Sometimes you can feel an inflection point.
We’re seeing it in waste water, where, in the Boston area, evidence of COVID-19 has been plummeting for about a week.
That already seems to be reflected in moderating case numbers. And, soon, we may start to witness a radical shift in how we think about COVID and school.
Such a shift would impact a core part of society, one that has been a lightning rod for the last two years. And it may set the stage for a new chapter in the pandemic.
David Rubin, a pediatrician at Children’s Hospital of Philadelphia — one of the largest children’s hospitals in the country — insists: Not only do we need to keep schools open, but our entire approach to kids also has to change.
“I think if you were to ask a lot of folks, they were sort of waiting for someone to dip their toe in and say: ‘We need a reset,’” he says.
Rubin, who runs his hospital’s PolicyLab and serves as a professor of pediatrics at the University of Pennsylvania’s Perelman School of Medicine, has worked with colleagues on what might feel like fairly radical new guidelines.
Among other things, they argue that we should stop regularly testing asymptomatic kids, and we should allow teachers and students with in-school exposure to stay in school if they’re asymptomatic (they call it “mask to stay”).
If the exposure comes from home (where people spend more of their time and are more likely to spread the virus), “mask to stay” should be allowed only if the individual in question is vaccinated. That person could also be included in a smaller, more targeted test-to-stay program.
Rubin knows these proposals are unusual, at least for this moment. And for some, they’ll feel scary.
But, he says, we have hit that all-important inflection point. And if nothing changes about the labyrinth of policies we currently rely on, he’s worried about the road we’re headed down.
“Kids were asked to shoulder a lot of the burden last year in a collective community response to COVID. Now the issues around prolonging social isolation or continuing to deny access to in-person education are so far greater than the risk of the virus itself. Not just to the children but to their families themselves, particularly now that people can get vaccinated.”
Since 2022 began, some large districts — like Chicago, Milwaukee, and Atlanta — have closed or gone remote for at least a few days. Even in towns and cities that stayed open, many students and teachers have missed lots of school due to quarantines.
Testing — which is often hard to get — has seemed key to keeping schools open.
And, Rubin says, it has been. Children’s Hospital of Philadelphia runs a large testing program and advocated for test-to-stay policies early on. But in a fast-moving pandemic, such programs may become less and less important.
“When everyone’s exposed,” Rubin told me, “what does it mean to test everyone every week? This is a different phase.”
In the last few days, in fact, we’ve seen the entire state of Vermont make the shift away from routine, asymptomatic testing, instead allowing parents to do rapid testing at home when it makes sense.
“Many of the strategies that previously were effective for us will cease to be useful (if they haven’t already),” wrote Vermont Secretary of Education Dan French, “and will instead become a drain on scarce resources without a clear public health benefit.”
Dr. Benjamin Lee, a pediatrician at the Larner College of Medicine at the University of Vermont, warns that we need a new way of thinking about the pandemic.
“I do think it makes sense to understand that ... the days of relying on a centralized top-down response may no longer be the best approach going forward,” he told Vermont Public Radio.
Governor Charlie Baker may be edging toward this view as well, announcing on Tuesday that Massachusetts schools can now adopt at-home rapid testing as an alternative to the more formal “test and stay.”
Delaware County, just outside Philadelphia, has formally embraced CHOP’s recommendations, including allowing asymptomatic students and staff to stay in school if their exposure to COVID comes from a non-household member.
Rubin says that CHOP’s test-to-stay program taught him that “even though we got a lot of schools to do it, and we trained a lot of people to do it, a lot of schools couldn’t do it. Particularly under-resourced schools could not pull it off in a way that maybe other schools that had more resources could.
“So you started to create a system of the haves and the have-nots. And so you had some schools where kids were quarantined for 10, 14 days. And other schools that were getting their kids back in five days.” He said those disparities started to weigh on him.
And it’s important to acknowledge, he says, what is lost when kids quarantine.
There was a mental health crisis among kids before the pandemic, but now hospitals are increasingly seeing the effects of isolation and distancing.
As the Centers for Disease Control and Prevention has made clear, ER visits for suicide attempts among young people (particularly girls) skyrocketed during the pandemic. And this fall, the American Academy of Pediatrics declared a “national emergency” due to “soaring rates of mental health challenges” since the spring of 2020.
As a parent of young children who has been following local, state, and school coronavirus guidelines with a fervor that I generally reserve for returns on election night, it’s hard to imagine us ever getting out of this thicket of regulations, testing, and quarantines.
Can you really keep schools running when kids and teachers are exposed, but not routinely tested, as Rubin would have it?
Yes, he says. Because there are risks on both sides of the ledger.
“We’re actually seeing the patients. We’re seeing the spectrum of illness firsthand. And we’re also seeing the competing risks in our patients. And it’s time for someone with that level of authority that’s unconflicted, that’s not a health department, that’s not the CDC, to say: From our vantage point, the calculus now has changed.”
He says that, judging from what he sees in the hospital, COVID is now acting more like “a seasonal virus, with regards to the spectrum of disease,” and it’s not going away anytime soon. Along with other respiratory viruses, it will simply continue to circulate.
I asked Rubin about teachers who might be worried about walking into a school in which asymptomatic kids are “masking to stay.”
“Welcome to all of our world over the last couple of weeks,” he says. “I hear what you’re saying, but we have folks — restaurant workers, health care workers — who face that every day. And it’s not just from their patients — it’s from their colleagues. And that’s the world of Omicron.
“I would remind them that it’s the vaccination and the boosters, when they’re eligible, that are protective,” he says. “And in a typical flu season, no one would wear masks. You’re probably at a higher risk in that season of getting the flu. And flu can have particularly severe consequences. But for vaccinated individuals, boosted individuals, the risk is far lower.”
He says that for some very high-risk teachers, accommodations could be made on an individual basis.
Also, if a student or teacher has a health condition, they may want to continue to test frequently. “Let’s make that more of a voluntary or optional program, and we should provide the access to those individuals who do need to know.”
The transition back to normal, he says, also will eventually mean that kids take off their masks. (In December, as the Omicron wave was rising, he and his colleagues at CHOP “implored the schools” to keep masks on, but cases will soon start to fall.)
“I think most schools look at declining transmission and declining hospitalization,” Rubin says. “And so we’re helping schools try to identify when that moment is because everyone is doing it a little differently. But I think by February, we’re going to start to see a lot of schools moving to mask-optional postures.”
Rubin acknowledges that he is advocating an unorthodox strategy, especially during the upheaval of Omicron, but he feels compelled to do it. “It’s counterintuitive a little bit because of the phase of the pandemic that we’re at, and that we hear about in the news every day. But it is truly a different moment.”
Follow Kara Miller @karaemiller.