Month: April 2022

The US is struggling with a resurgence of the coronavirus in the South and West. But the severity of Arizona’s Covid-19 outbreak is in a league of its own.

Over the week of June 30, Arizona reported 55 new coronavirus cases per 100,000 people per day. That’s 34 percent more than the second-worst state, Florida. It’s more than double Texas, another hard-hit state. It’s more than triple the US average.

Arizona also maintained the highest rate of positive tests of any state at more than 25 percent over the week of June 30 — meaning more than a quarter of people who were tested for the coronavirus ultimately had it. That’s more than five times the recommended maximum of 5 percent. Such a high positive rate indicates Arizona doesn’t have enough testing to match its big Covid-19 outbreak.

To put it another way: As bad as Arizona’s coronavirus outbreak seems right now, the state is very likely still undercounting a lot of cases since it doesn’t have enough testing to pick up all the new infections.

The state also leads the country in coronavirus-related hospitalizations. According to the Centers for Disease Control and Prevention, more than one in five inpatient beds in Arizona are occupied by Covid-19 patients — about 42 percent more than Texas and 65 percent more than Florida, the states with the next-highest shares of Covid-19 patient-occupied beds. With hospitalizations rapidly climbing, Arizona became the first in the country to trigger “crisis care” standards to help doctors and nurses decide who gets treatment as the system deals with a surge of patients. Around 90 percent of the state’s intensive care unit beds are occupied, based on Arizona Department of Health Services data.

While reported deaths typically lag new coronavirus cases, the state has also seen its Covid-19 death toll increase over the past several weeks.

This is the result, experts say, of Arizona’s missteps at three crucial points in the pandemic. The state reacted too slowly to the coronavirus pandemic in March. As cases began to level off nationwide, officials moved too quickly to reopen in early and mid-May. As cases rose in the state in late May and then June, its leaders once again moved too slowly.

“What you’re seeing is not only a premature opening, but one done so rapidly there was no way to ensure the health care and public health systems didn’t get stressed in this process,” Saskia Popescu, an infectious disease epidemiologist based in Arizona, told me.

At the same time, recommended precautions against the coronavirus weren’t always taken seriously by the general public — with experts saying that, anecdotally, mask use in the state can be spotty. That could be partly a result of Republican Gov. Doug Ducey downplaying the threat of the virus: While he eventually told people to wear masks in mid-June, as of late May he claimed that “it’s safe out there,” adding, “I want to encourage people to get out and about, to take a loved one to dinner, to go retail shopping.”

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Ducey’s actions and comments “gave the impression we were past Covid-19 and it was no longer an issue,” Popescu said, “which I believe encouraged people to become lax in their masking [and] social distancing.”

After weeks of increases in coronavirus cases and hospitalizations, Ducey pulled back Arizona’s reopening on June 29, closing downs bars, theaters, and gyms.

Experts say the move is a positive step forward, but also one that came too late: With coronavirus symptoms taking up to two weeks to develop, there are already infections out there that aren’t yet showing up in the data. The state can expect cases, hospitalizations, and, probably, deaths to continue to climb over the next few weeks.

Ducey acknowledged the sad reality: “It will take several weeks for the mitigations that we have put in place and are putting in place to take effect,” he said. “But they will take effect.”

Ducey’s office argued it took the action as was necessary at the time, based on the data it collected and its experts’ recommendations. “Our steps are in line with our facts on the ground that we’ve been tracking closely,” Patrick Ptak, a spokesperson for the governor’s office, told me.

Arizona now offers a warning to the rest of the world. The state’s caseload was for months far below the totals in New York, Michigan, and Louisiana, among the states that suffered the brunt of the virus in the US in the early months. But by letting its guard down, Arizona became a global hot spot for Covid-19 — a testament to the need for continued vigilance against the coronavirus until a vaccine or similarly effective treatment is developed.

Arizona was slow to close and quick to reopen

Arizona was initially slow to close down. While neighboring California instituted a stay-at-home order on March 19, Ducey didn’t issue a similar order for Arizona until March 31 — 12 days later.

