In the Bubble: On the Frontlines

The Case For Reopening Schools (with Emily Oster)

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Description

Dr. Bob calls up Brown economist Emily Oster to discuss one of the most complicated and controversial issues of the pandemic: what to do about schools. Emily created the COVID-19 School Response Dashboard, a database that indicates that schools aren’t a significant source of COVID-19 spread. She also talks about how the school debate ended up getting politicized, what it’s like doing real-time data analysis, what elements need to be in place for successful school reopening, and how she’s managed her own kids during the pandemic.

 

Follow Dr. Bob on Twitter @Bob_Wachter and check out In the Bubble’s new Twitter account @inthebubblepod.

 

Follow Emily Oster on Twitter @ProfEmilyOster.

 

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Transcript

SPEAKERS

Dr. Bob Wachter, Emily Oster

Dr. Bob Wachter  00:09

Welcome to IN THE BUBBLE from the frontlines. I’m your host, Dr. Bob Wachter, there have been a lot of issues that have been debated back and forth in this pandemic. And frankly, some of them should not have been the source of debate. Masks should not have been, testing should not have been. I understand the debate over vaccines, but the vaccines are so remarkably effective. And so important and so safe, at least from the data we have now that there shouldn’t be much debate about them. There’s one issue though, that has been the source of massive amounts of debate. And it’s understandable because it is remarkably challenging and emotional.

Dr. Bob Wachter

And the stakes are so high at every level. And that is the question of the schools. And like everything else, in the early parts of the pandemic, it got politicized. And that made it difficult to take a good hard evidence based, scientific based, rational look at what the right things to do about the schools were. But there’s really no issue that’s more important in the schools and the dynamic about it is changing. Even now, as testing becomes easier to come by, as the vaccines begin to roll out, as cases begin to fall. And yet the variants remain a threat. So as usual, it remains complex, but some of the issues have become a little bit clearer, in part because we now have far more evidence about the schools than we did in the early days.

Dr. Bob Wachter 

And our guest today is a person who has been responsible for developing that evidence, probably more than anyone else in the United States. It’s Emily Oster, who is a professor of economics at Brown University. Her academic work focuses on health economics and statistical methods. And she’s had a particular interest in why consumers do not always make rational health choices. But again, as it comes to the school, it’s hard to be completely rational because the stakes are so high, and the emotions are running so hot. She thought a lot about health care and has done that through some of her academic work, as well as some books that she’s written on parenting and pregnancy.

Dr. Bob Wachter  02:21

Including books called: “Expecting Better”, a book called: “Crib Sheet”, and an upcoming book called: “The Family Firm” She has been an advocate for trying to keep the schools open and not just based on her feelings, but based on a project that she launched early on in the pandemic to collect data on the spread of Coronavirus in schools. And as you’ll hear from our interview, the story of the launch of that database in that project was a story we’ve heard over and over again, on this podcast, people saying, you know, I’m not sure I’m the person to do this, but I’m looking around and it seems important, and nobody else is doing it.

Dr. Bob Wachter 

So, I will step up to the plate and do it and create this important new source of information. And Emily did that in a way that has been quite valuable. And she’ll describe some of the results as we go forward. Let me add a brief program note. We recorded this with Emily last week. And on Friday, the CDC came out with their long-awaited recommendations about the schools. I think it’s terrific that the CDC is actually coming out with recommendations. If you think about it in the past week, they came out with new recommendations about masking. They came out with new recommendations about what the vaccinated people didn’t need to go into quarantine.

Dr. Bob Wachter 

And I think we’re seeing more and more guidance from the CDC. I’m still processing the CDC guidance, it does promote getting the schools open really at all costs, allowing elementary schools to open even with fairly high community rates. There are some restrictions that they are recommending on opening up schools for older kids. There are recommendations about masking and distancing, and ventilation. Just from Emily’s tweets, I haven’t had a chance to loop back with her. It looks like she’s a little concerned that the recommendations may set the bar a little bit too high in terms of what they’re asking for six feet distance, as you’ll hear in the interview, she thinks the three feet might be good enough.

Dr. Bob Wachter  04:26

There’s not a whole lot of emphasis on ventilation. And I’ve seen some concerns raised on Twitter about that. So these recommendations are not the be all and end all they will not end all of the controversies about the schools but at least we’re getting some thoughtful recommendations from the CDC and I think we’re all going to be processing them over the next few days and see what they mean. So we don’t address these recommendations in the interview. It happened a day or two before the CDC recommendations came out. We may loop back in the next couple of weeks and see what these recommendations mean for the schools because we know that schools remain an incredibly important issue for, for many, many of our listeners.

Dr. Bob Wachter

With that, let us ring up Emily Oster.

Dr. Bob Wachter 

So Emily, welcome to IN THE BUBBLE. Thank you for joining us.

Emily Oster 

Thank you for having me.

Dr. Bob Wachter

So you’re an economist. But over the course of the pandemic, you’ve become one of the leading voices in the country on the issue of schools and reopening and opening in general. How did that happen?

