 Dear colleagues, welcome to today's meeting of the McLean Center and Bucksbaum Institute's annual lecture series focusing on COVID-19. Dr. Megan Collins and I go back a long way. We worked together at the McLean Center for eight years as the principal ethics advisors to Dr. Jeff Bluestone and to Dr. Tony Fauci on an NIH-supported $200 million research project entitled The Immune Tolerance Network. Dr. Collins currently is an assistant professor of ophthalmology at the Wilmer Eye Institute of Johns Hopkins School of Medicine and an associate faculty member at the Johns Hopkins Berman Institute of Bioethics. Dr. Collins received a medical degree here at the University of Chicago where she also completed a fellowship in clinical medical ethics and then completed her ophthalmology residency at the University of Chicago. By a pediatric ophthalmology and strobismus fellowship at the University of Toronto's Hospital for Sick Children, Megan received her master's in public health from the Johns Hopkins University Bloomberg School of Public Health, a school widely regarded as the leading public health school in the world. Dr. Collins' research includes health disparities and access to pediatric eye care and the impact of vision problems on learning for school-aged children and on their academic outcomes. Dr. Collins is co-principal investigator on vision for Baltimore and vision for Chicago, two research collaborations that examine strategies to build sustainable models of school-based vision care. Megan Collins is widely recognized for her contributions and has worked with national and international organizations such as the National Eye Institute, the Lancet Global Health Commission and the Prevent Blindness Foundation. Megan is a national leader in the field of school children's vision and pediatric eye care. Dr. Collins founded and co-directs the Johns Hopkins Consortium for School-Based Health Solutions. In the spring of 2020, she also founded the Johns Hopkins East School Initiative, the university-wide collaboration examining the impact of kindergarten through 12th grade school closures on children from disadvantaged backgrounds and on providing guidance on the reopening of these school strategies for key stakeholders in education and policy. Today, Dr. Collins will speak to us on a topic that she and Ruth Faden, the original founder and director of the Berman Institute of Bioethics at Hopkins, have worked on together. Megan's talk is entitled, quote, equity and K through 12 school reopening during the COVID-19 pandemic. Let me just end by saying previously, Dr. Collins and Dr. Faden had done a webinar on the same topic that received social media responses, sit down for a moment, for more than 6.4 million people, 6.4 million social media responses. It's a delight to welcome Megan back to the University of Chicago to talk to us on equity and kindergarten through 12th year school re-openings during the COVID-19 pandemic. Megan Collins. Thanks, Mark. Thank you, Lainey and Mark and Brian for the invitation to speak today. I don't know if it's because you like me or you really don't like me to invite me to speak the day after yesterday. I feel a little hungover. I didn't drink at all last night, but I'm a little hungover from too much news. So I'm going to talk about a very timely topic. I'm going to share my screen here, Lainey confirming I'm sharing my screen, right? Okay. Yes. Perfect. I'm going to get this up in just a second. Okay. Can you see? I'm going to take myself off of presenter view. Okay. Can you see it? Yes. We see it and we hear you. Perfect. Two good things. Okay. I don't have any financial relationships to disclose and we are not discussing any investigational medications today. So what I would like to spend the next 40 minutes or so talking about is what's happened with COVID-19 and how it's impacted K through 12 operations. I'm going to focus on the United States. I should say that a lot of the stuff I will discuss has implications globally as well. I'm going to talk a little bit about what I call the school support framework. And hopefully that will help tie in why as a pediatric ophthalmologist I'm talking today about school reopenings. There are a ton of equity issues that have happened because of school responses during COVID. So we're going to go through some of that. And then we're going to hopefully end on a positive note to discuss how do we move forward. We're in a really challenged position right now for millions and millions of kids across the United States. So I'm hoping we can move in the right direction. As Mark mentioned, I'm part of this wonderful new collaborative that we've developed at Johns Hopkins. It's called the East School Plus Initiative. It includes myself as well as Ruth Faden from the Berman Institute and our other co-leaders in that Anderson from the School of Education. We have wonderful representation from faculty from across the institution as well as several other institutions. But what this work highlights is really these issues about how do you reopen schools sit at this intersection of public health and education and ethics and medicine. So we've really tried to bring together a group across the institution to think about this in a thoughtful manner. This is a website that houses a lot of our work. So I would encourage you if you're interested to go ahead and take a look at it. The address is at the bottom. As Mark was pointing out, the day our website launched, we developed a tracker about school reopenings. And given, I think, the visibility of Johns Hopkins for the Coronavirus Resource Center and their tracking of cases across the world, as soon as we started a tracker of what was happening with schools, we got a ton of hits from around the world. So how did this all start? How did we start thinking about this issue? It actually started with something Ruth Faden wrote in the Baltimore Sun this past February, which now seems like decades ago. And she wrote, as in all public health emergencies, poor children and poor families will suffer the most. And ethically defensible policy of government school closures needs not only to meet the basics of public health necessity, it must also include active measures to mitigate the disproportionate burden that will fall on our most vulnerable children. And, you know, Ruth was very prescient. This was before schools had closed in the U.S. at all, but she was anticipating that this may happen. And if it happened, we really needed to be looking out for our vulnerable children. So who are in... Who is our vulnerable population? Who are we worried about right now? There are over 50 million children in public elementary and secondary schools in the U.S. right now. Roughly 20% of your population under 18 is living in poverty. Roughly 14% of kids in schools have special learning needs that are covered by the Individuals with Disabilities Education Act. And half of students across the country qualify for free reduced meals, which again is another metric of poverty, but it's the provision of food services within the school setting. And then about 10% of children across the country are English language learners. So you start to begin to get a picture of a number of vulnerable individuals who might be impacted as schools close. I'm going to just give a little bit of the timeline as to what happened. Ruth wrote that article, February 27th, March 13th was really the day that almost all schools across the U.S. shut down. And what happened was at least the Maryland story of the spring break, they shut down and said, well, we're not going to come back until after spring break and we're going to make spring break a little bit longer. So they shut down, but not with, not with a, I think a vision of how long they were going to be shut down for. And what sort of plans they would have for their students while they were shut down. So sometimes they extended spring break and said, we'll revisit it another week. And they said, well, we're not going