That might not seem like too much time, but experts say it really is: When the number of Covid-19 cases statewide can double within just 24 to 72 hours, days and weeks matter.

Arizona was also quick to reopen its economy. After states started to close down, experts and the White House recommended that states see a decline in coronavirus cases for two weeks before they reopen. Arizona never saw such a decline. In fact, it arguably never even saw a real plateau. The number of daily new cases rose slowly and steadily through April and into May, and then the exponential spike took off.

So it’s not quite right to say that Arizona is experiencing a “second wave” of the coronavirus. It arguably never controlled the first wave, and the current rise of cases is a result of continued inaction as the initial wave of the virus spread across the state. (The Navajo Nation, which is partly in Arizona, was an initial coronavirus hot spot. But its case count has declined since May, in part because it took strong measures against the virus.)

Arizona and other states experiencing a surge in Covid-19 now “never got to flat,” Pia MacDonald, an epidemiologist at the research institute RTI International, told me. “That means the states didn’t get to very good compliance with the public health interventions that we all need to take to make sure the outbreak doesn’t continue to grow.”

Despite no sustained decline in Covid-19 cases, Arizona moved forward with reopening anyway. Ptak, the governor’s spokesperson, acknowledged that the state didn’t meet the two-week decline in cases, but he said the state had met another federal gating criteria for reopening by seeing a decline in the test positivity rate “week after week” throughout May.

Once the state started to reopen, it moved quickly. Within weeks, Arizona not only let hospitals do elective surgeries but started to allow dining in at restaurants and bars, and gyms and salons, among other high-risk indoor spaces, to reopen. The short time frame prevented the state from seeing the full impact of each step of its reopening, even as it moved forward with additional steps.

Will Humble, executive director of the Arizona Public Health Association, argued it was this rate of reopening that really caused problems for the state. “It was a free-for-all by May 15,” Humble told me. Referencing federal guidelines for reopening in phases, he added, Arizona effectively “went from phase 0 to phase 3.”

It’s not just that Ducey aggressively reopened the state, but that he also prevented local governments from imposing their own stricter measures. That included requirements for masks, which Ducey didn’t allow municipalities to impose until mid-June — weeks after Covid-19 cases started to rapidly rise. (Ptak claimed the governor acted once he received requests from mayors along the southern border to do so.)

Some of that is likely political. As recommendations and requirements for masks have expanded, some conservatives have suggested wearing a mask is emblematic of an overreaction to the coronavirus pandemic that has eroded civil liberties. President Donald Trump has by and large refused to wear a mask in public, even saying that people wear masks to spite him and suggesting, contrary to the evidence, that masks do more harm than good. While some Republicans are breaking from Trump on this issue, his comments and actions have helped politicize mask-wearing and other measures.

For example, there was an anti-mask rally in Scottsdale, Arizona, on June 24. There, a local council member, Republican Guy Phillips, shouted George Floyd’s dying words — “I can’t breathe!” — before ripping his own mask off, according to the Washington Post. (Phillips later apologized “to anyone who became offended.”)

Evidence supports the use of masks: Several recent studies found masks reduce transmission. Some experts hypothesize — and early research suggests — that masks played a significant role in containing outbreaks in several Asian countries where their use is widespread, like South Korea and Japan.

But for a Republican governor like Ducey, the politicization of the issue means a large chunk of his political base is resistant to the kind of measures needed to get the coronavirus under control. And those same constituents are likelier to reject taking precautions against the coronavirus, even if they’re recommended by government officials or experts.

Ducey himself seemed to play into the politics: One day before Trump visited a plant in the state, and as the president urged states to reopen, Ducey announced an acceleration of the state’s reopening plans.

Other factors, beyond policy, likely played a role as well in the rise in cases. While summer in other parts of the country lets people go outside more often — where the coronavirus is less likely to spread — triple-digit temperatures in Arizona can actually push people inside, where poor ventilation and close contact is more likely to lead to transmission.

