- Schools reopening should not be a politicized topic.
We should let science guide us to make
the best possible decision.
It's not gonna be a perfect one,
but it's gonna be the best one we can do
in our given situation and adapt as we go.
Here I sit down with Dr. David Epstein
to talk about schools' reopening,
who is a pediatric ICU physician,
who also works in a pediatric urgent care
right on the front lines during COVID-19, enjoy.
Dr. Epstein, I wanna welcome you to the channel.
Tell me your background,
tell me why you would be one of the best people,
if not the best person to talk about this subject.
- Well, thank you, Dr. Varshavski, I really appreciate you
inviting me to the conversation.
Well, I'm a boarded in pediatrics
and I did subspecialty training
in pediatric critical care medicine.
I worked a few years at UCLA and then worked about 10,
14 years at Children's Hospital, Los Angeles,
in the cardiothoracic ICU there.
And over the last five years, I opened up a pediatric
Urgent Care in which we've been caring for children
on the front lines with urgent care needs.
So being exposed to a lot of variety of illness
in pediatrics, from those that are minor to those that
are quite life threatening.
- Since we're gonna be talking about the subject
of schools' reopening, I guess the first thought
that everyone has is, are children gonna be safe
because they're going to be exposed to other children
who potentially could be spreading this virus?
- California in general, maybe about nine, eight or 9%
of the total positive population has been children.
- I wanna make a statement and you correct me
if you think it's wrong, or perhaps you'll agree with me.
If I had a five year old child and I was faced with
this very weird hypothetical situation where I had to choose
between them getting the influenza virus or COVID-19,
I think I would want my child to get COVID-19
'cause statistically, at least right now,
it looks like they fare better with the virus,
would you agree?
- Of the kids less than 17 years of age, California
hasn't documented any deaths less than 17 years of age.
You know, most of the deaths have been
in the population greater than 65 years of age,
so I have to think of it in terms of morbidity
and mortality, things like that,
and so from a mortality standpoint, it seems like,
you know, kids, the population it's an,
it seems to be almost negligible as far as mortality.
When you talk about kids who die from influenza,
that seems to be a very rare event as well,
I mean, I think annually, there's probably about 180 kids
that die from influenza per year.
And I'm sure the national numbers for kids dying from COVID
is not negligible, I'm sure that, you know,
there are a number of cases.
So you're trying to balance that,
the concern is, and the anxiety is,
is that you have a vaccine for influenza,
you have treatment for one, for influenza,
and you're still only having, you know,
you're still having a mortality of 186 children,
which you feel is kind of more preventable.
When you're talking about COVID you don't have any of the,
that safety net as far as treatment or vaccine.
I think the anxiety of not knowing what could happen
is an issue because we're worried about, you know,
kids who have, may have underlying illnesses
like a juvenile idiopathic arthritis,
or they may have some other immunodeficiency
or they may be immunocompromised and they may not show up
on the mortality board,
but they may show up on the morbidity board of getting
more severe disease and having issues with their medications
and having them step back while the numbers don't look bad,
as far as mortality and contagion and having kids passing
along to adults, I think some,
some anecdotal reports have said that maybe the index case
of children passing to adults is probably 9%
or something like that and so they don't seem
to be passing along for, you know, the young, young kids.
- I think your answer is very fair that we don't know
what that answer is.
We can lean one way or another in the moment,
looking at the current evidence that may shift
as more evidence comes out because for example,
we see this low index number that you mentioned,
which is this how easily children spread this virus
and we think, okay, maybe they're not spreading it as much.
We see the lower number of that multiinflammatory syndrome
being not so high and we think, okay, not so bad,
but did those radically change when we go back to school?
Very possible, right. - Yeah, yeah
we, and we don't know that yet
and I think, you know, a lot of countries around the world
are going back to school in various forms or fashions
but we have to think that, you know, it's only,
we're looking at something that's only gone on for months,
you know, and the information we have on influenza
is years, in the ICU, we like to know
what we're dealing with, we don't like to know
about the unknown and so, - Of course.