to be shut down. And they said, well, we're not going to be shut down. And then children were often at a loss of, they didn't have learning plans. They didn't have access to digital technology at all. So they didn't really, there was, there was not a lot of learning that happened this past spring, particularly in high poverty schools that just didn't have access to the same resources or technology in order to connect with their children. The other thing that happened at the same time as any of the other schools were shut down, all of those were suspended as well, of course, because schools were out of session. You get into May and June of this year and state boards of education said, okay, we need to start thinking about how we're going to reopen this fall. And again, at that point in time, the conversation was really not whether or not we will reopen, but how are we going to reopen? And over the summer, that conversation has changed a lot. A lot of this was infused by politics as well as evolving information on the science of COVID and transmission and morbidity and mortality in children and possible onward transmission in schools. But this past August, schools started to open in various fashions. 75% of the largest school districts across the U.S. open virtual. So the vast majority of schools in the U.S. started their school year online. I pause for a second. So how did I get involved in this effort? One of the things, as Mark mentioned, you know, I've spent the past five years building a partnership across Baltimore City called Vision for Baltimore. And the point of this initiative is actually to bring eye care to kids directly in schools. We know that kids who struggle to see struggle in school. So we developed this entire initiative that would bring the vision care directly to schools. So what happened to a program like this as of March 13th? It shut down. And this is, this is not the only one. There are hundreds, if not thousands of similar programs across the U.S. that while schools have been out of session, programs like this that came to add additional supports to students in the school setting are, are largely not operating right now. And that brings me to what I call the child wellbeing school support framework. And this is the concept that has really evolved, I'd say at least over the past decade, that schools are more than a home of learning. They certainly are a place that we, we do educational instruction and benchmark assessments and things like that, but they are also for millions of kids. Also the place where they get food, they're where they get their breakfast lunch, sometimes three meals a day. They are a place where a number of kids get health services. That could be things like eyeglasses, but it could also be things like their, their asthma monitoring them, their use of their asthma treatments. It could be dental health. It could be mental health. And again, all of these things are impacted when schools are not in operation. There are millions of children who are unstably housed in the United States. And schools are a place of safety and security and supervision during the school day. So as we think about what happens when schools close and stay closed for a prolonged period of time, it's not only what happens to a child's sort of educational trajectory, but what happens to their, you know, entire wellbeing, their health and their safety. So I'm going to give you a couple examples of some of the information we're starting to learn. And I will tell you all of it is scary. So there, there are a lot of people starting to talk about these issues. One of them is a report that came up from McKinsey and the company this last June. What they did was estimate just from past spring, what the impact of learning loss could be for children. And what they did was they, they modeled out a few different scenarios and then they looked for children from low income families, children of color. And what they found is that children from low income families and children of color, they estimated just from spring alone, they were going to suffer eight to 12 months of learning loss. And this is just last spring. We're not even talking about this fall yet. Food security has become sort of one of the areas I'd say that has gotten more attention. There, there have been a number of projects looking, this graph to me is really striking. If you look at, you know, the, the X axis down here tells you years. And then there's a breakdown by different ethnic and racial minorities of what happened June, 2020. And basically you see sort of this massive increase in children who are food insecure, particularly more noticeable among black and Hispanic households. If you take the safety issue, this is one I actually did not know before, but I'm learning a lot more about from two perspectives. One teachers actually tend to be in at least 20% of cases, ones who report suspected child abuse. And with schools closed, actually reports of child abuse have gone down dramatically. So the question was, well, has child abuse itself dropped? And the answer unfortunately is no. We're seeing cases, but the teachers who are often the ones to help intervene early are not doing this anymore because they're not seeing kids. From an ophthalmologist perspective, we've actually seen an uptick in the number of kids who are admitted through the emergency room for some type of non-accidental trauma that often has ocular manifestations as well. So what's at stake with school closures? This is a, this is a white paper that our team put together to look at, to sort of frame all of these issues. I've just told you about sort of this whole school framework of what the different things schools do. And really why do schools do this? Schools do this because there's a lot of pre-existing structural injustice. It impacts child wellbeing. COVID has exacerbated that. And schools are typically a place that lessens and mitigate some of the systemic inequity, but the problem is with schools closed, with COVID happening, you've really had this compounding of structural injustices with this to the detriment of child wellbeing across the country. So our team has trying to track and understand sort of what happened this past spring and how do we think about things this past fall. So I'm going to take you through a couple of our projects, but one of them was we actually started to look at districts this past spring about how they were supporting students in these different areas. Again, the five key areas being continuity of learning, food security, health services, housing, safety and supervision. So what we did was we actually looked at, we took a small sample of 45 school districts across the country. Now, just to put it in perspective, there are 14,000 school districts across the country. So this is small. But so we looked at all the districts in Maryland. Maryland is a really interesting state because it has a lot of high poverty and low poverty districts. It has rural, it has urban, it has suburban. So it actually gives you a good representation. And then we looked at some other key districts in California, New York, Michigan, Florida and the District of Columbia. We collected this three times a week. So what we did is we went to all the district websites and looked three times a week about what types of data they were reporting about what they were doing. And if you can see this is just a extraction from one of our air table documents, but what were schools talking the most with families about? It was about continuity of learning. They were telling them about where they pick up their learning packets or how they log in for things. And the next most common thing was food. And this is what we saw pretty commonly across the country. Schools immediately responded and heroically so in all honesty to try to figure out learning with lots of struggles and to try to figure out food distribution. The problem is they weren't as good as some of these other things, such as