Some officials have argued Black Lives Matter protests played a role in the new outbreak. But the research and data so far suggest the demonstrations didn’t lead to a significant increase in Covid-19 cases, thanks to protests mostly taking place outside and participants embracing steps, such as wearing masks, that mitigate the risk of transmission. In Arizona, the surge in coronavirus cases also began before the protests took off in the state.

Arizona is now stuck playing catch-up

Arizona saw its coronavirus cases start to increase by Memorial Day on May 25. The increase came hard — with the test positivity rate rising too, indicating early on that the increase was not merely the result of more testing in Arizona. Hospitalizations and deaths soon followed.

Yet Ducey didn’t begin to scale back the state’s reopening until more than a month later — on June 29. This left weeks for the coronavirus to spread throughout the community.

The sad reality is Arizona will suffer the consequences of the governor’s slow action for weeks. Because people can spread the virus without showing symptoms, can take up to weeks to show symptoms or get seriously ill, and there’s a delay in when new cases and deaths are reported, Arizona is bound to see weeks of new infections and deaths even after Ducey’s renewed restrictions.

“Even if I put in 100 percent face mask use and everybody complied with it in Arizona right now, there would still be weeks of pain,” Cyrus Shahpar, a director at the global health advocacy group Resolve to Save Lives, told me. “There are people out there spreading disease, and it takes time [to pick them up as cases], from exposure to symptom onset to testing to getting the testing results.”

Experts argue the state still needs to go even further. Humble advocated for more hospital staffing, a statewide mask requirement, more rigorous rules and better enforcement of the rules for reopening businesses, and improved testing capacity and contact tracing. He also pointed to the lack of timely testing in prisons as one area that hasn’t gotten enough attention and could lead to a blind spot for future Covid-19 outbreaks.

One potentially mitigating factor is the state’s infected have trended younger than they did in initial bouts of the US’s coronavirus outbreak, with people aged 20 to 44 making up roughly half of cases. That could keep the death toll down a bit — though Covid-19 deaths in Arizona have already risen, and experts warn of the risks of long-term complications from the coronavirus, including severe lung scarring, among young people as well.

Above all, experts say that the rise in cases was preventable and predictable.

The research suggests the lockdowns worked. One study in Health Affairs concluded:

Adoption of government-imposed social distancing measures reduced the daily growth rate by 5.4 percentage points after 1–5 days, 6.8 after 6–10 days, 8.2 after 11–15 days, and 9.1 after 16–20 days. Holding the amount of voluntary social distancing constant, these results imply 10 times greater spread by April 27 without SIPOs (10 million cases) and more than 35 times greater spread without any of the four measures (35 million).

The flipside, then, is likely true: Easing lockdowns likely led to more virus transmission.

This is what researchers saw in previous disease outbreaks.

Several studies of the 1918 flu pandemic found that quicker and more aggressive steps to enforce social distancing saved lives in those areas. But this research also shows the consequences of pulling back restrictions too early: A 2007 study in JAMA found that when St. Louis — widely praised for its response to the 1918 pandemic — eased its school closures, bans on public gatherings, and other restrictions, it saw a rise in deaths.

Here’s how that looks in chart form, with the dotted line representing excess flu deaths and the black and gray bars showing when social distancing measures were in place. The peak came after those measures were lifted, and the death rate fell only after they were reinstated.

This did not happen only in St. Louis. Analyzing data from 43 cities, the JAMA study found this pattern repeatedly across the country. Howard Markel, a co-author of the study and the director of the University of Michigan’s Center for the History of Medicine, described the results as a bunch of “double-humped epi curves” — officials instituted social distancing measures, saw flu cases fall, then pulled back the measures and saw flu cases rise again.

Arizona is now seeing that in real time: Social distancing worked at first. But as the state relaxed social distancing, it saw cases quickly rise.

This is why experts consistently cautioned not just Arizona but other states against reopening too quickly. It’s why they asked for some time — two weeks of falling cases — before states could start to reopen. It’s why they asked for states to take the reopening process slowly, ensuring that each relaxation didn’t lead to a surge in new Covid-19 cases.

