero-risk scenario for school reopening is a commitment to long-term remote learning, which most people agree is not acceptable. We owe it to educators to do everything we can to mitigate risk.

Vaccines can help lower this risk even further but do not save the day just yet. It will take time to vaccinate all teachers (who are only currently eligible for shots in just over half of states) and, still longer, students. And even when people are vaccinated, we do not yet know for certain that the vaccine prevents transmission of the virus (which has been a sticking point for educators and their unions because it means that, theoretically, they could pick up the infection without getting sick and transmit it to others, like unvaccinated family members).

Still, all states need to immediately put teachers at the head of the vaccine line. If we are asking teachers to assume any risk and return to classrooms for the sake of education and our society, then our society should treat them as the essential individuals they are.

At the same time, teachers also need to recognize that full vaccination is not a prerequisite for safe schools, as some educator unions have called for. We did not have a vaccine in North Carolina or Wisconsin when they safely opened schools in August 2020.

We must also not let other demands, such as universal asymptomatic testing or large-scale capital improvements to buildings, stymie the return to in-person learning. Yes, we should be working to implement more screening in schools and improving air exchange, but we can do that in parallel with reopening. We know now from good data that we can effectively stop Covid-19 at the school doors and get American education back on track without these things. Essentially, all we need to safely reopen schools are mask mandates, reasonable distancing of at least 3 feet, minor and affordable upgrades to existing HVAC systems, and teachers.

Many educators and their representatives have proposed we wait out this school year in whatever form it is taking and assess the prospects for reopening public schools over the summer. But for millions of Americans, “the next few months” are a crisis of lost income, unstable housing, and mental health disorders that cannot wait until next year.

It is also true that many people of color whose communities have been hardest hit by Covid-19 are worried about the safety of returning to school, and a lot of urban Black and Latinx families have elected to remain in remote learning even when an option for in-person school exists. To bring families back to school, we need to earn trust. The best way to do that is to open our school buildings and establish an empirical track record of safety while families still have the option of remote learning.

If we hope for our schools to be open full time in fall 2021 and for all families to feel more comfortable in the building, our best chance for success will be if we begin the ramp-up now.

A realistic plan for reopening schools is to immediately begin bringing the youngest learners back to full-time in-person learning with strict guidance for masking indoors, 3-foot minimal distancing with effort to maximize distance as much as possible. Districts can certainly conduct air-exchange surveys in classrooms as an extra precautionary measure and use simple and affordable mitigation strategies for suboptimal conditions, such as upgrading HVAC filters, opening windows, and deploying portable HEPA filters in problem spaces.

Over the course of the rest of February and March, successive waves of older learners can return to school with the same guidelines, in a stepped process that allows teachers and administrators to adapt to growing numbers of students in their buildings.

With this approach, we could have every public school child back to safe in-person learning by April — without optimal screening, before wide-spread vaccination, and without community transmission benchmarks that reflexively trigger school closures.

So, here we are, nearly one year into our national project in remote learning. It is clear that we did what was needed when Covid-19 struck. But it is also quite clear that our solution — remote learning — is failing our children and our families.

I love my kids’ teachers and believe in my core that they want what is best for my girls, but I am losing patience. The time has arrived to open our schools for in-person learning — now. We should be working to quickly implement universal asymptomatic testing of teachers as well as universal vaccination, but we cannot wait for those things to be in place before we begin moving. And the science shows that we don’t need to. At stake is the 2021-22 school year and, arguably, the future of American public education itself.

Benjamin P. Linas is an associate professor of epidemiology and an infectious disease physician at Boston University School of Medicine. Find him on Twitter @BenjaminLinas.

Blue states and red states are both doing school reopenings wrong

2020-11-19T11:14:42-05:00

Students at Wilson High School in West Lawn, Pennsylvania, on October 22. The school has been taking precautions for in-person classes to prevent the spread of the coronavirus. | Ben Hasty/MediaNews Group/Reading Eagle/Getty Images

As America enters another phase of rapid growth in cases and hospitalizations in its Covid-19 epidemic, among the mounting losses is public education. Schools around the nation are being forced to return to remote learning, or have never returned to an in-person model. Without a national policy, states and even individual school districts have been left to navigate the high-stakes and difficult decision of whether to proceed with in-person, hybrid, or remote education alone.