supervision, such as housing and safety and health. And, you know, from the healthcare perspective, it really left a lot of kids in a challenging situation as if they were part of a school-based health center where they were getting some of their primary pediatric care, a lot of kids did not necessarily know where to go once the pandemic happened and they were, you know, stay at home orders across the country. So where do they go for healthcare at that point in time? We knew that a lot of things were happening with kids suffering this past spring. And our dean of the school of education and one of our deans from the school of public health wrote this really important article in JAMA in early June where they not only talked about the challenges of reopening schools but the urgency. And at this point in time, again, we're now kind of early June, 2020, the emphasis is this past spring has been a loss. Let's get kids back to school and let's figure out how we're going to get kids back to school. In particular, prioritize children most at risk for missing school. So those are children experiencing barriers to remote learning. Those are children who have special education needs getting nutritional support through school. It's also a lot of the younger children. The younger children were the ones that we saw particularly this past spring having the most issues connecting online. And there's a lot of, you know, social and emotional development that happens from being in the school setting. That was not happening with kids at home. But what I also want to draw your attention to is some of the some of the recommendations here, which I think are all very important, but additional space, educational technology, restructuring school time to permit distancing, offering, you know, sort of offering alternate schedules, which again, very important idea and one that can help with social distancing and risk mitigation measures. But when you think about a less well resource community, they may not have the flexibility to be able to kind of bring their children to school on alternate day or alternate week schedules or things like that. So out of this, our team started developing a reopening checklist for schools across the U.S. and we developed this document. It was meant intentionally for stakeholders in this space for them to start thinking about what children had lost this past spring and what schools would need to do to sort of assess some of these losses and help bring kids back up and lessen any of these growing achievement gaps. We also partnered with the center for health security. So if you think back, and it just seems ages ago now, but if you think back about what did we know about COVID transmission in kids last, you know, February, March, April, it was not a ton. And it's not to say we know a ton more now, but we certainly know more than we did then. So there was a lot of questions. Is it safe to have kids in school? And what's going to happen if we bring kids back to school? Is there going to be onward transmission? What are the risks for teachers? What are the risks for students, particularly students who may live in a household with an individual who could be immunocompromised, multi-generational families. And as the E-School Plus initiative contributed to this project, what we tried to do was bring attention to all these equity issues and these growing gaps in achievement and health and looking at ways to prospectively understand them and think about mitigating them. So that was sort of part of the impetus for the E-School Plus reopening tracker. As I mentioned, May 2020 is when school systems across this country really pivoted to the discussion of how are we going to reopen? And what we did is we conducted a comprehensive analysis of every single state across the U.S. with the reopening documents that they made publicly available from their state boards of education. We also included the District of Columbia, the Bureau of Indian Education and the major U.S. Territories. And I'm going to show you on the next slide sort of what our tracker looks like. So this is a snapshot from our website and this is a more recent snapshot showing that, so we show all the states and what we've coded every single state on their reopening plan, we coded them on 12 categories. Six categories are purely operational. How are they teaching kids during the pandemic? What are they doing if they're in person about before and after school programs? How are they handling transportation? How many kids can be on a bus? What are they doing about student health services? How are they handling food and nutrition? The second six categories, though, are all equity and ethics related. Do the plans give any considerations that there's a parent choice about sending their child back to school? Is there any option for a teacher to have a choice that they don't want to come back to school? How are they specifically dealing with children of poverty and systemic disadvantage? And these are children who are experiencing homelessness. These are children who didn't have access to digital technology during the past spring. Children living in juvenile detention centers. All kinds of groups of children who we felt were the most vulnerable. We also looked at children who had special learning needs, as well as English language learners gifted and twice exceptional. The final two categories, privacy and engagement, we're looking at what were reopening plans saying at the time, how were they handling privacy? What happened if they had a COVID case in the school? Were they going to tell people? Were they not going to tell people? And what level of engagement did they have with the school community about how they were reopening? And what they were doing to keep kids safe. As we know, parents are going to be worried about sending their kids back to school if they don't feel they're safe. So in looking at these 12 categories, what we did is we coded every single document as it came out and documents kept coming out every day. And we continued to kind of code and update them. And what you saw was a map across the country with all of the operating shades of completeness that they had, you know, zero categories to all 12 categories. And on the next slide, I'll show you, so this was when we launched this in early July. If you look here again, the top of the slide has all of the operational categories. The bottom of the slide has all of the equity categories. So I will say when we, you know, N equals 56 was all of the places that were included. So this point in time, July 13th, only 51 state boards of education had reopening plans. So almost all of them at that point in time, largely had provisions about core academics, infection control, and food services and school access. But what you'll notice is they drop off when you get to the equity categories. They actually aren't saying a ton about parent choice, teacher choice, but they really aren't saying anything is about children of poverty and systemic disadvantage. And I should say when we coded these, we were if anything generous in that if a, if a state plan mentioned something at a minimum, we would include it, but often they didn't go into very much detail as to how they were going to actually help, you know, with considerations of parent choice for sending their child back to school or considerations for the accommodations of kids who had special learning needs. But what happened is, as this went public, we, there was a ton of attention. I think, you know, many states, state newspapers started publishing Hopkins says, Rhode Island cares about equity more than Massachusetts or Hopkins says, you know, Nevada has it right. Which was, which was not the intention, but what happened as a consequence of it, what we think is that it started, it started raising this issue for states in that they had to think about these equity considerations and they had to think about kids who had previous, they had may not have previously been considering