Opening Healthy Schools

It seems that every educational leader in America, and every health professional involved in any way with children, is currently trying to figure out how to open schools safely this coming fall. This is a very complex problem, and I would not presume to offer solutions to all of it. But I would humbly offer some thoughts on key health aspects of the school opening problem, beyond the purely educational issues I have been discussing in previous blogs (here, here, here, here, here, here, and here).

I am not an epidemiologist. I don’t even play one on television. However, I do know a little bit about school health, from working with very talented colleagues at the Johns Hopkins School of Medicine, the Baltimore City Health Department, and the Baltimore Cuty Public Schools, on projects involving ensuring that all students who need them receive, wear, and benefit from eyeglasses. Also, I checked this blog out with colleagues who do know what they are talking about.

First, I will start with an observation. So far, it seems that Covid-19 rarely harms children. Using Maryland data, only 2.2% of cases, and no deaths, have involved children ages 0-9, and 4.2% have involved children and teens ages 10-19, and there has been one death statewide, in a state of six million people.  As a point of comparison, about four Maryland children die of asthma each year. In contrast, teacher-aged people, ages 20 to 59, represent 66.8% of Covid-19 cases, and 243 deaths (I would assume that these rates will be much less by September, or the schools would not be opening in the first place). Keeping children safe from the virus is essential, even if they rarely die from it, but from a public health perspective, the problem is not only what opening schools could mean for the health of students. It is also what opening schools could mean for the health of staff, parents, and other adult relatives and friends of staff and parents.  Unless the disease is completely gone by September, or unless there are widespread vaccines or cures, which seem very unlikely, any solution to limit negative health effects of opening is going to have to focus on staff and parents, not just students. Beyond the importance of protecting the health of the adults closest to the children, it is important to be aware that children who do get the disease probably get it from their families or other adults, not just from other children, so keeping these particular adults healthy is going to be a key way to keep children safe. Further, if staff members, parents, and other family members do become ill, this can have a profound impact on children even if the children do not get the disease themselves.

What these observations mean is that to be truly safe after re-opening, each school should create and implement plans to keep their entire community safe and healthy. One aspect of this might be to have schools build capacity to serve as a local health information and referral center, at least as regards Covid-19, for children, staff, and parents. My proposal would be first, to make sure that each school has a full- or part-time school nurse (currently, approximately 25% of America’s schools do not have even a part-time nurse). Then, I would propose that states, local health departments, or school districts assign one or more well-trained school health aides to each school, to work in partnership with other school support staff under the direction of the school nurse. These health aides might be people with college degrees, such as recent college graduates, trained specifically for this role. They would need to be paid for with federal funds intended to provide employment.

The purpose of the school health aides would be to use whatever resources are available by next fall to ensure that every child, parent, family member, and school staff member, is free of Covid-19, or if they have the disease, they are being directed to local health professionals for isolation and treatment. School health aides might take temperatures of anyone who enters the school, and take appropriate actions if anyone has a high temperature (as hospitals are doing now for everyone who enters). They could provide up-to-date information to parents, staff, and students about social distancing, symptoms of Covid-19, and sources of care. When a cure becomes available, the school health aides’ function could include notifying school community members about the availability of the medication, making sure that all who need it are receiving it, taking their medicine as directed, and doing whatever else is medically necessary. As vaccinations become available, they could help notify school community members about the vaccinations, and help keep track of who has been vaccinated and who has not. The health aide would not be expected to directly provide medical services, of course, but would be charged with keeping track of the health status of the whole school community (with all due concern for confidentiality consistent with HIPAA) and coordinating with local health providers to provide information to parents and staff on available services.

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Why is the school the right place to house health aides to serve the school’s own children, parents, staff, and community? One answer is that schools, especially elementary schools, are available in every community, and they are trusted and familiar places.  In inner city and poor rural areas, they may be the only trusted institution in the community. A key function of the school health aides would be to form positive relationships with children, parents, and community members. This is easiest in schools, where concern for community health can clearly be seen as concern for children, something that every community values. Providing services to school staff members would allow schools to help staff members stay safe. Services to parents would be purely voluntary, and would hopefully supplement services parents might receive in other ways. People who are not involved with schools should be able to receive similar information services from hospitals or community health centers, but the school community has unique needs and strengths that a health aide could help mobilize.

Covid-19 will, we hope, diminish in numbers and impact, so after schools have successfully opened and the virus begins to affect fewer and fewer people, the role of the school health aides could change. At least in high-poverty communities, many children have chronic health problems that seriously interfere with school success. Examples include students who have vision problems, students with asthma, and students with auditory problems. Especially in disadvantaged communities, children may not have treatment for these problems, and even if they have been prescribed eyeglasses, inhalers, medications, or other necessary treatments, they may not be using them regularly, so the problem remains unsolved. In addition to whatever they need to continue to do to keep Covid-19 under control, school health aides could take on roles in which they ensure that students who need eyeglasses receive them and wear them, students who need asthma inhaler medication are observed every school day to ensure that they are taking their medicine, and so on. I have proposed these functions previously, but in the age of Covid-19, the need for people in the school who can help make certain that all children are receiving needed health interventions has become even more important.

School health aides would provide a front line of information gathering, dissemination of information to school community members, relationship formation, and referral to established health providers.  As children or adults are found to need services, the school health aides would help link them up with hospitals or community health centers, as appropriate.

I am only roughing out what a system might look like, and there are many aspects that could be done differently, or adapted to local circumstances. My hope is just to provide an overview of a system of supports, based in schools, capable of helping entire school communities do the detailed family-by-family work necessary to eliminate Covid-19, and at the same time build up a trusted, capable, and community-friendly network to improve the health of all children. Whether or not this is the right system, something much like it will be necessary if we are to be able to strengthen the health of our schools and our communities in the aftermath of the Covid-19 crisis.

This blog was developed with support from Arnold Ventures. The views expressed here do not necessarily reflect those of Arnold Ventures..

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