Emily Oster 

So I think it happened because in addition to being an economist, I do a lot of writing on pregnancy and parenting. And so early in the pandemic, I was doing a lot of writing for that audience trying to help people think about how they could manage parenting and child care while they were having the pandemic and what kind of risks there were to kids. And then that sort of evolved into more of a data collection project. And like, as things happen, it just the school stuff just sort of took over, at some point kind of late in the summer.

Dr. Bob Wachter  06:05

Did you have a sense in the beginning that the schools would become this dominant issue, and also this dominant, incredibly controversial issue?

Emily Oster 

So I think no, and part I say that because I think if I had anticipated where it would go, I’m not sure that I would have started. You know, I think that when schools closed in March, I just had the impression, okay, well, first, I was like, they’ll open in April, they’ll open in May, and then at some point, of course, became clear, they weren’t going to open. But it took a long time for it occurred to occur to me, and I think too many others, that there was a chance they wouldn’t open in September. And then as the summer went on, it became clear that was on the horizon.

Emily Oster 

And I don’t think that I anticipated how complicated these reopening questions would be, and also just how controversial and even also how the patterns would go, you know, the, at some point in the summer, there was a sort of switch into a situation where the reopening started to be really along political lines rather than on other lines. And I think that was a switch, I think nobody anticipated at the time,

Dr. Bob Wachter 

Meaning that there came a point where sort of part of the partisan debate like masks who could have anticipated it would be the sign of which side you were on, but that schools became immersed in that partisan debate. You hadn’t anticipated that might happen?

Emily Oster 

Yeah, I mean I think partly because what happened is just the president said, all schools should open and then that kind of as with many of the things that the former president said, it then really made a debate about are you with him or are you against him? You know, are you with Trump? And are you going to open your schools? Or are you against Trump, in which case, maybe you’re not going to reopen your schools. And I think that totally shifted the debate in a non-helpful way and moved to kind of away from science. And we stopped talking about what’s it going to take and started talking about the politics of this. And I think that meant that we didn’t invest in the science, and that made it harder to open in the fall.

Dr. Bob Wachter  08:06

A lot of people have weighed in on the schools, but sometimes you found yourself in a position of being one of the foremost authorities on it, and someone who is really focused on it as a core issue. In doing that you came at this as an economist, that’s your background, your trading and what you study and teach. What are the advantages of having come at this through the lens of being an economist?

Emily Oster 

I mean, I think there’s sort of two things. So one is I was very focused on data, because that’s what economists are very focused on or at least the kind of economist that that I am, and, and really focused on sort of data about the problem that we were actually facing. So I think that one of the one of the things that happened early on was we started talking a lot about kind of auxiliary pieces of information. So how much transmission is there around kids? How much? You know, can they transmit to other people? How much viral load do they have? Sort of indirect metrics. And I think that that part of because some of the way we do data in economics is we kind of really step back from the mechanisms.

Emily Oster 

And it’s much more about just like, well, does x cause y? Without exactly understanding why my first instinct coming into this was to say, well, let’s literally just make sure that we are getting the most basic data on what is actually happening in the schools. Let’s step back from our can kids transmit how much how much viral load and just say, literally, we actually need to see the data from schools, and even if that is going to be imperfect and not mechanistic, it is going to be a kind of data that’s very, very valuable. I think the other piece of this is that, you know, as that economists are always about tradeoffs, like that’s our whole thing, you know, the like, line about, you know, give me an economist that only has one hand because there were always it’s on the one hand, on the other hand.

Emily Oster 

And so I think that, you know, some of the way I come into this is to say, look, there isn’t going to be the some, you know, perfect solution here. There are tradeoffs to either choice. Neither of these choices, openings, tools are not opening schools is without its risks. And recognizing that and thinking about the risks on either side and trading them off. That’s going to be kind of key to opening. And I think that was it’s not that many people have that perspective. I think that, that was where I came into it initially.

Dr. Bob Wachter  10:21

Yeah, that’s interesting. If you think about some of the other things that got partisan, masks, testing, there really isn’t a scientific on the one hand, and on the other hand, there’s a right scientific answer, and yet they got partisan eyes. This one is really tricky. I mean, it really is, if you’re following the science, you can, you know, if you’re in debating club in high school, you’re probably equally comfortable taking either side on this one, because there are compelling arguments on both sides, don’t you think?

Emily Oster 

Yeah, I do. I mean, I think certainly, you know, I obviously have a particular there’s a side that I would be on and I’m on, but I think it is much, much more complicated than then something like testing where I think most of the science would be aligned on just we need a lot of that. And testing is good and more testing is good. And people should wear masks here. You know, there are, you know, there are perspectives on both sides. And there isn’t one obvious solution.

Dr. Bob Wachter

Yeah. Interesting. When you talked about your perspective, as an economist, and you started talking about the measures, and the need for measurement, the measures were ones that a public health person or an epidemiologist would have talked about, they weren’t instinctively, let’s look at the economic harm, or the economic benefits and harms of kids being in school not being in school and weigh those, did you have to sort of instinctively put aside, the economics being the dominant measures that you want to look at in terms of framing this choice? Or, you know, just how did you come to recognizing that the data that was necessary was probably more public healthy than economic?