their plans with the impact of, when we started looking at this, only 16 states had all of the categories in their plans, all 12 by October 15, 36 do. So you could, if you're a glass half full person, you're going to say, this is great, more than double now have included these categories. If you're a glass half empty person, you're going to say, we still have a third of states who are not comprehensively considering issues of equity as they are, you know, publishing their reopening plans. The areas that still seem to be the biggest miss our teacher and staff choice and children of systemic disadvantage. And just, just sort of how we coded this and this is, there's a lot of texts on the slide, but we literally sort of had a code book of all of these different considerations of variables of if a state plan mentioned any of these they were considered as having, you know, acknowledged to some extent, children of poverty and systemic disadvantage. I'll tell you the area that almost all of them failed to mention was ongoing assessment of the extent of disproportionate impact on these groups, which is notable given the fact that we already know from past spring how much these kids have fallen behind in comparison to their peers. To flesh this out even further, we have expanded the tracker to not only look at these categories within reopening plans, but also try to match it with some other relevant metrics from the state. So we've pulled the coronavirus trends. So what's happening in terms of daily test positivity in their state, daily cases, and then a lot of metrics that are relevant to kids. What's the student population in the state? What's the English language learner population in the state? What's the eligible kids for, for a farm, free and reduced meals? Those who are, you know, getting special education services through IDEA and those at or below the poverty line. And what this, this starts to put together is this picture of case burden, other poverty metrics, and how states are considering equity considerations as the reopening schools. We have begun to, with everything with COVID, things move quickly. And what happened is as we, you know, as we worked over the summer with, on state reopening plans, pretty much as August came around the conversations shifted from the state to the district. So because obviously states had to come up with the reopening plans first, districts waited and took their cue from what was happening at the state level, but then districts started developing the reopening plans. And this is just a snapshot of a small project we're doing with the center of health for health security at Hopkins, actually starting to code all the district level plans. As I've mentioned again, there are over 14,000 districts. So this is a project of a great, greater order of magnitude than the state level document. The interesting thing to me here, and we'll talk about this when we get to some of the other new dashboards that have come out is the, the categories that we're lacking more often than not, we're actually privacy and teacher choice. So teacher choice is pretty similar to the national tracker. What seems to be happening, you know, at least more at least being acknowledged is the special considerations you need for children of poverty, children with special learning needs. So everybody is in this space. Everybody wants to kind of weigh in about how school should reopen and how to keep kids safe. And as a consequence, we've had a lot of fortunate, you know, a lot of attention to our work and helped to meet with some of these big stakeholder organizations who are in this space as well, who are thinking about what do we need to do to keep kids safe? How do we understand what's happening with schools reopening? So I'm going to take you into now fall 2020, what has happened as schools have started to reopen? And what are we learning from the other trackers that are out there that are sort of sprung up after our tracker and help supplement what we've learned with some other data? And one of them is out of Education Week. So Education Week is a great online resource used by a lot of education stakeholders. And what they looked at was reopening plans. They tracked reopening plans for districts across the U.S. and they actually looked at 900 of the largest school districts. But what they looked at was pretty much just whether states were going to be open for in-person learning, whether they were going to be virtual or whether they're going to be hybrid. And what we know from this is that 75% of the largest school districts across the country open with remote learning only. Actually, when you think about the 10 largest school districts in the U.S., the only one that had planned for opening for in-person instruction was New York City. And New York City's plans, of course, were delayed multiple times, but they were the first of the large school districts across the country to try to open for in-person instruction. So there's another tracker out there from Burbio. What Burbio is looking at, they are looking in real time. So this changes a few times a week. How many kids are now still virtual versus in-person? And they have a color gradient here, of course, from, I guess, violet to deep purple. It's interesting. I think you could draw some political implications here about which ones the deep purple states are in-person versus virtual. And of course, you know, California is primarily still a large number of the school districts are still virtual. Another one. So there's so many people looking in this space. This is MCH, maternal child health. What they're looking at is how are schools reopening? What type of instructional method do they have? But they're also looking at requirements for mask wearing. So are students required to wear masks? Are staff required to wear masks? They're also looking at sports participation. This has become sort of a big issue with a lot of schools of, you know, the limitation of sports. One of the things that I think is really useful about this data, it's helping to flesh out the picture is they have time lapse. So you can watch over time as things change in various areas across the country. So one of the ones that I would encourage people if you're, if you're really interested in this area to also look at is University of Washington and they don't have a tracker per se, but they have developed a pretty comprehensive database of actually looking at district reopening plans across the United States. And they came up with this rubric, which I think is very important in one that, you know, we should think of as a standard for first schools across the country. And this is what they think needs to be included in the reopening plan. Clear, inclusive, regular communication. Structured and meaningful learning. Clear fall reopening plan. Effective resource allocation. Educational services for vulnerable populations. Support to staff. Health and safety measures. Access to education for all students. So they are bringing out sort of the need for equity considerations as we're reopening schools and thinking about, you know, how do you, how do you handle resource allocation? How do you handle communication and engagement? Because what has happened, the decision to reopen has not happened in a political vacuum. There have, there has been a lot of pressure from, from states, from federal government, from policy organizations, from unions about whether it is safe to reopen or not with the consequence of, I think parents would have feel like they're yo-yoing back and forth between, I really want my children to be in school. And I'm scared about their safety and I'm scared about the resources of the school district and being able to provide for my child. Which brings us to sort of the newest hot topic in school reopening, which is our kids getting COVID when they go back to schools and is there onward transmission, meaning that somebody comes into the school and has it, and then other kids within the school