Unfortunately, many of these decisions seem to be driven by partisanship, rather than solid public health guidance and robust evidence. Much of the pattern of public school reopenings falls along political lines. The map of districts that are learning in-person and those that are in some form of hybrid or remote learning looks strikingly like an electoral map, with many politically “red” states largely allowing in-person classes, and many “blue” states doing hybrid or remote. And neither side — red or blue — has gotten it right.

Understanding how we are currently failing helps to shed light on how an effective, national strategy to open America’s schools, which the incoming Biden administration could spearhead, should look.

Blue states’ policies ultimately hurt children and families without controlling Covid-19

Blue states, which I define here as states that have voted Democratic in recent presidential elections, are certainly not a monolith, and there is variety among districts’ approaches. These, however, are more likely than red states to have remote or hybrid learning plans and are less likely to have fully in-person learning, as a Brookings analysis found.

In California and Washington, for example, approximately half of students remain in fully remote learning. In New York, about 74 percent are currently in a fully remote or a hybrid model, with about 26 percent in full-time in-person learning.

Over the summer, when plans for reopening were being developed and put into place, many blue states enjoyed low rates of Covid-19 transmission, making opening schools there fairly low risk, per Centers for Disease Control and Prevention (CDC) guidance. Nevertheless, many districts in states such as California and New York proceeded with all-remote or hybrid models in which millions of children were not receiving much, if any, in-person instruction with professional educators.

In September and October, when daily case rates were rising slowly, but still under reasonable control, these states were slow to bring children back to school. Now that case rates are rising more quickly in much of the country, these districts remain in remote and hybrid models, and have perhaps missed their window to reopen.

At the same time, data has been emerging about the harms of ongoing school closures. Washington, DC’s public schools, which remain in a largely remote model despite having low local new case rates until recently, report substantial reductions in kindergarten students meeting or exceeding benchmarks for reading. And Chicago Public Schools, which also remain in a largely remote model, report a stunning 15,000-student decrease in enrollment this year. Unforeseen extended school closures lead to lower test scores, lower educational attainment, and decreased earning potential.

These gaps are not impacting all groups equally. The Center on Reinventing Public Education (CRPE) reports that districts with the highest rates of poverty are nearly twice as likely to be operating with remote learning as districts with the lowest rates. The higher a district’s share of white students, the more likely it is to offer in-person instruction — a pattern that generally holds across cities, towns, suburbs, and rural areas. A great racial and economic disparity is widening unnecessarily, one that will be sewn into the fabric of our society even beyond this generation if we do not rectify the problem now.

Blue states are trying to control their Covid-19 epidemics, which is absolutely appropriate in the middle of a pandemic, but they misunderstand the utility of school closures. We now have experience with school openings, both in the US and globally, and there is little data to support the idea that schools are a major site of transmission or a driver of community spread.

For example, New York City has had schools open in a hybrid model since early October and monitors Covid-19 in the district by testing a random sample of students and staff. As of November 12, results show that of more than 123,585 total tests conducted since October 9, only 228 were positive (0.19 percent) — 95 students and 133 staff. These results are still early in the year, and students are not back yet full-time, but with more than a month of data, and during a time when cases are rising in New York generally, Covid-19 is not tearing through New York City public schools.

Nationally, the most recent data on the Covid-19 School Response Dashboard shows Covid-19 case rates among students and staff that are generally the same or lower than rates in the surrounding community. Nationally, there is no evidence that schools are hot zones of transmission.

To be clear, as rates rise in the community, rates are rising in schools. Children, of course, can be infected with Covid-19, and schools are not protected zones. But because schools have not been identified as a location where many cases of Covid-19 are transmitted, it is reasonable to think that with proper mitigation and a careful approach, we could have schools open and see little impact on Covid-19 transmission.

In comparison, there is a great deal of evidence that indoor dining, bars, and gyms are common sites of Covid-19 transmission. In a CDC study that tested 314 individuals for Covid-19, those who were infected were about twice as likely to report recently eating in a restaurant as those who tested negative. And the Wellcome Trust, which has been tracking the sites of reported Covid-19 outbreaks since the epidemic began, found many examples of clusters linked to a wide range of other indoor settings, including restaurants, bars, parties, and workplaces, with few reports coming from schools.

Despite the evidence that schools often have lower Covid-19 rates than their surrounding communities and that gathering in settings like restaurants, bars, and gyms drives Covid-19 transmission, many of the states that vote blue are maintaining remote and hybrid educational models while simultaneously trying to minimize restrictions on businesses.

In Boston, where case counts are rising, Mayor Marty Walsh announced in October that the city would move all public schools there to remote learning to, he says, protect the health of children and staff.

But restaurants have remained open in Boston, as have gyms and other public meeting places. The governor of Massachusetts recently enacted a statewide curfew on bars and restaurants, but he did not close them.

Philadelphia announced recently that its schools will remain in a fully remote model for the indefinite future. The Philadelphia situation is complex, because the city is now seeing out-of-control Covid-19 transmission, with case rates over 270 new cases per 100,000 people and a 12.5 percent test positivity rate as of November 13, which puts it in the CDC’s “highest risk” category for school opening. With this much coronavirus circulating in the community, it’s wise to close schools.

At the same time, the state of Pennsylvania remains in the “green” phase of reopening, meaning that there are minimal restrictions on businesses and meetings. In effect, the only response to the alarming case rates has been to close the schools.

Schools do not operate in a bubble, of course. If closing schools is the only intervention a jurisdiction takes to control its Covid-19 epidemic, incidence will continue to rise and schools will remain shuttered indefinitely.

Quickly closing schools — where we have not seen a lot of transmission — while leaving higher-risk establishments open — where there is a lot of transmission — does not make sense. When faced with overwhelming case surge and crushing hospital demand, school closure could be necessary to prevent further Covid-19 surge, but only as one component of a larger plan to reduce mobility and control transmission.

Further, when school closures are necessary, if those closures are not coupled with restrictions designed to more generally reduce social mobility and prevent transmission, then Covid-19 cases will continue to rise and it will become still more difficult to open schools. Right now, in many blue states, schools are the first thing to close, while governors try desperately not to impact businesses. Such a policy is sacrificing our children in favor of working out, going out to dinner, and meeting friends for drinks. Blue states have it wrong.

Red states’ schools are open, often when they should not be

If the blue states are for holding back, many red states are recklessly opening their schools and increasing the odds of exposing children and staff to Covid-19 in the midst of raging outbreaks.

Many states that have voted Republican in recent presidential elections had more districts that returned to fully in-person learning this fall, even as their states were recording new highs in Covid-19 infections.

One district just outside of Salt Lake City, Utah, reopened for in-person learning at the same time that it saw case counts rising dramatically in their community. Approximately one month later, it reported one of the largest known school-based outbreaks to date. Many schools in Indiana opened for full in-person instruction in August, as the state was experiencing nearly 1,000 new Covid-19 diagnoses per day. Several schools quickly closed again when Covid-19 cases presented in schools there.

By late October, Indiana had reported a cumulative prevalence of more than 5,000 cases of Covid-19 in its schools. In Idaho, where the largest districts have been either in-person or hybrid since September and community transmission is among the top 10 highest per capita in the country, schools saw their cases double in the first month and reported over 4,000 cases by mid-October.

Districts that have seen more Covid-19 in their schools have two things in common:

1) They opened when case rates in the community were very high, clearly higher than public health guidance recommends for safe reopening. For example, when Utah opened schools, the 14-day moving average of Covid-19 case rate in the community was 187 per 100,000 people, far above the CDC’s threshold for “lower risk” reopening, which is 50 per 100,000 people.

2) They did not have statewide mask mandates, or masks were not routinely in use.

Conservatives argue that we cannot continue to hide from Covid-19 and that we must return to our normal activities, like school and work, if our country is to thrive. The paradox is excruciating to public health professionals, because we all agree: We do need to live and work in this pandemic and we do need to have our children in school.

But creating a false choice between reopening our economy and controlling the Covid-19 epidemic is counterproductive and will ultimately result in more Covid-19 cases and worse economic performance.

Behind the drive to return to life as it was before the pandemic is a very real concern for the economy. One estimate of the economic damage caused by Covid-19 is $16 trillion, an unfathomably large number.