Emily Oster 

You know, I mean, I think part of it is that the economic data actually isn’t that complicated. And so, you know, when sort of, there wasn’t as much need, from my standpoint, to learn the even the direction of the effects on that. So when I sort of looked at the landscape of like, what are we going to need to see to reopen, it was sort of clear that the information that we needed was what’s going to happen inside schools that an economist didn’t need to know, like, it’s really bad for the labor market, that, you know, all these women are not working, or it’s, you know, it’s really bad for kids.

Emily Oster  12:23

That they’re not learning in some ways, those, those pieces seemed clear to me, I will also say, you know, like, although I am an economist, I do a lot of work in this sort of public health space. So I think my instincts relative to the instincts of some of my colleagues were much more just sort of go to like, okay, we want the public health data, and the, you know, rates in schools and the COVID data, rather than the counts of number of, you know, people who are who are out of work.

Dr. Bob Wachter 

But there is an economic trade off, I noticed the other day, the CDC put out their report on what the NFL did, and the NFL did 623,000 tests over about a six-month period, in order to open safely. So the economics of how much should a society be willing to pay to create an environment in which the schools can safely open is sort of an economic trade off argument, you know, it is worth investing x in order to get these economic benefits, whether it’s in the current labor market, or in the future productivity of kids who are being harmed by staying out of school. Is that something that, or did you think the economics were such a slam dunk that the key thing really was the public health measures?

Emily Oster 

Yeah, I mean, I think the economics are totally obvious there. And I think that, you know, we, you know, people made a number of points early on about testing, and about schools and about all these places where basically, the economics so clearly favors investing quite a lot in anything that can help us to return to normalcy. So an argument, you know, there was kind of nothing that one was going to learn at this point, that would say that there isn’t an enormous economic benefit to reopening schools. And, you know, by extension, of course, there’s huge benefits to more resources for schools.

Emily Oster  14:05

And I think part of what was so what has been so frustrating and remains very frustrating about this is that, you know, we don’t have those kind of resources, even though this is very important. I think it’s very, very important. But it’s also part and parcel of some of our general investments in schools. You know, we’re now having these debates about like, well, can we really reopen these school buildings where they don’t have hot running water for people to wash their hands? Well, let’s put aside the Coronavirus. People should have hot running water in their schools. And the fact that we don’t is really shameful. And you know, I don’t think you need public health data about COVID to tell you that.

Dr. Bob Wachter 

Yep. Okay, so we’ve talked about sort of the motivation for you to get involved in this issue as well as to as your instinct that measures were going to be important. So you created the National COVID-19 School Response Dashboard as I guess the kind of operational piece of we need to measure. Why did you do that and how did you proceed from that idea to making it real?

Emily Oster 

Why did I do it? The answer is sort of that nobody else seemed to be. And so, you know, we kind of came into August, and it became clear that some schools were starting to open, they, you know, and particularly, they were opening in places where a lot of people, in some sense, myself included, thought, “Boy, that’s probably a mistake.” So opening in Georgia, in Indiana, places where the rates at the time were quite, were quite high. And you started seeing some of these articles come out, but they sort of had a flavor that I think a lot of us found very frustrating, which was that they were articles that said, you know, here’s a picture of this school in Georgia, and look at all these kids in the hallway, or, you know, this school quarantined a lot of people for exposure, and they were numerators, or stories, or, you know, case counts, but not enough information to actually figure out the broader picture of what was going on.

Emily Oster 

So, you know, here’s one high school, well, a lot of high school is open, and you know, that the whole state open all their high schools, like, is it that this is an example where there’s a single high school, and it’s emblematic of all the other high schools? Or is it a single High School, and it’s literally just a single high school and all the other high schools did fine. And you saw a little bit of a flavor of this actually, early on with nursing homes, where the data collection was not very systematic, and it was more like, here’s an example of a nursing home that’s doing poorly, then, of course, when you expanded that it turned out that all nursing homes did very poorly.

Emily Oster  16:24

And so I think there was a question What about whether schools would sort of be like that. And in order to learn that, you need to collect information on how many COVID cases there are in school, how many kids are in school, how many schools are open, you need to track them over time, and that seemed really clear to me. But it also became clear that the federal government was not planning to do that. And most states were not either planning or in a position to do that systematically.

Emily Oster

And so I was connected through some other connections with a couple of different partners, most notably the School Superintendents Association, and two of the School Principals Associations, and also a data collection company. And we kind of decided that we would build this, we build some version of this dashboard that we thought should exist at the federal level, really because we thought there was a was a gap.

Dr. Bob Wachter 

So I guess you’re implying that had the pandemic hit in January 2021, rather than January 2020, this might have been something the CDC would have done as sort of an instinct, this is an important issue around public health, we do measurement for a living that normally would have been a federal function?

Emily Oster 

Yeah, I would have hoped. So I think, you know, maybe the CDC, the CDC, and some combination with the, with the ED department, those are sort of the two central players here. And actually, you know, at some point, you know, Betsy DeVos said, well, it’s not our job to track what’s going on with COVID and in schools. And, you know, I think that that attitude might be different in the current administration.

