Dr Raghib Ali is a Clinical Epidemiologist at the University of Cambridge and an Honorary Consultant in Acute Medicine at the Oxford University Hospitals NHS Trust.
We are “back in the eye of the storm” – the grim warning from the head of the NHS as we passed the first peak of Covid-19 hospital admissions across England. Pressure in many hospitals across London, the East and the South East is now much higher than when I was on the frontline in April, as we try to keep all elective services going to avoid the pain, suffering and loss of life caused by these services being cancelled last time.
Which is why it is of course essential that both government and the public do what they can to reduce the harms of the virus.
However, the interventions implemented should be based on some key criteria – firstly, that there is good evidence for effectiveness in reducing Covid-19 infections in the over 60s, hospital admissions and deaths; secondly, that is has been shown to produce more overall benefit than harm: i.e. any proposed intervention must focus on the balance of benefits and harms, in order to produce the best overall outcome; thirdly, where harms are certain but benefits are uncertain, the intervention should not be used; and, fourthly, that there is no reasonable, alternative option which produces less overall harm.
And it is with these criteria in mind that the current decisions regarding school closures should be taken.
Looking back to the first wave, the decision to close schools was understandable, as so little was known about the risks to children, teachers, parents / household members and the role of schools in community transmission. However, we now have much more evidence about this and it is clear that schools are safe for children and the best place for them given the multiple harms to children from school closures which have been well-documented.
If this pandemic has a silver lining, it is that the risk to children of dying from the Coronavirus is almost zero, and much less than their risk of dying from accidents or even influenza (Although as I have stressed previously, the virus is overall deadlier than flu, especially in those aged over 65.) Although they may be equally likely to be infected, they are less likely to develop severe disease and while there are reports of ‘long Covid’ in children, it is not as common as in adults and certainly its overall harm is far less than that of not going to school.
It is also very good news that the risk to teachers is low, with studies from the ONS having shown that they were at lower risk of dying than the general population during the first wave, despite the likelihood of having been exposed to tens of thousands of infected children (and other staff) in the two weeks before schools closed.
This was not that surprising as most teachers are at very low absolute risk due to their age and being generally in good health but of course, all should have a risk assessment and those at high risk should be given additional protections.
And since schools fully re-opened in September, the ONS have also shown that teachers were at no higher risk of infection than other key workers.
And, now that the Oxford vaccine is approved and there is less scarcity, it makes sense to give priority to vaccinating teachers to reduce staff absence and help ensure schools stay open.
With regard to transmission and the risk to household members and the wider community, evidence has shown that children are not significant drivers of community transmission and that there was no increased risk of severe Covid-19 outcomes for adults living with children – including crucially in adults over the age of 65. SAGEs own comprehensive assessment of the impact of the virus on children; teachers; and the role of children and schools in transmission came to similar conclusions. And while they only had low-medium confidence in the role of children and schools in transmission, they had high confidence in the harms of school closures on children’s education and health and increased inequalities.
Of course, it is possible that the situation has now changed due to the new variant which is likely to be responsible for the increased cases, hospitalisations and deaths in the regions where it is now dominant. However, the key point is that we do not have evidence (in the public domain at least) that these increases are due to increased infections in school children.
This is what needs to be shown – i.e: what number and proportion of hospitalisations and deaths can be linked to school children?
The fact that closing schools may decrease R overall (i.e: across all age groups) does not demonstrate that it would decrease hospital admissions and deaths (as they are so concentrated in those aged above 60.)
Even if this were shown, the decision should still be based on the trade-off / cost-benefit. i.e: does the harm from Covid-19 outweigh the harm from school closures – to children, their parents, society, lives and livelihoods, etc.
And even if that were demonstrated, alternative options should be explored – i.e: advising no mixing of school-age children with anyone over 60 / at high risk for a few weeks until they are vaccinated. I know that will be difficult for many – including my recently-widowed mother who would not be able to see my children – but there are no good options here and we have to find and choose the least harmful solution.
I appreciate how difficult these cost-benefit analyses are having worked with the Legatum Institute on their impact assessment tool to assist such decision making, but they must nevertheless be attempted,
As a school governor, I am also very aware of the huge efforts teachers and staff have made over the last term to keep children in school and provide the best possible education – despite the many challenges – for which they often receive scant recognition. But I am disappointed that some unions (not teachers) are again calling for schools to be closed knowing how much damage this did – especially to those from disadvantaged backgrounds – further widening of educational inequalities. (And although they say it would be for two weeks, we know how difficult it is to re-open schools once closed and two weeks could easily turn into two months.)
A good education is the only route out of poverty for most children, as I know from personal experience. As a child on free school meals attending one of the worst-performing primary schools in England, my chances of going to Cambridge and becoming a doctor were almost zero, but my life chances were transformed by getting a scholarship to a good secondary school and supportive teachers. But I was one of the lucky ones and the vast majority of children don’t get a second chance.
Also, like many children today, I would not have had access to the computers – or even books – and other support effective home/online learning requires and the only way to ensure that every child is given the same opportunity they deserve is by them being at school with their teachers.
In conclusion, all children have the right to a good education and they have suffered enough this year already. Unless there is good evidence that closing schools will significantly decrease hospital admissions and deaths, and that it would produce less overall harm over the long term – and that there is no better alternative – the Government should hold its nerve and keep schools open. It is time to put children first.