Because Arizona and its leaders didn’t heed such warnings, it’s now suffering a predictable, preventable crisis — making it the state with the worst coronavirus epidemic in the country that’s suffered the most widespread coronavirus outbreak in the world.

Covid-19 testing in the US improved dramatically over the first half of 2020, but things now appear to be breaking down once more as coronavirus cases rise and outstrip capacity — to the point that the mayor of a major American city can’t get testing quickly enough to potentially avoid spreading the virus.

“We FINALLY received our test results taken 8 days before,” Atlanta Mayor Keisha Lance Bottoms tweeted on July 8. “One person in my house was positive then. By the time we tested again, 1 week later, 3 of us had COVID. If we had known sooner, we would have immediately quarantined. Perhaps the National Guard can help with testing too.”

Anecdotally, I’ve heard of similar delays across the country — people waiting days or even weeks for their Covid-19 test results after standing in lines for hours to get tested. Labs have warned about problems: Quest Diagnostics, one of the biggest lab companies in the US, said wait times for test results are now averaging between four and six days for most people.

“Basically, two things are happening,” Ashish Jha, faculty director of the Harvard Global Health Institute (HGHI), told me. “One is the outbreaks are getting much bigger, so the amount of testing we need to get our arms around the outbreak is going up. And second, what we did [before] was some tweaking on capacity issues to get ourselves up to 500,000 to 600,000 tests a day, but didn’t fundamentally address the supply chain problems.”

He added, “This was supposed to be the job of the White House. … But they just never have prioritized really building up a robust testing infrastructure for the country.”

The problems have become more localized than in previous months. New York and Connecticut’s testing capacity seems to be holding up pretty well, largely because their Covid-19 outbreaks seem to be under control for now. States where epidemics are raging, such as Arizona, Florida, and Texas, are where testing problems seem to be spiraling.

As Bottoms’s story conveys, this is a big problem for getting the coronavirus outbreak under control: Testing is crucial for controlling disease outbreaks because they let officials and individuals see when further action, such as isolation and contact tracing, is necessary. But if testing is slow or insufficient, it can’t show people they’re infected and need to take action until it’s likely too late. That’s especially true with Covid-19 because people can have the virus and spread it without showing any symptoms.

“This is the same story we heard in the earlier days of the outbreak,” Jennifer Kates, vice president and director of the Global Health and HIV Policy Program at the Kaiser Family Foundation, told me. “But it’s much worse because everyone felt like the US was a little caught off guard at the beginning. … What we’re learning now is that none of the things that should’ve happened in the interim [during lockdowns] happened.”

So as America faces a surge of new coronavirus cases, the testing delays threaten to make the pandemic even worse.

America improved its testing capacity — to a point

America made huge improvements in Covid-19 testing capacity over the past few months, largely due to local, state, and private action as President Donald Trump’s administration delegated the issue downward and said the federal government would act merely as a “supplier of last resort.”

Nonetheless, the improvements were substantive and real. The US went from testing hundreds of people a day (at most) in late February and early March to consistently hitting 500,000 to 700,000 tests a day in June and now July.

The benchmark of 500,000 tests per day was particularly important, as it was the minimum experts had long called for in order to get the pandemic in the US under control.

But as the country neared that benchmark, attention to testing seemed to plummet. The Trump administration, which had already delegated testing down to lower levels of government and private actors, especially appeared to lose interest: The country’s “testing czar,” Brett Giroir, stood down and went back to his regular job at the Department of Health and Human Services. Trump falsely claimed in May that “America leads the world in testing”; at his Tulsa rally in June, he said he told his people to “slow the testing down” because the rising case count made him look bad. (He later asserted that his statement at the rally was not a joke, despite White House officials insisting it was.)

As all this happened, many of the underlying problems with testing capacity remained.

For one, there’s still a lot of variation between states. While most states, as of July 8, had 150 new tests per 100,000 people per day — the equivalent to 500,000 daily tests nationwide — 18 states still didn’t.

The state-by-state situation looks worse through another metric: the test positive rate, or the percentage of tests that come back positive. If a place tests widely enough, allowing it to catch even the people who show few symptoms but could still spread the virus, it should have a low positive rate — typically below 5 percent, though some experts now argue for less than 3 percent. A high positive rate indicates only people with obvious symptoms are getting tested, so there’s not quite enough testing to measure the scope of an outbreak.

As of July 8, most states in the US had a positive rate above 5 percent, suggesting their testing capacity isn’t keeping up with the scale of their outbreaks.

The consequence is delays in testing results as the demand for tests outmatches the supply. So people can’t get their test results quickly enough to act on a positive report, preventing tests from achieving the exact goal they’re supposed to accomplish.

Testing was always supposed to scale with larger outbreaks

The diversion between many states hitting 150 daily tests per 100,000 people and still having positive rates that are too high exposes another problem: The call for 500,000 tests a day nationwide was supposed to be only the minimum. Experts always warned that if the Covid-19 outbreak got much worse, there would likely need to be even more testing to keep up with the rise in new potential patients and cases.

“There’s the testing capacity you need to get to the place of opening up, then there’s the testing capacity you need to be open,” the Kaiser Family Foundation’s Kates said. “Once economies start to open again, people start moving and returning to the public sphere, and there are outbreaks. If there’s not enough testing, and testing hasn’t been built along with contact tracing, you’re going to have this explosion that we’re seeing, and the testing is not going to catch up with it.”

Jha, from the HGHI — which was one of the more vocal advocates for the threshold of 500,000 tests — said he worries something got lost in his communications to journalists and government officials.

At the same time, Jha and the other experts I spoke to were always clear, at least to me, that the 500,000 benchmark was a minimum. In fact, even before the current testing problems, Jha and the HGHI said the number was likely too low to keep up with the US epidemic and called instead for a minimum of 1 million daily tests.

“We were the ones who generated the 500,000-a-day number. We did it based on a particular size of the outbreak,” Jha said. “Clearly, things have gotten much worse since then.” He added, “We’re learning. We’re trying to figure out how to control the virus and where the country should go. And obviously in that we’re going to be updating data as it goes along.”

With the positive rate, it’s a similar story. Thomas Tsai, a health policy expert at Harvard, said the real goal for the positive rate is 0 percent — when the coronavirus is vanquished. So it’s important for states not to get complacent just because they’re now below an “acceptable” maximum of 3 percent or 5 percent. “The tests are a mean to an end,” Tsai said. The metrics “are just signposts along the way to give you directions.”

But as Covid-19 cases dropped and plateaued for the greater part of May and early June, much of the public and officials may have become complacent with the testing situation. They set their attention to other issues, such as the rise of new Black Lives Matter protests. Trump and the rest of the White House stopped focusing on the topic, halting daily press briefings about Covid-19, perhaps as officials realized that the president’s botched response to the crisis had made him look much worse. Meanwhile, there was a push, from Trump in particular, for states to reopen as quickly as possible to boost the economy.

Now it’s clear that problems with Covid-19 testing remain.

Earlier on, the hurdles with testing were linked to supply chain problems: not enough swabs to collect samples, vials to store them, or reagents and kits to run the tests. Over time, those problems were fixed or worked around.

The issue, experts say, is that these kinds of problems were always bound to come back as testing demand increased. Fixing a bottleneck for kits may let the country get to 500,000 tests a day, but that bottleneck can easily come back if, for instance, the nation needs 1 million per day and there are only enough kits for 700,000.

Jha pointed to basic economic concerns as a key problem. “If we decided to tomorrow, do we have the technological capacity to be able to get many millions of tests a day? Absolutely,” he said. But labs aren’t sure that making the massive investment for way more tests is financially sustainable, he explained, especially as Covid-19 outbreaks ebb and flow — and, as a result, occasionally deplete demand for those tests, as well as the number of people who need them.

Ideally, the federal government would be in charge of handling these problems. It’s the one entity that can go to labs across the country, see what the holdups are, then work along the global supply chain to see what can be done to address the issues. It has the funding ability to ensure labs and suppliers remain whole. And it can prioritize limited resources to specific cities, counties, or states that need them most, instead of leaving these supplies to a free-for-all.