The economy cannot truly return until we have Covid-19 under better control. If the disease is still surging in our communities, students are exposed and need to quarantine for 14 days — and in many cases, their parents cannot go to work. Some people might suggest that we simply stop the quarantining, continue to work, and abandon all efforts to control transmission in favor of economic stability. But we have seen what happens when Covid-19 spreads without mitigation; it overwhelms hospitals and threatens to collapse the health care system.

Further, the harms of out-of-control Covid-19 transmission are distributed unevenly in our society. The same way that closing schools tends to harm children of color and vulnerable populations, raging Covid-19 transmission tends to impact people of color and the under-served. Black and Latinx people are two and a half to three times more likely to contract Covid-19 than white Americans, and four to five times more likely to require hospitalization. These disparities reflect the fact that Black and Latinx people are less likely to be working at home and more likely to live in close quarters, outcomes of structural racism.

The way to safely and more equitably reopen our schools and our economy is first to control Covid-19 in our communities so that it is safe to open schools, and then to consolidate those gains with strict mask mandates and reasonable restriction on social gathering. Blindly opening schools as one plank in a platform of Covid-19 denialism is exploiting our children for political gain and is unacceptable.

What a smart plan to open schools in America would look like

Our current political leaders are failing to provide a clear, national plan for reopening America’s schools. The incoming Biden-Harris administration has announced that it will provide new funds and guidance, but details have not yet emerged. Below are four essential elements for such a plan.

1) Clear guidance for when and how to open (and close) schools

Such guidance includes two components. One is reasonable, evidence-based thresholds for opening and closing our schools. The CDC has such guidance, but it is not clear how the thresholds were chosen. Further, the guidance has no bite.

At no time has the CDC said that districts may not open above a given threshold. They simply “advise caution” or “reconsideration” of current policy. We need strong federal action to prevent schools from opening when Covid-19 is not yet controlled in their communities. We also need clear and effective guidance for when schools should be open.

Second is making new strategy that envisions schools as one part of a larger public health policy. No district should employ school closures as the first intervention when Covid-19 cases rise. In a Covid-19 crisis, it may be necessary to close schools, but if so, then the school closures must be one component of a larger strategy that seeks to generally reduce mobility and social interaction, including restrictions on activities such as indoor dining, bars, gyms, and other places that we know Covid-19 is being transmitted.

2) Clear guidance for distancing in schools

While 6 feet has become the default stance on appropriate distancing from others in most of the US, 6-foot distance requirements greatly limit the ability of public schools to bring all students back full-time. The reality is, in many public school districts, if we insist on all students being 6 feet apart at all times, many districts simply will not have the space (and thus not really be able to bring all kids back to school full-time until there is an effective, widely distributed vaccine). That means that there is a very realistic scenario in which even in 2021 schools will need to use a hybrid instructional model.

Globally, the WHO identifies 1 meter (about 3.3 feet) as a minimum for distance from others. We need data-driven guidance for situations in which it is acceptable to distance less than 6 feet in educational settings.

Fortunately, data does exist to help us gauge the risk of Covid-19 transmission with contact of various distances. Perhaps, with quiet activity and good air flow and all students reliably in masks, a 4-foot distance might be acceptable. Covid-19 is always a question of risk and benefit. The benefit of being back in school full-time is clear. What are the real risks of occasionally being 4 to 5 feet apart during the school day if everyone is wearing masks?

3) Strong mask mandates at the federal, state, district, and school levels

Every message from every person of authority needs to reiterate the civic duty to wear a mask in public. Currently, many states leave masking mandates up to districts. This needs to change. People do not have a right to walk down the street naked, and almost every school district has a definition of clothing that is not appropriate to wear in school. Likewise, people do not have a right to have a naked face in school during this viral pandemic, and not wearing a mask is at least as inappropriate as wearing short shorts.

4) Robust testing and contact tracing

It’s critical that whenever any child develops symptoms consistent with Covid-19, it is fast, easy, and free to obtain testing. It is not possible for parents to keep their child out of school for many days every time that child develops a new runny nose, or winter cough. Symptomatic testing is important to make it possible to stay in school.

The role for asymptomatic screening is more complex. Routinely screening all members of the community holds promise as a strategy to identify and quarantine asymptomatic cases that may otherwise come to school. But we do not currently have the infrastructure or resources to make this happen. And in any case, the real pillars of safe school operation are community control, masks, and distancing. We cannot make asymptomatic screening a prerequisite to opening schools, because if we do, we will not be able to reopen.

This is what a plan to reopen looks like, but implementing it requires courageous leadership at the federal and state levels. With this plan in place, however, America can open its schools, keep students and teachers healthy, and contribute to a larger public health strategy to end the Covid-19 epidemic.

Benjamin P. Linas is an associate professor of epidemiology and an infectious disease physician at Boston University School of Medicine. Find him on Twitter @BenjaminLinas.

I’m an epidemiologist and a dad. Here’s why I think schools should reopen.

2020-07-31T14:13:22-04:00

Gov. Mifflin High School in Shillington, Pennsylvania, on May 1, 2020. | Ben Hasty/MediaNews Group/Reading Eagle/Getty Images

Covid-19 is upending our lives and forcing us to make complex decisions with little information and conflicting guidance from authorities. Summer, typically the season of staying up late and popsicles in the park, offers no escape. Many of us are already turning to the fall, and the fate of schools.

What will we do with our kids? Can we really send them back to school? If we keep them at home, will they forget how to read? If we send them to school, what might be the consequence? We are living a nightmare, but this is where we are. The choices are high-stakes and plagued by uncertainty. Even thinking about them makes me sweat.

I am the father of three girls ages 16, 13, and 10, and like every parent in America, I am worried about the fall.

I’m also an infectious disease doctor and epidemiologist, and have spent the past four months drinking from the fire hose of Covid-19 science, designing infection control policies for my hospital, and caring for patients on the front line. I serve on the reopening committee for my synagogue and for my school district. I consult for businesses as they reopen.

I have a first-row seat to the coronavirus pandemic, both as a parent and as a professional. In both of those roles, I hear the same questions, repeated with mounting urgency: “Are our kids going to be safe?” “Are our teachers going to be safe?” “Will kids bring Covid-19 home to our family?” “Will opening schools lead to a second wave and lockdown?” “What are the risks of not reopening?”

I have spent time reviewing the data and seeking answers to the challenging questions we face. Having the knowledge to make your own assessment, however, need not be a position of professional privilege. With this short primer, I hope you can add your voice to the debate and advocate for yourself, your family, and your community. The good news is, we can hope to send kids back to school in the fall, but there is a lot of work to do.

Are our kids going to be safe?

If any of us is ever going to send our kids to school again, we need a clear answer. Fortunately, I think we have one, at least for the children. Children are less likely than adults to be infected with Covid-19. There are multiple ways to study this question, and all the approaches arrive at this same conclusion.

First, when we look at public health reporting, children under the age of 18 make up only 2 percent of cases in the US, even though they represent 22 percent of the total population. Similar studies in Chicago and Massachusetts found that children make up fewer Covid-19 cases than expected, as have studies in Italy, South Korea, and Iceland. For me, that is a lot of similar results for this to be a fluke. When one study in one location produces a finding, it is notable. When five studies from five different settings find the same thing, it is compelling.

One reason case counts may be lower among kids than would be expected is that we did close our schools in March. Maybe we protected our kids by keeping them out of harm’s way. But if we send them back to school this fall, will they still enjoy protected status from the coronavirus?

One way to study this question is to estimate the “attack rate” of the disease — that is, the proportion of people exposed who become infected. Multiple studies from China investigated the attack rate among people living in a house with someone who is infected. They found that only about 4 to 5 percent of kids developed an active infection. In comparison, about 17 to 20 percent of adults became infected after exposure.

To be fair, data in the US is more concerning. In New York state, 57 percent of people living with a Covid-infected person developed an infection. It is hard to take reassurance from that fact. But even with such a high attack rate, children were still less likely to develop an infection and there was a gradient over ages, a sort of “dose effect” for age.

Finally, even in the worst-case scenario, in which a child does contract Covid-19, the outcomes of the disease are less severe in younger people than among older adults. In one analysis of more than 550 confirmed cases among children under age 18 in China, Italy, and Spain, only nine people (1.6 percent) had severe or critical disease. In another study, approximately 5 percent (one out of 20) developed symptoms that required hospitalization, but only 0.6 percent required intensive care. In comparison, a recent Centers for Disease Control and Prevention report indicates that among those ages 60 to 69 who have the coronavirus, 22 percent require hospitalization and 4 percent require intensive care.

Are teachers going to be safe?

There is far less data specifically on teachers and staff than on kids. One study in France is reassuring. In that investigation of 541 students and 46 teachers, there were no documented transmission events from students to teachers. However, while many of us immediately think of the risk to teachers from exposure in the classroom, we may not consider the additional risk that teachers face in break rooms and staff meetings.

Working in the hospital, I have personally seen that staff have a difficult time maintaining personal protection at all times. Doctors and nurses tend to let down their guard when they are away from patients and during breaks. Masks come down, people eat snacks in potentially unsafe spaces, and social distancing lessens.

The same will likely be true in schools. The potential risk to teachers, therefore, goes beyond the classroom. Staff risk in schools likely looks similar to the risk of any adult working in a crowded indoor environment during the pandemic. School opening plans must consider teacher safety in addition to the well-being of students.

Will my kids bring Covid-19 home to our family?

For most parents, the next question after the safety of their kids will be their own safety and that of loved ones in the house. Even if the kids are all right, could they bring the coronavirus home?

Here, again, the data appears reassuring. One large review of over 700 scientific publications found that children accounted for only a small fraction of Covid-19 cases, and that they were rarely the first case in a cluster of infections in a household. For example, in China, only 5 percent of household clusters were found to have a child as the index case. Similarly, in Switzerland and Holland, children accounted for only 8 percent of household transmission clusters.

Unfortunately, the US numbers make me a little less certain. In a Chicago study of 15 households with available data, 73 percent of infected children contracted the virus from an adult. However, that means that 27 percent of infections were child-to-child, which is substantially more than 5 to 8 percent.

Still, the Chicago study only examined 15 households, and adult-to-child transmission remained far more common than child-to-child or child-to-adult.

Will someone in America contract Covid-19 from their sick child? Yes. Should I structure my life around such a rare occurrence? I do not think so.

Will opening schools lead to a second wave and more lockdowns?

We have reached the most challenging question to answer and one that is a holy grail for Covid-19 epidemiologists. I want to give you the plain answer here — we do not know.

An objective summary of the evidence in hand suggests that schools will play little role in sustaining the pandemic. A recent review of 210 transmission clusters around the world found that only eight of them (3.8 percent) involved school transmission. Case studies of outbreak investigations in Ireland, France, and Australia demonstrate almost zero cases of in-school transmission.

Modeling studies demonstrate no clear role of in-school transmission in explaining current Covid-19 epidemiology. All of this data tells us that despite our gut instincts and parental anxiety, schools will likely be okay this fall.

But the story does not end there. First, there are examples of in-school outbreaks that did force a second shutdown. Israel is an example.

Israel reopened schools with limited class sizes in early May and lifted class size restrictions on May 17. By June 3, they had to reclose after a major outbreak. The largest outbreak was 116 students and 14 teachers at one school. Per NPR, one child tested positive without symptoms and the school decided to quarantine the grade. Next, a child in a different grade tested positive and they closed the school.

At that time, they discovered that they already had more than 100 cases. It is not certain that all of those children were infected in the school, but the story is concerning and it raises the bar on monitoring our schools.

The data that’s available is mixed. If a person (or school district) wants to tell you that schools play little role in transmission, then ask them how their district is different from Israel’s. Why can an outbreak happen in that setting but not yours? Perhaps there is a reason, but until someone can give you a good one, be skeptical.

What are the risks of not reopening?

A discussion of school closures that focuses only on Covid-19 and not at all on education is incomplete. There are real risks to keeping our children at home. In fact, the risks of staying home are in many ways clearer than the risks of returning to school.

One study using statistical models projects major losses in math performance if we continue with remote learning until 2021. Perhaps more compelling than statistics, however, is some simple common sense.

On any given day, it is hard to point to the loss of learning from home. At the same time, we all agree that education is essential. If we keep our kids home for another school year, they will have missed 12 percent of their total education. I cannot identify the specific losses from that much absence, but I am confident there is a cost to missing that much school. For perspective, missing 12 percent of school time is the same as missing 22 days of school in a single year.

Further, the losses will not be equal. The “Covid-19 slide” will likely be greatest among the socially vulnerable, such as children with learning disabilities and those whose situation at home is not conducive to homeschooling.