get it as well. So there is the COVID-19 school response dashboard. This is out of Emily Oster's team at Brown University. And what they had developed in partnership with a couple of the big educational associations, as well as Qualtrics is a survey that, it's a voluntary survey that schools would complete a baseline survey. And then I think they complete it once a week or so. That actually looks at what types of, you know, how many students are in school, how many students are absent from school and how many cases they have. So, you know, one of the major criticisms of reopening schools is the fact that we don't have good data at the state or national level about COVID cases in schools. So Emily Oster's was sort of the first to really dig into this issue. She's received anybody who's kind of following this area. She's had a lot of negative feedback on this in the past week. Because of what happened is most of the school districts, as I mentioned, this is voluntary. Most of the school districts that have responded to her so far, it looks like the case transmission rate is incredibly low. And it looks like cases that we're seeing in schools incredibly low. That part is reassuring. The problem is the school districts have, that have responded have generally been suburban, rural, more well-resourced districts. So it doesn't necessarily give you the same type of picture that you would have, for example, if you open Detroit public schools or, you know, another kind of equal high poverty urban school district where you may not have the ability for the same levels of safety measures in the school just because of lack of resources. The other one that has gained a lot of the national attention is what's called the COVID-19 monitor project. This is a project out of a team in Florida run by an investigator, Rebecca Jones. And what her, you know, sort of, I think impetus for getting into this area was realizing that states just were not being very transparent in how many cases of COVID were happening in schools. So she started a, she started a database that, well, that public could report cases and say, well, I heard of there being a case, you know, in this school or there was a child sick in my class. The challenge with that, however, is when you have, you know, individual kind of public reporting of cases, sometimes it may not be accurate. Sometimes it may be somebody had, you know, was a person under investigation. Sometimes it may be a kid who had a cold. So they have, they've expanded their database now actually trying to get, not only get those public reports verified, but also get things from the state and district level as well. So where does this leave us? I've taken you kind of on a journey through a lot of what we know has happened with schools being closed, how there has been widening of, of equity gaps that existed before COVID, but have only been exacerbated by it. But I think there's a pathway to reopen schools. And I'm just going to take you through this. So, so obviously there are all of the public health things that we need to consider about. You have to have low community transmission. That sort of, you know, is the foundation of everything. But just starting at the top and we'll go around, you need to have availability of testing. So testing so that if a child or a teacher would seem, would become sick or become symptomatic, they're able to be tested. If they're not able to be tested, it's not only are they out of school, but their entire cohort or pod is out of school until they, you know, are found to be negative. Now the problem is at least early on, as we started working on this issue, testing was not widely available, particularly if you got into less well-resourced communities. LA Unified and New York City are both trying to do testing school-based. They're the only big school districts in the country who are doing this. And LA Unified is of course doing it on a much larger scale. They're not in person yet. Versus New York is trying to do, I think testing of 10 to 20% of kids who are asymptomatic, just so they can sort of continue to, to keep tabs on transmission in their school community. After you test, you also be able, you need to have an infrastructure to contact race, either through the schools themselves, which is probably less ideal, kind of in partnership with health departments. You'll also then need to be able to understand what type of, if you have COVID cases, how and what your reporting infrastructure will be for that. Is the school reporting those cases? How are they reporting those cases? There's, there's a huge desire for data. Sort of one of my, you know, concerns about this is we want to give data people can understand. And so try making sure that we're putting data in the way that it's meaningful to people and not just causing more fear and more confusion is important. Risk mitigation measures are another one. So what are risk mitigation measures? Those are, those are our masks. Those are our social distancing. Those are restructuring of our classroom. They're restructuring of our hallways are using outdoor space or using extra space. So we can reopen schools. Health education for stakeholders at every level has also become really important. And this is because parents, teachers, school district leaders are now in the kind of untenable position of having to make decisions that often require a vast knowledge of public health that they don't have. And, and, you know, it's not their fault. They don't have, you know, a lot of people don't have all the information about, about COVID, but they're trying to make decisions about how to reopen schools and, you know, how should we, how many kids should we put on the bus and things like this. So trying to figure out what types of information we can give to those district leaders so they can make informed decisions. I think is really critical. We have a team at Hopkins actually working on this right now developing specific education modules for education stakeholders. So they understand what it means when we're talking about community transmission, onward transmission, risk mitigation, all of those terms. The biggest one I've saved for last is engagement and trust. This is, this I think is probably going to be the one of the biggest challenges to reopen these schools. And it's because there have been so many changes and sort of an evolution of what the science is and what schools are trying to do. And, and we've saw pictures early, early September, late August of schools in Georgia where no kids were wearing masks. And we have, you know, stories of Israel where schools were open and then they had to close. And we have lots of different things that parents are genuinely scared. And we need to be able to build that trust in that engagement so they understand what schools are doing and what schools can do to keep kids safe. I have this slide twice because I think all of the, all of the considerations are also potential barriers. So more well-resourced schools are able to do all of these things much more easily. Than less well-resourced schools. So while we know this is the formula for getting schools open, our challenges we know are most disadvantaged kids are the ones suffering the most. We also know they have the highest barriers to us successfully reopening schools. And really sort of the challenge now is how do we do that? And how do we overcome all of these barriers? Obviously probably the biggest challenge is how do we do that? And we need more financial resources for states to be able to help schools be able to do all of these things that they're being asked to do. And an unprecedented time for all of us. So when I was thinking through all of these things, I sort of put this in, there's really three waves of inequity for vulnerable populations. There's what happened this past spring where we started having learning loss. We started having high rates of absenteeism. We started having less access and technology, less likely to have more formal