- having that, you know, things be a little bit
more concrete and no one is a little bit
more comforting to us, control
we're controlled first. - Obvious.
Yeah, as physicians we oftentimes
have to make recommendations with limited evidence,
that happens quite often, you know,
a B or C level recommendation
and we have to give that to our patients
because that's what we know in a given moment.
What I think is gonna happen is in some way,
we're gonna return back to school or return back to normal.
And we have to be flexible enough and adaptable enough
to pivot at any given moment.
That's why in my stance, it makes sense to either,
A, delay school until we have more information
and not be hard set by these deadlines where,
you know, by August 7th, we have to have a decision.
Well, if we don't have the good info to guide us then,
maybe we can push that a few weeks and see what happens,
because ultimately we're tryna play this game of risks
and balances without all the cards on the table.
And perhaps if we buy ourselves two weeks,
if we fit, allow our study to be finished,
we'll be able to make a better decision for schools,
for parents, for teachers, all of the above.
What are your thoughts on teacher safety and all of the
conversation that's surrounding teachers being safe
around children in COVID-19 ara?
- I think in general, pediatricians are in favor
of going back to school in some form or fashion.
While we take into account the pediatric standpoint,
oftentimes I think we forget about the teachers
who are the adults in the classroom
and different countries around the world
have had some experience
and I know we hear about Israel and Germany
and, you know, in Israel, there was a lot of contagion
and they had to shut back down and there were teachers
who were affected and you know kids
in Germany, I think there was less so,
I think it was more a spread by children and,
or spread amongst kids and not so much staff.
Every country seems to be a little bit different,
I think they we're still learning
and I do think that the teachers have
a voice in all of this, because it's their lives
that are on line and some of them may be elderly.
- We have to be honest and talk about the disparities
in socioeconomic factors that some schools are dealing with
a lot less resources than others.
I've been, my entire childhood, I've,
went to inner city schools and I've seen how
they've had to manage with low resources.
And I can't imagine some of these things that are
on the CDC checklist being accomplished.
While I think it's great and the CDC put out
the correct recommendations,
just from a realistic standpoint, where are you gonna get
these employees that are gonna be doing contact tracing?
Where are you going to be getting substitute teachers from
when teachers who are elderly can't come in
or when someone has an immunocompromised state
or checking on students who didn't come in
because their parents are sick?
It just, there's so many variables that it's impossible
to get a perfect scenario.
So we have to lose that idea of perfection right away,
and be open to this nuance conversation where perhaps
there's not a one size fits all solution,
especially on a geographic level,
like what works in an area where there's low infectivity
versus where it's peaking has to be completely different.
I wanna ask you a pointed, very difficult question,
what is your stance on schools reopening?
- Yeah, no, I think that's a very good question
and I, it's something that I've been thinking about a lot,
because I have school aged children and you know,
they're going back, you know, need to go back to school
and I vote for going back to school,
bottom line. - For what reasons,
specifically?
- Okay, well, this is good.
So, I agree with everything that you said
in as much as every area of the country
is going to be different.
What works in, you know, the middle of Montana
is not gonna work in the middle of Los Angeles, yeah or
you know, or Los Angeles County, so it,
there are different geographic areas.
There are different places that have different incidents
of disease and so the precautions will likely be different
and we have to shape those accordingly and like you said,
there are disparities in districts and it's gonna be hard
to accommodate all those recommendations
which are the right thing.
The reason why I believe that kids need to be
going back to school, the important things
are, A, the education and I know that in some districts,
they may not have the ability to do remote learning,
you know, tele-education, those kinds of things,
as adequately as other areas.
The other things are just the socialization of children,
children like respond and map out their world,
depending on the contacts they make.
Right now, we're creating like a two dimensional environment
for our kids and for us and really as human beings,
we develop in a three dimensional world,
with that contact, with other people,
those exchanges or those kinds of things.
