We need to work together to help schools reopen [PODCAST]

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes

“Children cannot afford to wait, especially our youngest learners who have difficulty engaging on a screen.  We need to all work together to help schools reopen, especially in low-income communities that are disproportionately suffering and may lack the resources.  I stand with the AAP, CDC, European CDC, WHO, and UNICEF to support safe school re-opening.”

Lekha M. Rao is a pediatric neurologist.

She shares her story and discusses her KevinMD article, “Children cannot afford to wait: We need to all work together to help schools reopen.”

Did you enjoy today’s episode?

Please click here to leave a review for The Podcast by KevinMD. Subscribe on your favorite podcast app to get notified when a new episode comes out!

Do you know someone who might enjoy this episode? Share this episode to anyone who wants to hear health care stories filled with information, insight, and inspiration.

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Here on the show, we have Lekha Rao. She is a pediatric neurologist, and she wrote the KevinMD article “Children cannot afford to wait: We need to all work together to help schools reopen.” Lekha, welcome to the show.

Lekha M. Rao: Thank you so much for having me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Lekha M. Rao: Sure. I am what you might call a consummate neurologist. I started out as a neuroscience major at Johns Hopkins and then went on to do my medical degree at Drexel University. I did my pediatric neurology residency at UCLA and then a pediatric epilepsy fellowship at UCLA, and then I stayed on there as faculty. I did a short stint as part-time academic, part-time private practice, then came back to academics. Now I work mostly at UCLA, and I also spend some time at the county hospital, which is also part of the UCLA system.

Kevin Pho: So through your lens as a pediatric neurologist, just describe what you’re seeing through your past year during the pandemic.

Lekha M. Rao: Yeah. We had to make a pretty big shift in neurology to go to mostly telemedicine, but also providing in-person services when we needed to. Being one of the younger faculty, not junior faculty, but younger faculty, I have also volunteered to go into the hospital and do inpatient services to cover for some of our over-65-year-old faculty with some underlying conditions.

During that time, it was somewhat challenging as well, because I have two school-age children. I have a kindergartner, well, at the time it was a preschooler, and a second grader, and there was an immediate shift to distance learning. So there was the balance of being a working mom and also suddenly being thrust into the role of being an educator. In that context, I also sympathized with a lot of the families that I was dealing with, who were also in similar situations.

I have two different patient populations that I work with. The area around UCLA tends to be a little bit more of an affluent community, we do draw from other areas of Los Angeles, versus the county hospital, which is primarily of a lower socioeconomic status. So I got to see, through the lens of a pediatric neurologist, how children were being impacted by this pandemic. Because of that, I developed an interest in not only the effects of COVID on children, but also effects of neurological disease, and then also the secondary effects of how the pandemic had been affecting my patients.

Kevin Pho: So what are some of the biggest effects that you see from a pediatric neurology standpoint?

Lekha M. Rao: Pre-pandemic, I’m an epilepsy specialist, so I was seeing a lot of epilepsy patients and a lot of headache patients. A lot of these high-achieving kids might have more headaches, tics, things like that. But what I saw with school-related closures wasn’t apparent right at the beginning of the pandemic. As school-related closures went on, especially in the fall, I started seeing a lot of kids struggling, and this spanned all socioeconomic statuses: having headaches related to being on screens all day, having muscle spasms from sitting in front of a computer all day, feeling socially isolated.

I had patients with epilepsy who were seizure-free, and this was the best control that they had had in their life, and yet they were debilitated by depression. They felt that things were not going to get any better; they couldn’t see their friends. I had kids as young as nine, 10 years old saying, “I just don’t want to be here anymore. I don’t want to be alive anymore.” I had never encountered that before in my career. I certainly see teenagers who have had that before, especially with epilepsy, which can have depression as an underlying comorbidity. But this was profound, in that these were kids whose epilepsy was otherwise controlled, but they were suffering from the isolation.

Kevin Pho: So let’s transition into the KevinMD article, where you talk about schools needing to reopen, and it’s titled “Children cannot afford to wait: We need to all work together to help schools reopen.” Now, before we get into the article, just share what the current status is regarding the schools in your area. We’re speaking towards the end of February. After that, just walk my audience through the article for those who didn’t read it, and maybe share the story of why you decided to write it.

Lekha M. Rao: In Los Angeles right now, the vast majority of schools are not open. A lot of private schools have reopened, including my own children’s school. So I’m extremely fortunate in that my children go to a private school, which is in my community; it’s actually right up the street. They’re very fortunate in that they have a large community of physician parents to help advise them, and they started actually from the spring of last year. As soon as the initial data came out of Wuhan that kids, for whatever reason, are less likely to transmit, yes, they can transmit COVID, but they’re less likely to transmit, and that school settings did not seem to be a large source of spread, they started to work on reopening plans.