This is, in fact, what the federal government does with other issues — such as when it ensures that a manufacturer has all the parts needed for an order of guns, tanks, or jets.

“The military has visibility into the entire supply chain, and the military oversees the entire supply chain,” Jha said. “It may be working with private companies, but the [Department of Defense] doesn’t leave this all up to chance.”

The Trump administration, however, has described the federal government as a “supplier of last resort.” That’s very different from the kind of proactive approach the feds take on other issues to get ahead of supply constraints.

So the problem is left to private actors as well as local and state governments, which often face legal, financial, and practical constraints that hinder their ability to move quickly. And the problem persists, even as Covid-19 cases continue to rise.

Testing always mattered and still matters

It’s been said a countless number of times in recent months, but it’s still true: Testing is key to stopping the Covid-19 pandemic.

When paired with contact tracing, testing lets officials track the scale of an outbreak, isolate the sick, quarantine those with whom the sick came in contact, and deploy community-wide efforts as necessary. Aggressive testing and tracing are how other countries, such as South Korea and Germany, got their outbreaks under control, letting them partly reopen their economies.

This testing problem is solvable in the US. “New York at its peak had people dying in the hallways of hospitals. Test positive rates were routinely above 20 percent,” Tsai said. “Look at it now, with a test positive rate of about 1 percent. In Massachusetts, our positive rate is about 2 percent now. These states show that concerted efforts … can not just mitigate the pandemic, not just flatten the curve, but also contain and suppress the pandemic.”

This only works, however, if officials can move quickly on a test, preferably within 24 to 36 hours. In the time it takes to confirm whether someone either has Covid-19 or came into contact with someone who has it, the person is more likely to continue their typical routine, potentially infecting others in the public or even within their own homes. In this context, every day and hour matters to get people to stop the spread of the coronavirus.

Testing and tracing can’t solve the pandemic all on their own. They have to be paired with precautions such as wearing masks and keeping 6 feet apart in public. In extreme cases, lockdowns can still be warranted if an outbreak is so out of control that a stay-at-home order becomes the only way to reel things back.

Lockdowns, however, were also supposed to buy the nation time to build up its testing system. As Natalie Dean, a biostatistics professor at the University of Florida, previously told me, “The whole point of this social distancing is to buy us time to build up capacity to do the types of public health interventions we know work. If we’re not using this time to scale up testing to the level that we need it to be … we don’t have an exit strategy. And then when we lift things, we’re no better equipped than we were before.”

It’s now clear that the US didn’t take full advantage of the time it bought with lockdowns. While testing did dramatically improve compared to the early days of the pandemic, it’s still not at a point where America can handle the higher demand brought on by another surge in coronavirus cases.

“It’s pathetic. This is not how a first-world country functions,” Jha said. “That people should not expect to access a test to an infectious disease many, many months into a pandemic — I find myself amazed that this is where we are as a country.”

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Covid-19 is upending our lives and forcing us to make complex decisions with little information and conflicting guidance from authorities. Summer, typically the season of staying up late and popsicles in the park, offers no escape. Many of us are already turning to the fall, and the fate of schools.

What will we do with our kids? Can we really send them back to school? If we keep them at home, will they forget how to read? If we send them to school, what might be the consequence? We are living a nightmare, but this is where we are. The choices are high-stakes and plagued by uncertainty. Even thinking about them makes me sweat.

I am the father of three girls ages 16, 13, and 10, and like every parent in America, I am worried about the fall.

I’m also an infectious disease doctor and epidemiologist, and have spent the past four months drinking from the fire hose of Covid-19 science, designing infection control policies for my hospital, and caring for patients on the front line. I serve on the reopening committee for my synagogue and for my school district. I consult for businesses as they reopen.

I have a first-row seat to the coronavirus pandemic, both as a parent and as a professional. In both of those roles, I hear the same questions, repeated with mounting urgency: “Are our kids going to be safe?” “Are our teachers going to be safe?” “Will kids bring Covid-19 home to our family?” “Will opening schools lead to a second wave and lockdown?” “What are the risks of not reopening?”

I have spent time reviewing the data and seeking answers to the challenging questions we face. Having the knowledge to make your own assessment, however, need not be a position of professional privilege. With this short primer, I hope you can add your voice to the debate and advocate for yourself, your family, and your community. The good news is, we can hope to send kids back to school in the fall, but there is a lot of work to do.

Are our kids going to be safe?

If any of us is ever going to send our kids to school again, we need a clear answer. Fortunately, I think we have one, at least for the children. Children are less likely than adults to be infected with Covid-19. There are multiple ways to study this question, and all the approaches arrive at this same conclusion.

First, when we look at public health reporting, children under the age of 18 make up only 2 percent of cases in the US, even though they represent 22 percent of the total population. Similar studies in Chicago and Massachusetts found that children make up fewer Covid-19 cases than expected, as have studies in Italy, South Korea, and Iceland. For me, that is a lot of similar results for this to be a fluke. When one study in one location produces a finding, it is notable. When five studies from five different settings find the same thing, it is compelling.

One reason case counts may be lower among kids than would be expected is that we did close our schools in March. Maybe we protected our kids by keeping them out of harm’s way. But if we send them back to school this fall, will they still enjoy protected status from the coronavirus?

One way to study this question is to estimate the “attack rate” of the disease — that is, the proportion of people exposed who become infected. Multiple studies from China investigated the attack rate among people living in a house with someone who is infected. They found that only about 4 to 5 percent of kids developed an active infection. In comparison, about 17 to 20 percent of adults became infected after exposure.

To be fair, data in the US is more concerning. In New York state, 57 percent of people living with a Covid-infected person developed an infection. It is hard to take reassurance from that fact. But even with such a high attack rate, children were still less likely to develop an infection and there was a gradient over ages, a sort of “dose effect” for age.

Finally, even in the worst-case scenario, in which a child does contract Covid-19, the outcomes of the disease are less severe in younger people than among older adults. In one analysis of more than 550 confirmed cases among children under age 18 in China, Italy, and Spain, only nine people (1.6 percent) had severe or critical disease. In another study, approximately 5 percent (one out of 20) developed symptoms that required hospitalization, but only 0.6 percent required intensive care. In comparison, a recent Centers for Disease Control and Prevention report indicates that among those ages 60 to 69 who have the coronavirus, 22 percent require hospitalization and 4 percent require intensive care.

Are teachers going to be safe?

There is far less data specifically on teachers and staff than on kids. One study in France is reassuring. In that investigation of 541 students and 46 teachers, there were no documented transmission events from students to teachers. However, while many of us immediately think of the risk to teachers from exposure in the classroom, we may not consider the additional risk that teachers face in break rooms and staff meetings.

Working in the hospital, I have personally seen that staff have a difficult time maintaining personal protection at all times. Doctors and nurses tend to let down their guard when they are away from patients and during breaks. Masks come down, people eat snacks in potentially unsafe spaces, and social distancing lessens.

The same will likely be true in schools. The potential risk to teachers, therefore, goes beyond the classroom. Staff risk in schools likely looks similar to the risk of any adult working in a crowded indoor environment during the pandemic. School opening plans must consider teacher safety in addition to the well-being of students.

Will my kids bring Covid-19 home to our family?

For most parents, the next question after the safety of their kids will be their own safety and that of loved ones in the house. Even if the kids are all right, could they bring the coronavirus home?

Here, again, the data appears reassuring. One large review of over 700 scientific publications found that children accounted for only a small fraction of Covid-19 cases, and that they were rarely the first case in a cluster of infections in a household. For example, in China, only 5 percent of household clusters were found to have a child as the index case. Similarly, in Switzerland and Holland, children accounted for only 8 percent of household transmission clusters.

Unfortunately, the US numbers make me a little less certain. In a Chicago study of 15 households with available data, 73 percent of infected children contracted the virus from an adult. However, that means that 27 percent of infections were child-to-child, which is substantially more than 5 to 8 percent.

Still, the Chicago study only examined 15 households, and adult-to-child transmission remained far more common than child-to-child or child-to-adult.