And it's very difficult for kids because their learning
and their development depends on that.
And you look at, I mean, one of the things that I've seen
in the clinic is seeing people, adolescents,
and this was near the end of the school year,
having physical manifestations of their anxiety,
their depression, their isolation from their peers,
not being able to go to prom,
not being able to graduate with their peers,
not being able to interact in this most important milestone
of their lives and granted, you know, at that time,
that's a very, very important thing in their life.
And so going back to school means a lot of those things
and not going back to school and isolation,
kind of, it promotes almost, it's almost
like a traumatic event.
You know, the educational aspects,
the trauma that develops from isolation,
I think those are very, very real concerns.
Obviously we have to balance this with the medical aspects
and as a physician, I'm extremely torn because I know
the potential and having worked in the ICU
and being in the clinic and hearing about what's going,
what, when, what New York went through,
I have images in my mind and understand
how severe things can get and so trying to balance
those issues with the issues of children, not going back
to school, it's a very, very real thing,
but I do advocate for going back to school,
but you mentioned one important word in your,
in your explanation of why you felt, you know,
going back or going back to school was important,
or how to go back to school and that's the word pivot.
And I really liked that term because we have to be flexible
and we have to reassess.
It's like the plan, do, study, act, cycle, you know,
of quality improvement.
I mean, we have to assess what we've done and we have to
modify depending on what the outcome is
and so it shouldn't be like you a very concrete,
you know, yes at all costs, no at all costs.
It has to be somewhere in between.
- You know I completely agree with you on the topic
of opening schools.
At the same time, if I'm a teacher and I'm elderly,
or I'm not elderly, or I have someone in my home
that's elderly and I wanna teach, it sounds like
you're saying the children's social educational development
is more important than my safety.
How would you respond to that?
I'm strictly playing devil's advocate here.
- That's a very hard thing, I mean, I wouldn't wanna
put teachers' lives at risk by any means,
you know, there's gonna be more data as time goes.
I would hope that schools would find a way to be able
to pivot or be able to do things in a way
that can make it safe for teachers
but I do think it's important for kids to go back to school.
And, you know, maybe if it had, you know, maybe if it is,
you know, some form of, you know, mixed tele-education,
you know, live education, I know that a lot of countries
and a lot of schools that are,
been planning, have been doing planning pods, yeah,
and shifts of when kids go back
so you're creating smaller environments,
creating more distancing, having kids wearing masks,
creating a, you know, regular hand-washing,
you know, screening kids by, you know, temperature,
although that's not always accurate,
having kids sit out who are, who have been sick.
- Unfortunately we're forced to be in a position of choosing
the lesser of two evils, almost like a rationing
of care situation, which we obviously hate
in the healthcare space.
Basically rationing of care is when you have two patients
and you only have one ventilator,
and you have to make the choice,
who's more likely to benefit from this.
That's almost what we're doing when we're saying,
you know, should we open schools or not?
'Cause we see the detrimental effects to kids
on a mega scale and we see the potential risk for teachers
'cause at this moment it's a potential risk,
we don't know it for certain because we don't have the data
to back that up.
So, we're sort of saying, okay, look,
there is this potential danger,
but we know this other danger for children
most definitely exists, so let's start up
in a gradual approach and build up
and continually reassess our strategies.
Will teachers have negative outcomes from this?
It to some degree, yes, we have to be honest about it.
Will teachers catch COVID-19 as schools reopen?
Yes, we just have to say that.
Saying anything otherwise is a lie.
As our federal leaders go on television, if they just say,
"Oh, it's no big deal, no one's gonna suffer,"
that's a lie.
The approach that I feel has worked best for me
in the healthcare space has been the most upfront
that you can be with what you're doing,
why you're doing it and how you will pivot
if information changes.
And once you can get the people who you're treating
in this situation, teachers, on the same page
as to why you're making these decisions,
the more likely they are to be, to accept the outcome.
And I feel that the federal government,
the media has done a really poor job arming teachers
with good information about what risks they face,
what mitigation strategies they can use,
because some of the things listed in the CDC manuals
are just impossible for many school districts,
like the six foot rule is great.
It's not even a perfect rule,
but it's not realistic for many schools.
So perhaps we need to downgrade to the three foot rule
that the WHO set forth.
Perhaps we could move some classrooms outdoors,
whether we see less transmission.
There's all these things that are being pushed aside
of the conversation in favor of a political talking point
that really should not be anywhere in this discussion.
Politics should mean the least
when it comes to opening schools,
because at the end of the day,
whether you're the independent, Republican, Democrat,
your child is your child and if you have a family member
that has children, or has a teacher in their family,
you should care equally for them.
- Communication is really important
and I think communication with teachers is gonna be
ultimately important and trying to educate them
with regards to what information we have on COVID right now,
which like you said, it's very imperfect
and we're still learning and we need to reassess
but I think to have,
have two groups suffer, needlessly, you know,
children and teachers is wrong.
I think, and we have to balance each of their,
each of their,
their needs
and we have to reassess, I mean, it's a,
it has to be a very balanced approach.
- Let's take a look sometime and talk about the outliers
in this situation.
You know, we've mentioned social determinants of health,
we mentioned lower socioeconomic school districts.
You know, there are schools out there
that receive funding from property taxes
in very wealthy neighborhoods that can, you know,
put acrylic across, acrylic is that plastic
see-through covering you see in some of the stores
and medical offices, they could put that across
the entire classroom. - Okay.
- And then there's some areas where
that's gonna be completely impossible.
There's some areas where students rely on school
for feeding their children. - Yeah.
- Some areas that require the schools
so that they can get to work themselves
because they don't have childcare options
available to them. - Yeah.
- Unless we bring all of these very important pieces
of the conversation to the table,
we're gonna be leaving a significant population
of the US behind.
And that's not good either.
I can easily see two individuals on this subject,
you know, a teacher on one end who's immunocompromised
and is worried about going back to school
and at the same time, I can see a parent
in a low socioeconomic neighborhood,
the special needs child saying,
"I need my child to go back to school,
"I can't care for them without going broke
"because I need to go to work" or "I don't have the ability
"to teach them because I'm not trained in this."
And both sides are right in what they're saying.
They both need to be heard, but where do you go from there?
That's where I struggle myself even at times.
- Well, I don't think you're alone,
I mean, I think the whole country is struggling with that.
I think there are a lot of people,
I mean, if it was easy, you know,
we wouldn't be having these discussions.
I mean, really we wouldn't, if everything was going
the way it should be going, but there are a lot of
competing demands and trying to prioritize one over another
sometimes is very difficult, but we do have to invest
in our children and you know, the children are our future.
- People watch this conversation, you and I speak,
they understand where both of you and I are coming from,
what is the one line you wanna leave them with?
- Yeah, you know, I am,
the things that we're doing aren't hard to prevent this.
And the one thing that I, if we work together,
you know, we're gonna get through this a lot easier
and a lot quicker and so if you're wearing a mask,
if you're doing simple things like trying
to distance yourself, washing your hands,
not touching your face, staying away
if you have a cold symptoms,
these are very, very simple things to do.
There's a lot of controversy surrounding these topics
and a lot of pushback on doing certain things,
because it's not what we're used to.
It's not what we feel comfortable with.
This is gonna be something that's transient
and the time that we invest now on prevention and spread,
it's going to pay off in dividends in the future
because we'll be able to go back to work the sooner,
we'll be able to be comfortable with having our kids
in school sooner, without restrictions.
You know, there's a lot of things,
so the sooner that we can implement these things
and be more, work as a team,
- Yeah. - yeah, that, you know,
we're gonna get through this a lot quicker.
- Check out this great interview with the psychologist
who talks about good intentions, having bad outcomes,
or check out me, hanging out with my man, Dr. Fauci,
click it, click it and as always stay, happy and healthy.
(upbeat outro music)