learning plans. All of those issues unfortunately have continued into the fall. With the fact that they compound each other. So, you know, not doing well in math this spring means that when you come into school this fall, you're going to have a harder time catching up and you're going to have a harder time catching up. If you're in a remote curriculum that you may not be able to connect with your teacher on a regular basis. So obviously what happened this past spring and what happened this school year will be incredibly consequential. But what I worry the most about and what I don't think people are talking enough about is what's going to happen after this year. So how are we handling benchmark rates for kids? How are we handling, you know, how are we handling benchmark rates for kids? How are we handling assessments? How are we handling, are we going to have, you know, we're going to have a high percentage of kids that we don't feel can graduate from middle school to high school, from grade school to middle school, or even graduate from high school. And, or are we going to err on the side of saying, let's, you know, let them, let's let them move to the next level. If we do that, are we doing them a disservice? How are we handling things like assessments, graduation? What impacts will it have on graduation rates? What impact will it have on college attainment, future employment and health? Back to, again, what sort of brought me into this area in the first place is kids get a lot of their healthcare in the school setting. And what happens when they lose those relationships, whether it's with their eye doctor, whether they're visiting dentist or their school based health clinic for a prolonged period of time? What are the short and long term impacts that's going to have on their health? So, final, a couple things, a couple positive points to end on. I don't leave us more depressed than we may have been since somebody gave a speech at three o'clock in the morning. So one of the things that I would say that this has forced both the educational system and the healthcare system is really to be more innovative about the use of technology than we used to be. And think of that as a way to connect with parents much more so than we have in the past. There's still a huge lift there and there are a lot of barriers to people who don't have equal access to technology, but the fact that we are forcing ourselves to use it more I think is a step in the right direction. Because what's happened through technology is we've increased engagement with through parents and families. This fast spring when our team began helping some schools across the country as they were thinking about how to support kids during school closures, literally the first thing that many had to start with was figuring out contact information for parents and contact information for kids because they may not have had it updated since the beginning of the year and they had changed addresses, phone numbers, e-mails so they needed to be able to connect with kids in the first place. We've been forced to do that so much that I think schools are doing much better at that and being able to engage with parents more effectively than they had. What we have seen out of the pandemic and out of a lot of discussions this spring and summer is we are talking about this more so than we have ever had before about these massive inequities and health and academic achievement for children across the country. I think the only way we're going to make any changes is at least if we acknowledge it in the first place and we figure out a pathway ahead. With a lot of interest in the education field of how do we reimagine our education system? How do we reimagine this whole school support framework to help our children to help their health and education but also build more of an infrastructure for more community engagement so that schools are not doing this alone? Because really they had been doing a lot of this alone. Those are some thoughts as to where we might go. I think that's my last slide. My e-mail address is here. I'm happy to answer questions at this point in time. Thank you very much, Megan. I will, that was just fabulous. And what you guys did was really great. And as you pointed out, Ruth was really prescient in realizing that this was going to become a big issue. And kudos to you and to your team for following through and continuing to follow through. The first comment comes from Martin Chen who wants to know, do you think there are different risks for different groups? So like the pre-K, the middle school, high school colleges and which groups are riskier? And we can interpret riskier whether we're talking about riskier for learning loss but also riskier for when we get them together. The risk that they pose to each other and the staff. Yeah, it's a great question. I would say, you know, sort of all of my expertise is within K through 12 education. So what happens after kids leave high school? So from, you know, the interesting thing is, and perhaps the beneficial thing is the more we've learned about the risk of COVID transmission, the less we have seen it in the youngest kids. If they get it, they don't get as sick. There, you know, there's a lot of questions from epidemiologists because we just don't test kids that much. They may, there may be more asymptomatic cases than we know about, but still they tend to be the less likely to get it and the less likely to be sick, which is good. If you're thinking about what are the kids who will benefit the most from in-person instruction? It is the youngest kids. It's the youngest kids who, maybe some of them are way savvier than I am with PowerPoint, but they need that social and emotional development and connections that have been in the classroom. I mean, my hat goes off to pre-K and K teachers across this country. I have no idea how they are doing virtual learning right now. I have several friends who are doing it and it just amazes me, but those are the kids that I think, you know, we want to prioritize getting back first. The other ones are kids with special learning needs. They really are struggling with how you do, you know, the various supports we do for our kids with special education remotely and it is not going well in many districts across the country. Great. Thank you. The next question is, do you think school lunchtime, so when everyone takes off their ill loop face masks pose particularly great threat compared to other learning activities and will half day instruction solve those problems? Also a great question. You know, I am not an infection control expert by any means. I will say that what schools, what a lot of schools have been trying to do is actually keep kids in pods or cohorts. So they eat with their class. A lot of times they're trying to keep them eating in their classroom. So again, if they are with other kids and their mask is off and somebody gets sick, it's with the 12 plus kids that they spend the rest of their day with and not causing something that the entire cafeteria is now at risk, particularly because CDC did just change its guidelines about what qualifies as a close contact. It used to be, it used to be, I think I have this right. It used to be sort of 15 minutes. But now it's become 15 cumulative minutes over the course of the day. Okay. Well, within six feet. Yes. Yes. Thank you. The John Lantos. Hi, John Lantos. There you go. He says aside from looking at what schools are doing for education and meals and child abuse reporting. Do any of the databases look at rates of COVID transmission? And if so, which particular activities seem to be high risk? So clearly lunchtime, but also our schools going back to doing physical education, which is a very important part of the data. And so, what are the other enrichment activities? Yes. So, uh, so this is data that we are only beginning to understand. Only beginning to understand for two reasons. One schools haven't, you know, a lot of schools haven't been open. And the second is there has not really been this systematic way of collecting that data. So as they are starting to collect that data, they're getting more information about things. So, um, you know, you know, you know, you know, you know, sports activities, outdoor sports activities as kids seem to be doing pretty well with those. Um, but I, again, I'm just because I don't have that infection control background. I don't know what particular activities are the highest risk. Got it. Julie Campbell asks, what level of community spread would, or I'll change it to should trigger remote versus in-person communication. So, um, I think the newest guidelines out for the level of community transmission and what they have is they don't, they don't sort of have a yes, no, they have a continuum of red to green, uh, in terms of what would be the, what would be your safest and what would be your least safe. Um, but this brings up a really important point that it's important that we've been trying to get across to education and, um, we've been trying to get a vaccine without a treatment, there's never going to be zero transmission. So, and we can't get to the point of saying, we're not going to reopen schools, at least in my personal opinion, I don't think we should wait to reopen schools until we have zero transmission. We have to recognize that there's going to be some level of risk with reopening schools, but typically we're talking about less than 5% case positivity rate in the community before, um, we're not going to be able to reopen schools. We're not going to be able to reopen schools. We're not going to be able to reopen schools. We're not going to be able to consider it acceptable to reopen. Which goes to the next question, which are how are schools dealing with the issue of legal liability associated with reopenings? That's a good question that I don't know about. Um, one of the areas that we are starting to get more involved in are the, the, um, the legal liability issues around disclosing or not disclosing, but I don't know, um, anything about that issue. We should. By disclosing and privacy, you mean disclosing whether to other classmates and parents of other classmates or disclosing to the public health department. No, disclosing to classmates and parents. So, and how to keep that, um, de-identified. So if you have a class of, you know, a teacher and one second grade teacher, and you say the second grade teacher got COVID. Um, so how much can you, how much can you aggregate and de-identify the data without actually identifying the individual? Yeah. So, uh, there have been, uh, one individual wants to make a comment, but the way that this is structured, you're going to have to write your comments in so that we can read them. Um, Mike Missol has commented that there's robust data on vulnerable children, children with special healthcare needs. And children head starts, but, um, Mike, I apologize. You're not, not able to comment because of, um, the way, the way this, uh, is structured. And I think he mentioned in the chat, Laney, that he's in Chicago. So he may have. Yes. Yeah. Yeah. He's here at the University of Chicago. The, um, Those are our questions. Are there any from our panelists? Uh, yeah, I, I had written a chat question, um, regarding the, the organization that Megan had established, the vision for Baltimore, which was also a vision for Chicago. And I think began to be applied in New York. We, which is to provide, uh, glasses for free, especially for vulnerable, uh, poor children, but not, not only for them, um, in order to get them to be able to see in, in a regular normal way. And I just learned at this meeting that, that that program has been, um, uh, given up. And, uh, and my question for Megan is what is being done for these children's, uh, vision in the absence of your program. Yeah. Thank you, Mark. And, and I apologize if I, um, miscommunicated that. So vision for Baltimore is, um, Has been severely impacted by COVID, but we certainly have not given up at all. Um, and in fact, to, to my knowledge, we are actually one of the only programs of, um, school-based vision care in the country that's still trying to operate with schools closed. So what, what we're doing is actually, we are still bringing the mobile vision clinic to the school sites across the city. Um, but we're doing appointment based. So, so we'll call parents and say, do you want to bring your child in? So it's literally almost the same as coming in to see a doctor in the clinic setting. Um, and we felt that was really important that, you know, this program has been kind of a, you know, kind of a pride of many of us across the city for the past five years. And we didn't want it to get completely sides swiped because of COVID. So we've, we've figured out sort of innovative ways. We developed a specific, um, infection control protocol to make sure we were minimizing any risks to kids or providers from the ISAMs. You know, we made sure we had lots of PPE and things like that. Um, but you know, it's very interesting. So Maryland State Department of Education, which I think is fairly similar to other state departments of education across the U S they hadn't suspended all types of vision or hearing screening requirements for school age children across the U S as of last March, just because schools weren't open. So the, to me, the really interesting question is cities that don't have programs like ours, um, because they may not be doing screenings right now. And even when they resume screenings, the fact is a lot of, you know, a lot of your high poverty schools, they don't have a patchwork of kids in and out. Um, and just higher rates of absenteeism. So it's actually even going to be harder to screen kids in the first place. So, so that's why sort of one of my areas. That I'm very interested in looking at prospectively is what happens to all of these health indicators that, um, that works in some way related to services in schools pre COVID. I want to flip back and talk a little bit about technology. Um, there was one school district in Illinois that had actually established pre COVID, a program of once a week or once a month, uh, learning by technology pre COVID, um, for snow days, because otherwise we could lose a lot of school. And therefore, um, this was a solution. And so they were one of the first school districts, yes, the suburban school, but yes, they were one of the first schools to be able to just make sure that they didn't switch because they had already prepared it. Um, so do you think virtual learning is going to continue forever and in some way shape or form and in the K to 12 schools? I do. I do. And I think it should. I think what are we here over and over again? Um, is that this is probably not going to be our last pandemic. Um, and, and honestly, uh, it's a massive lift of resources and professional development. Um, and I think that we're going to have to start using technology. Uh, I mean, it was such a pivot even for me to start doing all of my teaching for my trainees through zoom. It's just a very different platform. So when you think about trying to do that with, you know, K through 12 kids, it's very different. So I think we will need to continue using it, but I also think, you know, the, the kind of corollaries, I think we're going to need to continue using it in healthcare. Um, and I think it's just a little bit humbling to realize how many times you could probably see somebody through telehealth that you've made from several hours to come see you and wait three hours in your clinic. Um, and some things you can use technology for. And I think we've always been, you know, somewhat kind of, um, hesitant to do that. So I think that's part of this overlining is it's going to force us to use technology better. But to do that well, we're going to have to use technology to make sure that we have the same access to the patients in people who don't have the same access. And we've got to figure out ways to increase, increase