The surest way to completely open schools is to reduce or eliminate community broadcasting while increasing testing and surveillance. Adults would need to maintain a social distance from each other and take other measures to reduce adult-to-adult transmission: for example, wearing personal protective equipment (PPE), closing school buildings to all non-personal adults, and holding digital meetings faculty. These precautions are especially important as 17.5% of teachers are 55 or older.25 But we believe that schools in low-transmission settings could probably provide pedagogically sound and socio-emotionally appropriate instruction to all students, in person, so that they do not expose educators or families to undue risk.26
Any region experiencing moderate, high or increasing levels of community transmission should do everything possible to reduce transmission. The path to low transmission in other countries has included compliance with strict community control measures, including the closure of non-essential indoor and recreational spaces.eleven Such measures, along with the use of universal masks, must now be implemented in the United States if we want to reduce case numbers to safe levels so that elementary schools reopen this fall across the country.
Epidemiological evidence suggests that mortality rates can be reduced by 90% within 9 to 11 weeks after strict control measures begin (see Supplementary Appendix, available with the full text of this article at NEJM.org). Given the delay between new infections and deaths, an equivalent effect on new infections should be evident in less than 2 months. If such measures were taken now, transmission in many states could likely be reduced to safe levels by reopening schools in mid-September or early October. Many school districts could open even earlier, although major improvements in test volume and reporting speed would be needed to allow for adequate levels of community policing.
Districts and states that refuse to implement these essential public health measures, on the other hand, face a profound social and moral dilemma: namely how to weigh the known risks to children, families, and society of closing school buildings or operate at reduced capacity against unknown risks (especially for school personnel and household members of educators and children) of opening schools when the virus is still circulating at moderate or high levels.27.28 This dilemma is exacerbated by school segregation and racial and class injustice: the reopening of schools serving the poorest and predominantly minority populations poses the greatest risk to the safety of families and educators, but its continued closure it also imposes the greatest harm on children and families.14
Many families, particularly those with medically vulnerable household members, will choose to keep their children at home in these circumstances, regardless of whether the schools are physically open.29 We understand this risk calculation. Remote teaching and other school services (including meal provision and medical and therapeutic services) should be available to all families who choose this option, and designated educators will be solely responsible for remote teaching.
But educators and other school personnel cannot necessarily dictate the place or terms of their employment, even (perhaps especially) when the social compact has been broken. It is tragic that the United States has chosen a path that requires a trade-off between the risks to educators and the harm to students, given the success of other countries in reducing transmission and opening schools with routine control measures. This dilemma represents a social and political failure, not a medical or scientific need.
However, we would argue that primary schools are essential, more as grocery stores, doctors’ offices, and food manufacturers than as retail establishments, movie theaters, and bars. Like all essential workers, teachers and other school personnel deserve substantial protections, as well as risk pay. Remote work adjustments should be made if possible for staff members who are over the age of 60 or who have underlying health conditions.5.18 Adults who work in school buildings (or drive school buses) must receive PPE, and both students and staff must participate in routine grouped testing.30
The social and physical infrastructure of schools will also need to be modified. Students and teachers may need to eat lunch in their classrooms, and staff rooms must be closed to discourage the adult congregation.31 Crowded buildings or open-plan layouts can make it impossible for adults to keep their distance from each other32; In such cases, schools can benefit from expanding or relocating to local middle or high schools, unused college classrooms, community centers, houses of worship, or businesses whose employees work remotely.11.12 Such changes will not be easy. The spaces and furniture must be adapted for younger children; Kindergarten children will need easy access to the appropriate restrooms; and schedules may need to be redesigned to accommodate special education providers and specialized teachers so that they can access children and classrooms at the appropriate times.
Even if schools can make creative short-term use of additional space, thousands of schools, particularly those serving low-income students of color, will require significant federally funded improvements to improve ventilation, sanitation, offices nursing and hand-washing facilities and the bathroom. .33 These improvements have long been necessary independently of Covid-19; they are essential investments in educational equity and opportunity.