I knew that was on the horizon, but we were somewhat limited by the public health guidelines. Here in Los Angeles, I think we have experienced some surges. At the time to reopen in the fall, we hit a low in cases, but of course, you can’t predict the future. You don’t know what things are going to happen. And so it seemed like every single time, we were told it’s not safe according to the case counts, according to test positivity. Then we hit the wintertime. As pediatricians, we were all kind of pushing towards school reopening starting from the summer, because we knew winter was coming and that there could potentially be widespread spread. By the time we got to winter, it was almost too difficult at that time, considering the levels of community positivity.

So now we’re in spring. It’s almost a year later, and despite the AAP having a stance from spring of last year that schools should start to reopen, there’s still a lot of debate within the medical community about the safety of schools. How this came about was not only that, at the start of the pandemic, seeing my own kids and how they were dealing with remote schooling was part of my motivation, but as their school reopened, it was not just about my own kids; it was about my patients. A lot of this came from talking with my patients and realizing how much the lack of in-person school was really impacting their lives.

So not only are these young kids saying that they wanted to kill themselves; I had one patient who started having non-epileptic seizures. These are psychogenic seizures that started only when she started seeing her teacher on Zoom. As soon as she saw her teacher on Zoom, she’d go into a seizure, and this is something that’s unprecedented. Same thing with my child psychiatry colleagues. One of them I talked to the other day said that in his whole 40-year career, he had maybe only had two or three patients under the age of 10 who had suicidal ideation, and just in the last seven months, he’s had 36.

I think that’s something to put into context here: When pediatricians and pediatric specialists are calling for schools to reopen, we’re looking at the whole child, and we’re advocating for children. I think something that’s been lost in the message sometimes is that if you’re pushing for school reopening, you must be anti-teacher or anti-educator, and that’s not the case at all. We are just trying to advocate for the children.

So what happened was, in our Southern California American Academy of Pediatrics listserv, there was some back-and-forth debate about whether schools should be open and whether teachers should be vaccinated before going back. People were trying to argue that schools are a source of spread, despite there now being large population-based studies that schools are not a significant source of spread. In fact, many schools have rates lower than community transmission, and schools have reopened in other parts of the U.S. where community positive rates have been very high at times, and yet they still didn’t have community spread from schools. So finally, it kind of hit a point where I said, “I can’t keep quiet. I need to say something.” And so the article was really born out of that.

Kevin Pho: You tell me about the debate within the medical community, and, I guess, are you talking about how there are some physicians who are advocating for schools not to reopen because of the concern about potential asymptomatic spread?

Lekha M. Rao: Correct. Despite, like I said, these large studies, not only in the U.S. but abroad, there are still some physicians that are worried: Schools haven’t reopened here in Los Angeles, so how do we know that they wouldn’t be a source of spread? We have a lot of communities with multigenerational families in the home, and so I understand that they’re also coming from the standpoint of wanting to protect people, so not only protecting children, but protecting the adults that live in their homes.

However, I think, although it comes from a good place, it’s somewhat misguided, because as scientists, as physicians, we only have our evidence-based guidelines to go off of when we’re trying to make these large community-based decisions. And although we shouldn’t let our personal feelings about something cloud the picture, it tends to happen. The vast majority of pediatricians are in support of in-school learning, but there are a few that still feel like everyone should be vaccinated, including children, and that you want to minimize risk as much as possible.

I wish we could minimize all risk for our children, but as a pediatric neurologist, I unfortunately also see sometimes the worst of the worst, especially in the ICU. And so I feel like sometimes we need to put things into perspective. We think about the terrible things that could happen. We think about that 0.005 percent chance that something terrible could happen, when in reality, 99.995 percent of the time, things are fine. Of course, nobody wants to be in that 0.005 percent, but we can’t forget about that 99.995.

Kevin Pho: Now, what do you say about the arguments that a lot of schools are old, they don’t have adequate ventilation, and they are certainly undersized, so it’s not possible to have kids sit a certain distance apart? These are arguments I commonly hear against schools reopening as quickly as they should. What do you say to that?

Lekha M. Rao: Right. I think the other thing that has been a point of contention is that if you’re talking about mitigation strategies in schools, you’re assuming that children are vectors of transmission. There’s a great article in JAMA recently, an editorial about how the question shouldn’t be whether or not children can transmit COVID. We know that they can; they just don’t do it as much. We have genomic studies to show that they transmit up to 50 percent less than adults do, children under the age of 12.