Dr. Bob Wachter

I would guess that’s right. So take us through what some of the key findings that you’ve come to from your database.

Emily Oster  18:15

So it’s probably worth sort of backing up and saying kind of the database evolved a lot over time. So our initial, the sort of initial approach to this was reserve sort of opt in approach where he basically said, we’re going to ask schools and districts to tell us this information, tell us how many kids you have in school, tell us, you know, let us track your COVID cases over time. And that was sort of early in the fall led us to a, you know, reasonably sized sample from which we thought we could learn something about kind of the presence of big outbreaks, but didn’t lead to a, you know, a huge sample. But then over the course of the fall, we’ve managed to add in either because they report publicly or they reporting to us information from whole states.

Emily Oster 

So that’s both a kind of a larger data set, and also in a more consistent over time. And so you know, what we’re seeing in the data is, you know, first some of these early fears that schools would be super spreader events, that there would be huge outbreaks, that has not come to pass, and it has not come to pass in a pretty robust way. So we see very few, very, very few examples, even of places where there are large outbreaks in schools, it doesn’t mean that there aren’t cases of people associated with schools who have COVID. There are a lot of those because people get COVID elsewhere, and they come to school, but sort of as school with sort of the question of like schools as sources of big outbreaks, we’re not seeing that in our data.

Emily Oster

And I think you’re not seeing that and other data, either. I think the other big headline is that more like this sort of Central way to organize what we are observing is that schools track their community. So when community rates are higher, you will see more people who are affiliated with schools have COVID and that is of course, what you would expect because even if there were no COVID spread at school, you would still see rates of school affiliates kind of track the community. And so that means, like in the data in the first two weeks after Christmas, the COVID rates are very high in schools.

Emily Oster  20:12

I mean, you know, by the standard of the other parts of the of the data, and you know, that really seems to reflect the kind of post-Christmas, post holidays, bump up that we saw in everything. And then, you know, in this most recent wave, which we just posted, which is the second half of January, everything is sort of starting to come back down again. So, I think that’s the really sort of basic organizing principle of what we’re seeing in the data.

Dr. Bob Wachter

So would you be able to see a signal that schools themselves don’t appear to be the site of a lot of infections, but the kids potentially are vectors and transmitting it to families outside of schools? Would you be able to catch that?

Emily Oster 

So we can’t see that in our data. Because what we do is we track kids and teachers, not their family members, I think, you know, to do that, you basically need to merge this kind of data up, or not even this kind of data, but data on school openings together with community rates. And that’s something that we’re working on some projects sort of tangent slightly tangential to this, although obviously related, and others have also looked for, for example, links between kids between school reopens, rather, and hospitalization rates and sort of seeing actually relatively little evidence that those variables are linked.

Dr. Bob Wachter 

There’s been a lot of discussion about not lumping all the kids together in one group, but maybe they have differential propensity to get COVID. And to spread it with often the cutoff being around age 12. Kids younger than that somehow being a somewhat lower risk to catch it and spread it and kids older than that, beginning to mirror adults. Are there signals in your data that tell you about that divide?

Emily Oster 

Yeah, so and then I think we do see that in the data. Or, you know, what we see the lowest rates in elementary schools, so lower rates in elementary than middle schools, lower rates and middle schools, than in high schools. And the other piece is that when there are sort of cases where there are like the small number of cases where there are larger numbers of kids who are infected in a given like two-week period, things which look more like they’re at least in any kind of an outbreak in the school community, whether there are results of math class or wrestling tournaments, or something else is less clear, that tends to be high schools.

Emily Oster  22:30

So that population seems to be higher risk, I still think it’s somewhat unclear. Whether that’s a behavior, or a biology is probably some combination of sort of both of them. Interestingly, the staff numbers in the data look very similar across the age groups of kids. So it sort of looks like the kids are aging into higher risk. But the staff are kind of very similar across the different school age groups. And that’s, I guess, consistent with even some of this new stuff we’ve seen that in North Carolina, where they do more detailed contact tracing, they don’t see they basically don’t see transmission from students to staff.

Dr. Bob Wachter 

So the fact that the staff have a similar rate of COVID, no matter if they’re first grade teachers, or 10th, grade teachers doesn’t necessarily sort of obviate the idea that the first graders don’t spread it as much it means that the staff may be getting it from their life outside the school?

Emily Oster

Yeah, or from each other. I mean, I think that’s the other that’s sort of the other piece of this. And I think a piece, it’s important to think about is that, you know, to the extent we do see spread in schools, it may be more often staff in you know, interacting with each other. And that kind of suggest caution in those interactions, which people may not always be thinking about.

Dr. Bob Wachter 

Do data tell you anything about the conditions for safe opening of schools in terms of masking or distancing, or ventilation or any of the other interventions or testing and other interventions that have been proposed?

Emily Oster

Yeah, so I think, you know, we see the sort of most robust thing we see is masks. And so you know, we definitely see evidence that that places where the students and staff are masked, the infection rates are lower than in places where they are not. So that’s the thing that kind of shows up most directly, we don’t see very much in the direction of things that would at least proxy for distancing. So we asked about three and six v distancing, we don’t see much there, that’s a little hard to exactly interpret, because I’m not sure that everyone implements those in quite the same way. But we also one thing we can look at very real, like in a basically all of our data is density.

Emily Oster  24:32

So sort of places that open at, you know, where the sort of typical in person day is, like, you know, 50% density versus 70 versus 90% density. And there we see, actually relatively little gradient, if anything, kids are actually a bit lower infection rate in the higher opening density things places that are closer to sort of full 100% in person, which you know, may reflect differences in other differences may reflect differences in miss mixing on days when they’re not at school it is a little hard to interpret, but masks come up pretty strongly.

Dr. Bob Wachter 

But even with the past, I imagine you’re doing an observational study, you’re not intervening in any way. And so a higher prevalence of masking in a school, I assume will be on the same gene as the community having a higher propensity to mask as well.

Emily Oster 

Yeah, thanks for because the causality. Yeah, so we can, so it shows up even consistent with even conditional and community […]. But you’re exactly right. And I think there’s a, there’s a sort of secondary point, which is that all of these things are kind of moving together. So the places that are distancing at six feet or also doing more ventilation or also doing, you know, more hand washing or also doing this and this and this. And so, you know, in a sense, there’s a kind of package of, of interventions. And I think we would need probably a different kind of data to really sort of dig into which things matter.

Emily Oster 

And I think, if I were to design a study, which would give me causality on this, you know, I think the big questions are, would be around some of these, either more expensive or disruptive features. So you know, can we, you know, how important is six feet distancing? Because, boy, it’s really hard to get everyone back in the classroom if you have to do that. And sort of, you know, similarly, how important is ventilation? And what kinds of ventilation? And I think it would be great in the next, you know, four months to see some more information on that. So we can use it if you know, we need to going into the fall.

Dr. Bob Wachter  26:27

Yeah, I actually love the causality police. So you’ve obviously heard these concerns. I thought I was being brilliant coming up with this question?

Emily Oster 

No, causality is very important. It’s very important.

Dr. Bob Wachter 

But, maybe seriously, you know, people will use your data, and you’ll use your data and make arguments about we should do x and we shouldn’t do y. So how do you and you’re in a very public space now and very controversial space? So how do you as a rigorous scientist, sort of make sure that you’re not getting over your skis in terms of what the data can tell us and really can’t, and yet advocate effectively based on what the data is telling us?

Emily Oster

Yeah, so I’ll be you know, totally frank, this has been a hard set of things for me to think about. So you know, I am at the core like, and person whose papers take a decade to come to fruition, because that is what it is like to, you know, be an academic. But, you know, this, this is also a space where we don’t have a decade, because kids are out of school now. And I think, you know, we came under some, you know, under a fair amount of criticism early on in this for saying, you know, I did for saying schools are super spreaders based on a small amount of data. And the truth was, you know, I thought about that data, I think about data and standard errors and what we can learn.

Emily Oster 

And although, you know, that data was not sufficient to say the kinds of things we can say now, you know, having half a million observations versus 10 million is different, but it was enough to say, look, we looked at a large number of schools, and we didn’t see any evidence, any places where there were big super spreaders, like, that’s informative, and the statistics kind of inform that. And so, you know, then of course, over time, you’re gonna, you’re gonna learn more and more data has come out. And I guess, I, you know, I think that some of some of what we’ve tried to do, what I’ve tried to do is just be clear on what the limitations of the data are.

Emily Oster  28:15

And what we think we can learn at each sort of moment in the in the data, but, you know, this kind of like real time policymaking is different than, you know, than doing academic work. And I think that there has been some incredibly good academic work done in this space in the fall, but it has been, you know, it has been slower. And I think that has its own risks.

Dr. Bob Wachter 

Yeah. Yeah. I think public sometimes has a hard time understanding, and particularly those of us who spend our life in academia, how careful we traditionally are in terms of being able to go out there and say, I’m ready to publish this paper, and how that doesn’t work. Or at least there’s real tension in an environment that, you know, a choice must be made today about whether your school in your neighborhood is open or not.

Emily Oster 

Yeah, exactly. And where there are, there is no, like a safe default. It’s not like you know, we have a lot of time to decide, because what we’re doing now is going fine. And so you know, if we want to change what we’re doing, we really have a lot of time to invest in learning about it. This is like no, what we’re doing now is not going fine. And so we really need to know if we need to change what we’re doing.

Dr. Bob Wachter

So take everything you’ve learned from your study and elsewhere. And I know you’ve heard from 10 trillion people with their opinions, some of some informed some less so and a governor calls you up and or a superintendent and says, okay, Should we open and how, what do you tell them visa v the actions they should take to open safely? What do you tell them in terms of what the community rate needs to be in order to open and safely? What do you tell them when they say my teachers do not want to come back? And the union is on my case? I’m sure you I’m guessing you’ve never gotten any of these questions, but assuming you do.