We must also acknowledge that the losses will hit people of color much harder than those who are white. Further, school officials account for approximately 20 percent of formal reports of child abuse and domestic violence. Without school-based counselors and social workers, these concerns may not be investigated.

All of these harms weighed on the American Academy of Pediatrics’ guidance that school reopening plans start with the goal of having students be physically present in schools.

What should we do?

A great mentor of mine, Milton Weinstein at Harvard, is generally credited as being the person who introduced the field of medicine to the concept of rigorous decision-science. The central question to all decision-science is: “What should we do, given that we have imperfect information?”

Milt is fond of the expression “a decision has to be made.” His wisdom has never been more pertinent than it is today. We have to make a decision. There is no choice to do nothing, because either way — go to school or learn remotely — we are making a decision.

Unfortunately for all of us, we are making a decision with significant uncertainty about all the risks involved. Fortunately, this is not the first time that people have been forced to make decisions with uncertainty. There are approaches to making uncertain decisions in a way that maximizes the chances of a good outcome and minimizes the harm if the outcome is poor.

You’ve likely heard of one of them: hedging your bets. When multibillion-dollar investment funds make a choice to invest, they recognize that they could be wrong. They do not make all-in versus out decisions. Instead, they hedge their bets. They may think that the newest beach toy is destined for greatness, but just in case of a rainy summer, they also invest in umbrellas.

When I look across all the data, I see an uncertain decision. First, I propose that the balance of data we have now suggests that we need to try to open schools in the fall. The risks of reopening are uncertain; the harm of staying home is clear.

If your school district cites the data above to you that “schools are safe,” ask your school board: What is the plan beyond reopening? What if we are wrong? How will your district know that things are going well (or not well)? Don’t let the conversation stop at “data suggests that schools are safe.” Don’t let the plan stop with “symptomatic people should call their doctor.”

If we are going to open safely in the fall, we must have the capacity to know — quickly — when an outbreak occurs. Israel is an important cautionary tale. When Israel closed down its schools again, it had only identified two school-based cases, yet in the end it discovered that more than 100 students had been infected.

To do this well, and to do it safely, we must have school-based Covid-19 symptom screening, testing, contact tracing, and isolation. “School-based testing” does not mean that the test themselves must occur in school buildings. “School-based testing” means that students and teachers can easily access a test by contacting the school, and that the results of those tests are sent directly to the school district in real time.

That seems straightforward, but it is not. The community does not yet have adequate testing, contact tracing, or isolation. Schools currently have nothing.

It requires building new capacity in schools for testing and contact tracing. It requires a budget. It requires a formal plan. Ideally, that budget should come from the federal government and be directed to states and ultimately school districts, as part of a national Covid-19 testing strategy. Realistically, given the lack of any such national plan, the funds need to come from individual states.

Building such infrastructure comes at a cost and many districts are already facing budget shortfalls. Districts that rely only on their existing testing infrastructure will not have the real-time information they need to make good decisions. Imagine a child has a fever and cough in October and is told by the school to call the doctor for a Covid-19 test. Results are typically returned in two days to the doctor’s office. After another day (or two), the data might make it to the school district. So it will take at least four to five days for the district to have any information.

We need testing within the school system to shorten the delay at every step of the process and reduce the turnaround time for the test to only a day. With that kind of time resolution, we can increase awareness of the situation at our schools, along with the ability to react appropriately. Without it, we are flying blind and gambling with the health of our children, teachers, and community.

Ultimately, when I look at the decision about school as both a father and a scientist, I see a difficult decision that must be made despite uncertainty. The risks of opening are uncertain, but the benefits are clear. We need to try to reopen.

We have been wrong before about Covid-19. In March, the epidemiology world was quite confident that transmission could not occur before a person develops symptoms. Three months later, there is consensus that asymptomatic people were likely one of the main drivers of the pandemic. In March, the CDC and the US surgeon general told the public that masks play no role in controlling the spread of the disease. Now we see masks as a central component of our reopening strategies.

We could be wrong about schools, but we cannot afford to wait to find out for certain. We need school-based Covid-19 symptom screening, testing, contact tracing, and isolation. Opening without a plan to test is irresponsible and a gamble with our children’s health.

Benjamin P. Linas is an associate professor of epidemiology and an infectious disease physician at Boston University School of Medicine. Find him on Twitter @BenjaminLinas.