that access. The next question comes from Ronnie Sellins, one of our fellows. Pediatric surgeon in LA. As a pre K and second grade parent or any community member, for that matter, what can we do to help our school districts minimize inequities locally? Um, you know, I think checking in with, um, schools and figuring out if there are opportunities to support, um, kids who may, um, you know, be in need. Uh, refurbished devices. Uh, you know, old phones, old laptops, things like that. Um, that, you know, you may have around your house. Um, there are, you know, one of the things we've been doing at, um, in Baltimore is actually trying to partner like undergraduates who have, you know, understand math and offered tutoring for kids and algebra or calculus or something like that. So certainly I think parents could offer the same types of things. Um, you know, food is the big one. Um, and I think the interesting thing that we've also seen, uh, across Maryland is that kids who were using the school, school, school, school food sites last spring are not using them as much this fall. I don't understand why, uh, and that's not my area of expertise, but, um, we do want to make sure everybody is, you know, not going home hungry. So one question comes up. Do you think we're going to see more myopia, even though you're not allowed to screen just because all the kids are going to be now on screen time. Yeah. So I, um, I will, I should share in the chat. So I just did a webinar on this a couple of weeks ago and I've got, I've got like a web MD interview about this as well. So I think it's actually a very real possibility. There is separate from that. There's what's called digital eye strain, which is just, we stare at computers for long periods of time. When we do that, uh, we don't blink as often and we're doing all of the wrong things. Like my laptop is probably 12 inches for me. It should be 16 to 24 inches for me. We should have the laptop level that the height of our, of our pupillary access. We should be taking breaks from our staring at our computer every 15 minutes and we're not doing those things. So, but yeah, I think that there's also going to be, um, we're going to have to watch what happens through it's myopia. The data so far about near activity in myopia is not great, but we, we will have a, a, um, a windfall of data because of COVID. Um, I think that's a good point. I think that's a good point. I think that's a good point. Yeah. There we go. The next question is from Joseph hang. I'm worried that the teachers and staff who helped to support the classroom environment and are being asked to do a lot as well. They are largely being left out of the discussion. They're just as vulnerable. And what can we do to assuage their fears and achieve thereby and back into school reopening? Joseph, thank you for the comment. That was exactly what I was trying to get at. In, um, what are the considerations for reopening schools? Um, teachers are on the front line and we have to think of teachers that way. Um, I mean, and, and try to figure out what they need for support. I think knowledge is one of the first things. Uh, there is some information that they may have about sort of health and safety. There's some information. They don't trying to make sure that they have that information trying to make sure that they have the, uh, the resources to safely teach in their classroom, whether that is masks plus face shields, because they may be with, you know, a special ed population that can't wear masks themselves. Um, anything like that. And the mental health toll on teachers is going to be sort of the next great, um, area of, of debate because this is a lot for teachers. They're worried about themselves. They're worried about their students. They want to be back in the classroom. So, um, I think bringing them into the conversation as much as possible is important. Uh, Dr. Missal has put his question in his equity question. Why can seniors who turn 65 get Medicare and Social Security within a month of turning 65 and children with special needs or disabilities not get any direct services, school based rehab services, the school health services, um, it takes us so long. And, um, just the whole difference of how we deal with vision issues in the elderly versus in pediatrics. It is, it is very true. And, um, there was a lot of discussion this spring that has moved into this fall about kids with special learning needs. Um, and sort of the, the lack of, um, resources that schools were providing and the lack of deadlines to, to be able to provide some of those services. We wrote, uh, we wrote an op-ed about this probably a couple of weeks ago about the number of kids who would, the growing number of kids who would need additional, um, instructional services because of the fact because of COVID and because they either were immunocompromised themselves or had somebody in the home that they couldn't be in the school setting. Um, and the potential implications that had for sort of the, the, the cohort of students that served through IDA, which is already too many that they're able to accommodate and we're bringing even more on without sort of the resources to support it. Great. Those are the questions. I'm going to turn again to the panel. Do we have any other questions or, uh, are we coming to our close? Megan, this is Brian counter again. I just have sort of more, I guess an altruistic question in line with one of the previous ones about like what can we do in terms of either donating funds or resources? Are there particular organizations out there that we can sort of donate money to that are trying to tackle some of these issues about increasing technology access or taking care of some of the sort of the food security issues as well? Well, if it had been Tuesday, I would have said go vote. That's Wednesday. Uh, so I think, I think voting, I mean, I think being part of the civic process, I think, um, I think that is really important because I think our legislators need to hear more and more about this. And this really needs to be front and center, but there are a lot of organizations, um, that may be local, maybe national. What I would, what I would look at for Chicago and I know I've done things similar with the Baltimore, the Johns Hopkins University has actually lifted up a ton of things that they have done to support the local community, either themselves or in partnership with other local organizations. I suspect University of Chicago has done the same. Um, and I think those would probably be the ones that, you know, we understand are already having a great, a great impact in the community and have the community relations to make things happen at times, which is so important because it's not just, it's not just sort of giving money, but it's sort of making sure it gets to where it needs to go to have an impact. Yeah, the, uh, the university food services did a lot with trying to provide food to the South side of Chicago during the spring. So, all right. Well, Megan, this is wonderful. It's so great to have you back now as a leader, um, having spent so many years here working with Mark and the rest of us in the claim center. So on behalf of everyone, I just want to give a shout out. You did a wonderful job and we've learned a real lot. Thank you very much. Thank you so much for this opportunity. It's so nice. I miss everybody in Chicago. And we miss you and we miss you particularly because you can't even come to do your research here on this outside. Oh, I know. Well, doing a lot of things virtual right now. Are you coming to the 130? I can't. I have, I actually have a patient that just checked in for me right now. So I got to go back to my patient duties. Um, I did offer. I am free as of three o'clock your time today. So if that is of interest to your fellows, I can meet then. I just, I have patients for the next hour and a half. Great. Now we'll, we'll be a case conference at three. So thank you again. Thanks everybody. Thanks. Bye. Bye.