Emily Oster  30:13

First time hearing of this. So, you know, I think that there’s a few different layers. And so I think that, you know, the first question is, you can say, like, you know, what should I do? What are the sort of things that need to be in place, and I think they’re, you know, there’s a lot of good guidance, but the basics are, you know, everybody wears a mask all the time, you try to enforce some amount of distancing, I think Joe Allen has made a good point that probably[…] is fine. But you know, try to have some additional space, try to improve the ventilation. And that can be done with you know, […] filters or a small amount of, of open windows, that those are, those are probably the most key kind of reopening pieces in terms of safety.

Emily Oster 

You know, I think the second piece, second, probably the biggest piece is just how do I get people to be willing to do this? And that’s not just teachers, it is teachers, but it’s also it’s also families, you know, how can we get people to believe that this is a good, you know, that this is something that is safe to do? And I think that there’s kind of two things to say there. One is, you know, you can show people data, and when we show people the data that we have here, they often find it very surprising, I think people’s perception of the risk is very different than the reality actually Brookings did a study where one of the things, one of the treatments in this study was telling them something from our dashboard.

Emily Oster

And the sort of additional support for reopening, like changed by 11 percentage points or something. So there is some misinformation that could be corrected. But I also think that particularly with teachers there is just like a huge absence of trust. And the places where we’ve seen more successful reopening’s are places where the underlying trust has been greater and similarly, the places where this has been most fraught, are places where there was already a trust issue. And so whether the way to rebuild some of the trust is with, you know, more testing is with discussions of vaccinations, I’m not sure, but I think that that’s like, that’s kind of a key element. And I think the other thing I would just say is like, the first day is the hardest.

Emily Oster  32:14

And I think that places like you know, Rhode Island pushed really hard to open in September. You know, the governor pushed really hard on all the school districts to do that. And I think the reason she did that was because maybe this wasn’t the reason, but I think one thing that was true is once we did that it was then people realized a couple of weeks in, wow, this is actually going pretty well, like, you know, it is going better than I thought. And it means that in the Providence public school district, you know, which is a, you know, not a high-income School District, it has a lot of issues.

Emily Oster

It serves as you know, relatively low-income population, a lot of students of color, suddenly, like 70% of the kids have opted for in person learning, which is much higher than the rates we’re seeing when, you know, say in Chicago. And so I think that kind of like realization that doing it, that doing something is a good first step, even if that’s a relatively small amount of kids coming back is worth a lot.

Dr. Bob Wachter 

There’s a lot of that, that sounds like vaccine hesitancy as well, that is sort of the importance of baseline trust, the existence of some baseline skepticism, from different populations, whether it’s the parents or the teachers, and then how do you overcome it, and really the damage that the past year has done in terms of making trust harder.

Emily Oster 

Yeah, no and I think that, you know, it’s not it’s it may not be an accident that some of the places that we have seen, you know, be more successful with vaccines are also places that had some, you know, more school reopening, even in the face of pretty high COVID rates. And I wonder how much of that is just that there’s a sort of community-based level of trust that has enabled them to do that.

Dr. Bob Wachter

Yeah. We have an interesting trial of what happens if you have more resources, and that’s called private schools. So what are the lessons from the experiences of private schools? What have they done? That’s different than public schools? And what are the lessons from what they have done?

Emily Oster  34:05

I mean, many, many, many more private schools. And I will say Catholic schools have been open and a lot of them have been open in places where the district public schools are not open. So you know, the Chicago come back to the Chicago example, the Archdiocese of Chicago has had all their schools open since September. And, you know, in a lot of places in California, where there haven’t been any public schools, we’ve seen private schools open. And, you know, my sense is by and large those have gone extremely well.

Emily Oster 

And, you know, the some of that is resources, potentially, I mean, certainly some private schools have more resources. I think that is why people appointed to the Archdiocese some because that tends to actually serve a not dissimilar population to district public schools, and they tend to be you know, less highly resourced than your kind of private independent school population. And you know, those have, you know, the question of what is made it possible for those schools to reopen?

Emily Oster

Some of it, its market pressure, you know that basically, the private schools kind of needed to open in a way that maybe the public schools didn’t, didn’t find that kind of pressure. And I think part of it is the sort of inherent levels of trust that are probably higher, at least in some cases, between, you know, parents and the school, and it’s just a different community. So but they have those have gone well, I think.

Dr. Bob Wachter 

So as you were picking up the things that schools should do to do this safely. To open safely, you talked about mass and distancing and density and ventilation didn’t say much about testing. So if you come down with your thoughts about the role of testing and all of this?

Emily Oster 

Yeah, so I didn’t mention it partly because we, you know, when we started this, we asked a little about mitigation, and nobody said they were testing now, that was back in September. So testing has become a much bigger thing. Now, I personally am very high on testing and think that it is that doing more of it is going to be really key for schools, not just now but actually going into the fall. So when I look to the fall, I look to a time when basically teachers are vaccinated, but the kids will not be. And I can imagine that we may still want to be doing some routine testing of kids in some of these settings, and that, you know, doing so would, or having the ability to do so may make people feel more comfortable about return to school.

Emily Oster  36:23

So, you know, I think doing some kind of rapid testing, cool testing, you know, figuring out how we can invest in making it very simple to test and not have it be a big deal. And just have it be like a routine thing that everybody does. You know, forget about school, you could do it every day, your house, but certainly in schools, I think that’s going to be important.

Dr. Bob Wachter

How important is vaccinating the teachers?

Emily Oster

I think that vaccinating teachers is a is a good idea. Because we need to I also think we just need to vaccinate people fast. And actually, it’s a pretty captive, captive is the wrong word. But it’s an it’s a sort of easy to access audience where there is some social pressure to do the vaccination, particularly if they’re doing in person learning, it is a group that is out in the world. And so that’s, you know, relatively a relatively potentially group with more exposure to high-risk people.

Emily Oster 

So, I think we should vaccinate teachers, I don’t think it can be a prerequisite to return. I mean, I agree with Randi Weingarten. I think that there are other ways testing other kinds of mitigation that we can do that make it possible to have safe in person learning without teacher vaccinations. But I certainly think that that is a group that, you know, I would argue for prioritizing.

Dr. Bob Wachter 

So you have been an advocate of and clearly here, you’ve been an advocate to try to keep the schools open or to get the schools open. What are the conditions under which you don’t believe that’s the right call? Is there a sort of a rate of community COVID? Or if the school we had a Atul Gawande on a couple weeks ago, and who’s advocated this as well. And he said, there are schools where you just cannot get the kids to keep the masks on. So how do you think about what the triggers would be for you to say, no this is not the right call?

Emily Oster  38:07

Yeah, I think there’s sort of a couple. So I actually generally am not a fan of using community rates as a sort of cut off, because I don’t think that it’s, I don’t think it’s very helpful. And also any kinds of cut offs are always a mistake. Because they lead to the kinds of things we saw in New York, where you’re, like, at the third decimal point, have some kind of meaningless number, I’m trying to parse it out. I think that, you know, one thing is if we’re seeing spread in school, in a given school, like an outbreak, I think at a minimum, you need to shut down and figure out what is what is going on in that school. So I’d like to say much more targeted, like, let’s focus in on what’s the problem, you know, what is going on?

Emily Oster

I think the second thing is, there are places you know, where certainly there were in the fall, where the rates were so high in the community, that it was just not possible to keep staffing the school. And like too many people were out in quarantine and that’s just not feasible. So I think that’s the kind of community cut off, you know, in terms of things like masks, I mean, if, if it turns out it is impossible to do some of these basic things. So if the school doesn’t have like hot running water and soap, you cannot be open, because you need to be able to wash your hands. And if you know, for some reason kids can’t wear masks. Then, you know, also, I would say that’s a downside. But I think, you know, beyond those things, I’m not sure that I would, I’m not sure that things like the community is just objectively too high is a reason to shut down.

Dr. Bob Wachter 

Okay. Talk a bit about the costs of keeping the schools closed. And I don’t just mean economic costs. What do we know about the impact on kids, on parents, on future success and productivity and educational attainment?

Emily Oster

Yeah, so I think, you know, we see they’re sort of short-term effects we’re clearly seeing that kind of mimic, maybe what we see in summer, like what we call Summer Melt except it’s long. And so we’re seeing increased failure rates. We’re seeing losses and literacy, particularly for younger kids. I think there are some kinds of things like learning to read that have been very difficult to do on zoom. We’re seeing, you know, mental health costs and work time loss, productivity promotion losses for parents, I think one thing that remains uncertain is the question of how long lived these losses will be for kids.

Emily Oster  40:25

So clearly, losses in school time can have very long-term consequences, you know, more or less for, you know, your entire life. And I think it’s also the case that we’re going to see some kids who were in high school who are not going to complete high school who are going to complete less education than they would have otherwise. And that will have consequences a long time down the road. How much some of these more mental health questions, how much the loss of the first grade, they need to repeat first grade, you know, how much that will matter? Two decades from now, five decades from now, I think is less clear, the answer is almost certainly some. But you know, how much is something I mean, people like me are going to be writing papers about, you know, 50 years from now?

Dr. Bob Wachter 

Well, it’ll take you 10 years to get the data to publish it. So we’re gonna have to wait a while for it to comment.

Emily Oster

Absolutely. It’s totally right.

Dr. Bob Wachter 

In the first couple of months in the States, it became clear that the kids don’t get sick very often and very rarely die. And then this new syndrome got reported of multi organ system inflammatory involvement. And I don’t have small kids anymore, but I imagine that might have changed my thinking that if I, prior to that was feeling like, alright, my kid is going to go, maybe they’re going to catch COVID. But they’re going to do fine. I might think one way and it might have altered my thinking a little bit that there’s some chance or be at very small, that they’re gonna have sort of a nastier disease, did that change people’s thinking, as they began to hear these reports?

Emily Oster

I think it was, there was a sort of moment of a lot of scary salience around that, where people said, oh, you know, I, I kind of thought that no, kids ever get very sick with this. And now, you know, it turns out that a few of them do, that fear died down a bit. And I think it was even in the moment, somewhat less rational in the sense that like, there are a lot of things that can make your kid very sick. And I don’t say that to scare people, or, you know, make people be afraid of other things. But RSV can make your kid really sick. And actually, like hospitalizations for RSV are much, much, much, much higher, like order of magnitude higher than hospitalizations for COVID and COVID related things, you know, in a typical year, even obviously, in the last year.

Emily Oster  42:32

So, I think that this is an example of one of these things that has happened where the salience the fact that we’re all talking about it, has it take on an outsized importance in decision making, but then sort of simultaneously, you know, that conversation, we’re having an April, and then by September, nobody was talking about that anymore. I don’t know why there weren’t that many cases of it, you know, people lost interest. And so then I think it wasn’t, it hasn’t been as important in decision making.

Dr. Bob Wachter 

I don’t know if you have school aged kids. But if you do, and you’re comfortable speaking about it, tell us how you have managed the past year?

Emily Oster

Yeah, I have two school aged kids, my daughter is in fourth grade, and my son is in kindergarten, and they were home all spring like everyone else’s kids. But then we’re very lucky this fall that their school opened, and they go there five days a week, full time, except for today, which is a snow day. But it’s been really great. And it makes me feel very, very lucky every time I drop them at the outdoor tent where they now get dropped off because you can’t go in the building. And you know, they were I think it was like with many parents who sent their kids back to some in person learning.

Emily Oster 

The first week was sort of scary and weird, and everyone was kind of on edge. And it’s all really different. And everyone’s wearing a mask and like, you know, they all have the different entrances and so on. But the kids adapted so fast. And they were so grateful to be there, that I think it sort of it made the whole experience really different very quickly. And you know, we’ve been lucky this school had a couple of cases after Christmas. But you know, from people, people who came back and had COVID over Christmas, we haven’t had any spread in school.

Dr. Bob Wachter  44:12

And what’s the school done to make things safe?

Emily Oster

Everybody wears a mask. They potted the kids, and so they’re in a sort of pot.

Dr. Bob Wachter 

Pot did not planted them somewhere.

Emily Oster

That didn’t work for the five-year-olds at all. They Yeah, they potted they potted them. So they’re in smaller groups. And you know, they wash their hands a lot. And now they’re going to do some testing, but they hadn’t been doing it before. So I think it’s been a pretty, you know, they’ve tried to do some distancing. But you know, it’s, I think, largely been some ventilation improvements and masking.

Dr. Bob Wachter 

Well, Emily, thank you so much for being with us. And thank you for all the work you’ve done taking a really complicated and fraught and emotional issue and bringing as much science to it as we can. So I’m grateful and I know, parents everywhere are grateful to you for doing that.

Emily Oster 

Well, thanks so much for having It’s great to get to chat.

Dr. Bob Wachter 

Thanks to Emily Oster for really a fascinating discussion. And you know, again, on one of if not one of its I think the hardest issue that everyone is grappling with, we all know the cost of keeping the kids out of the school, not just on the parents in terms of the ability to work, but on the kids and not just in the short term, but probably some significant long-term costs as well. So the evidence that she has helped generate, really does put us in a position to make more rational decisions about this than we would have been able to many months ago. So we should look at the evidence and we should take advantage of the science. And I know, the federal government is doing that. and state governments and local school districts are increasingly doing that, which is a positive development.

Dr. Bob Wachter

So really appreciate Emily, taking the time to educate us about where things stand. We have a couple of other spectacular episodes coming up here on in the bubble. On Wednesday, we have Dr. Don Berwick. Don is really the most important thinker in over the last generation in the issues of how do you improve the quality and the safety of healthcare. It’s an area that I have spent a lot of my career working in and Don is really seen as the founding father of these issues. In addition to the work he has done, founding something called the Institute for Healthcare Improvement. He also ran Medicare and Medicaid, the same organization that Andy ran at the time the Affordable Care Act was passed.

Dr. Bob Wachter  46:39

So he’ll tell us a lot about his experience, dealing with the politics of that, as well as what he has learned from the last year of COVID. On Monday, we will have another Toolkit and it’s another version of our Safe or Not Safe toolkit with our guests, Caitlin rivers and Farzad Mostashari. And this is Safe or Not Safe with a twist and the twist is 10s of millions of people have now been vaccinated. So the question is, how does that change your thinking about whether something is safe or not safe? And increasingly, as in my own household, you have vaccine dissonance where one person is vaccinated, and another one isn’t? How does that change your thinking?

Dr. Bob Wachter

It’s all tricky stuff. It’s always been tricky, but I think it’s gotten a little trickier as the vaccines roll through our population. So I really look forward to hearing from Caitlin and Farzad as they try to help us navigate this increasingly complex landscape. Look forward to seeing you back here for those shows and several other spectacular shows that we have planned over the next month or so. Until then please stay safe and look forward to talking with you soon.

CREDITS

We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced our show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produced the show. Our theme was composed by Dan Molad and Oliver Hill and additional music by Ivan Kuraev. You can find out more about our show on social media at @InTheBubblePod. Until next time, stay safe and stay sane. Thanks so much for listening.

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