So knowing that, I feel like there’s almost too much emphasis on the six-foot distance, for example, when in reality, the six-foot distance came out of laboratory studies without masks, and if you look at wearing masks, that’s an important mitigation strategy. The CDC study that came out of Wisconsin is a great example of that, where they actually did not distance. The senior author said they were not mandating a six-foot distance. They let the children, sort of by entropy, be closer or further apart as they needed to, but there was high compliance with masks, 92 percent compliance with masks, and at times, the community transmission positivity rate was 30 to 40 percent, which is higher than anything we’ve actually encountered here in Los Angeles.

So really, the strategy was to wear masks as much as possible. If there’s a window, you open it, and you focus on adult-to-adult transmission, because that’s what’s potentially higher in schools. So the teachers shouldn’t be eating lunch together in a small, closed space, and you utilize outdoor spaces as much as possible. Here in Southern California, today is a great example. It’s beautiful, it’s sunny outside, it’s almost 70 degrees. We should be utilizing those spaces.

The other thing that I think doesn’t always get effectively communicated between the school districts and maybe the public is that a lot of school districts have actually invested money into replacing old ventilation systems, installing handwashing stations, working and partnering with the state to have asymptomatic surveillance testing. So these measures are in place, and I feel like this is the time. Our children are suffering, and we all need to just work together to make sure that we can get them back to school safely.

Kevin Pho: We’re talking to Lekha Rao. She is a pediatric neurologist, and she wrote the KevinMD article “Children cannot afford to wait: We need to all work together to help schools reopen.” Lekha, in your ideal world, what do you think is the best way forward?

Lekha M. Rao: In my ideal world, I think that we should all be working together, regardless of race, regardless of politics, just to think about what is best for our children. I would hope that there is going to be a movement towards reopening schools, taking into account not only the fact that teachers have been working hard this whole pandemic. They’ve been adapting to distance learning. They’re feeling attacked right now with the push to reopen, and as physicians, we certainly empathize with how they’re feeling. We felt the same way in March and April of last year, when we felt like we were just being pushed into the hospital, sometimes when there were no masks available. At that time, there was no universal masking, and yet we reported to work anyway.

So I think we need to recognize that that fear is there, and the end is in sight. Vaccinations are increasing, supply is increasing, and so we need to not only have a robust vaccination program in place, but also start having strategies of how best to get these kids back as well, even possibly before the whole population is vaccinated, because I think that’s going to take too long.

Kevin Pho: So you mentioned earlier that one of the requests that you’ve heard is that teachers get vaccinated first before schools can reopen. Now, do you think that is a necessary step before we reopen schools?

Lekha M. Rao: At the time that I wrote the article, people over the age of 65, who account for 70 percent of the mortality in COVID-19, were already eligible for vaccination. I understand there have been a lot of challenges with vaccine rollout, and that’s understandable with something of this magnitude. But at the same time, we have a lot of schools that have been open even before teachers were vaccinated.

And again, if we focus on the fact that children can wear masks and children can follow rules, certainly there are always going to be exceptions. There are always going to be people who maybe lie about symptoms or don’t disclose a family member with a COVID-positive status. But we have a lot of data from other schools to show that even when that happens, there’s not significant COVID-19 spread. So again, if we can focus on the majority of the time rather than those rare instances, then I think that schools can reopen before all the teachers are vaccinated.

Kevin Pho: And by schools reopening, are you talking about full-time, or are you talking about a hybrid as kind of a step measure before opening full-time?

Lekha M. Rao: Yeah, I think that the best scenario is full-time. Hybrid programs are very challenging for educators as well, and I understand sometimes space can be a restriction, but that’s why the American Academy of Pediatrics had said that if six feet can’t be achieved, three feet can be acceptable. Of course, each public health department in its respective state or county is going to have its own guidelines based on its community spread, but ideally, if you can get the kids back as much as possible, that is the best.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Lekha M. Rao: My take-home message is that I think we need to get these kids back into school. We’re not talking about opening the doors and letting everybody in without masks, without rules, going back to pre-pandemic life. When pediatricians are saying, “Let’s reopen schools,” we’re talking about reopening them with safety measures in place, with access to contact tracing and testing, and, I’m not saying getting vaccinated, but with access to vaccinations for the teachers, and with keeping in mind that children, yes, they are resilient, but if this goes on, there are going to be long-term impacts to them. And so I think we all as adults need to work together to help our children.

Kevin Pho: Lekha, thank you so much for sharing your time and insight, and thanks again for being on the show.

Lekha M. Rao: Thank you so much for having me.

Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes