The School Closing Problem


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The School Closing Problem

The Editors of Effect Measure are senior public health scientists and practitioners. Paul Revere was a member of the first local Board of Health in the United States (Boston, 1799). The Editors sign their posts "Revere" to recognize the public service of a professional forerunner better known for other things.

The easiest way for public officials to scare the crap out of people is to tell them "not to panic." A variant on this is, "It's not time to panic," implying that there will be such a time or that there is ever such a time. The first to panic are usually public officials because they feel powerless at a time when people are expecting them to do something. So what they do is incite panic by telling people not to panic. Public anxiety -- often well founded -- is not the same as panic. If parents are keeping their kids out of school from fear [that] it is a flu incubator, that's not panic. That's a fairly reasonable judgment, which may be incorrect or fruitless but it isn't panic. Many parents don't let their kids walk home alone or drive around town for fear something will happen to them. That's not panic. So when I read this, it makes me shake my head:

Responding to an alarming increase in absences at two city elementary schools, the Philadelphia School District and the city Department of Public Health announced plans yesterday to quell a rising panic surrounding swine flu in schools.[snip]

District spokesman Fernando Gallard said the two schools - William H. Hunter Elementary, at Front Street and Kensington Avenue, Kensington; and Rowan Elementary, on Gratz Street below Godfrey Avenue, Ogontz - had experienced a high volume of absences.

After a meeting for parents held at Hunter on Wednesday night, Gallard said that parents weren't convinced that there wasn't a risk."Parents are really concerned. They have not been reassured enough that this is another seasonal flu," Gallard said. "[And essentially] they're saying, 'We don't believe you, we're keeping our kids at home.' "

At Hunter, 57 percent of its 560 students were absent yesterday - up from 33 percent earlier in the week - while at Rowan, 22 percent of its 523 students were absent. (Julia Terruso, Philadelphia Daily News)

Here's the situation. Two city schools in Philadelphia have high absenteeism at a time when a novel influenza virus is circulating in the community. Parents know this is a contagious disease. They are uncertain what the meaning is because the public health community itself is uncertain about the meaning. School and public health officials can't tell anyone if the absences are from flu and admit they are no longer keeping track of how many cases of the new flu there are. The state has hundreds of cases and two deaths. They apparently have tried to minimize what is happening by portraying it as no different than seasonal flu. The parents don't believe them.

The parents shouldn't believe them because this isn't seasonal flu. It's a novel flu strain that is circulating outside flu season and targeting school age children and young, healthy adults. That's not seasonal flu.

The similarity is the clinical presentation, which is much like seasonal flu, at least at this point. As city Health Commissioner Donald Schwarz is quoted as saying, "This is influenza, period. This is not influenza-plus." That's both correct and exactly the problem. While most flu cases recover without treatment, it's a miserable illness and "most" is not "all." Influenza has a nasty side and at the moment we don't know why some people get extremely sick or die while most don't. We know that if you have one of a number of fairly common underlying conditions, of which asthma is the most common, you are at increased risk. But half to a third of the serious cases are in healthy people without underlying medical conditions. Moreover it's the elderly and infants at most risk from seasonal flu, but this flu, even though it is clinically like seasonal flu, is making a different set of people sick: children and young adults. This includes school age children. So it is misleading to say "it's just seasonal flu." And parents aren't misled.

I understand the perspective of school and public health officials. Closing a couple of elementary schools won't slow flu in the community. The virus is afoot in Philadelphia, not just in the schools. Moreover there are real consequences to closing schools. It's an important source of good nutrition for many students and students need to learn. Many states stipulate how many days of school are required each year, so missed days whether from snow or flu have to be made up. For families where both parents work, closing a school creates a major child care problem, so there is a differential impact when closing a school. Policy makers must and shold take that into consideration. So it looks different from their side. But they should still be accurate about this. It isn't just seasonal flu.

No school official can in all honesty say sending a child to school when flu is being easily transmitted there is without added risk. That's just a fact. One option would be to keep the schools open but afford some flexibility for parents who wish to keep their children home. It's not an ideal solution, but it does satisfy several needs at once. I expect that parents will send their children back to school after a reasonably short interval if they feel confident it is not unduly risky. There are costs to pay for keeping a child home and no guarantee they won't get flu via another route.

This kind of thing is supposed to be part of a pandemic flu plan, but on paper it was still pretty abstract. This is not on paper. This is real life. And we may well be facing it again in the fall. It's best to start thinking this through now.

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