Will someone in America contract Covid-19 from their sick child? Yes. Should I structure my life around such a rare occurrence? I do not think so.

Will opening schools lead to a second wave and more lockdowns?

We have reached the most challenging question to answer and one that is a holy grail for Covid-19 epidemiologists. I want to give you the plain answer here — we do not know.

An objective summary of the evidence in hand suggests that schools will play little role in sustaining the pandemic. A recent review of 210 transmission clusters around the world found that only eight of them (3.8 percent) involved school transmission. Case studies of outbreak investigations in Ireland, France, and Australia demonstrate almost zero cases of in-school transmission.

Modeling studies demonstrate no clear role of in-school transmission in explaining current Covid-19 epidemiology. All of this data tells us that despite our gut instincts and parental anxiety, schools will likely be okay this fall.

But the story does not end there. First, there are examples of in-school outbreaks that did force a second shutdown. Israel is an example.

Israel reopened schools with limited class sizes in early May and lifted class size restrictions on May 17. By June 3, they had to reclose after a major outbreak. The largest outbreak was 116 students and 14 teachers at one school. Per NPR, one child tested positive without symptoms and the school decided to quarantine the grade. Next, a child in a different grade tested positive and they closed the school.

At that time, they discovered that they already had more than 100 cases. It is not certain that all of those children were infected in the school, but the story is concerning and it raises the bar on monitoring our schools.

The data that’s available is mixed. If a person (or school district) wants to tell you that schools play little role in transmission, then ask them how their district is different from Israel’s. Why can an outbreak happen in that setting but not yours? Perhaps there is a reason, but until someone can give you a good one, be skeptical.

What are the risks of not reopening?

A discussion of school closures that focuses only on Covid-19 and not at all on education is incomplete. There are real risks to keeping our children at home. In fact, the risks of staying home are in many ways clearer than the risks of returning to school.

One study using statistical models projects major losses in math performance if we continue with remote learning until 2021. Perhaps more compelling than statistics, however, is some simple common sense.

On any given day, it is hard to point to the loss of learning from home. At the same time, we all agree that education is essential. If we keep our kids home for another school year, they will have missed 12 percent of their total education. I cannot identify the specific losses from that much absence, but I am confident there is a cost to missing that much school. For perspective, missing 12 percent of school time is the same as missing 22 days of school in a single year.

Further, the losses will not be equal. The “Covid-19 slide” will likely be greatest among the socially vulnerable, such as children with learning disabilities and those whose situation at home is not conducive to homeschooling.

We must also acknowledge that the losses will hit people of color much harder than those who are white. Further, school officials account for approximately 20 percent of formal reports of child abuse and domestic violence. Without school-based counselors and social workers, these concerns may not be investigated.

All of these harms weighed on the American Academy of Pediatrics’ guidance that school reopening plans start with the goal of having students be physically present in schools.

What should we do?

A great mentor of mine, Milton Weinstein at Harvard, is generally credited as being the person who introduced the field of medicine to the concept of rigorous decision-science. The central question to all decision-science is: “What should we do, given that we have imperfect information?”

Milt is fond of the expression “a decision has to be made.” His wisdom has never been more pertinent than it is today. We have to make a decision. There is no choice to do nothing, because either way — go to school or learn remotely — we are making a decision.

Unfortunately for all of us, we are making a decision with significant uncertainty about all the risks involved. Fortunately, this is not the first time that people have been forced to make decisions with uncertainty. There are approaches to making uncertain decisions in a way that maximizes the chances of a good outcome and minimizes the harm if the outcome is poor.

You’ve likely heard of one of them: hedging your bets. When multibillion-dollar investment funds make a choice to invest, they recognize that they could be wrong. They do not make all-in versus out decisions. Instead, they hedge their bets. They may think that the newest beach toy is destined for greatness, but just in case of a rainy summer, they also invest in umbrellas.

When I look across all the data, I see an uncertain decision. First, I propose that the balance of data we have now suggests that we need to try to open schools in the fall. The risks of reopening are uncertain; the harm of staying home is clear.

If your school district cites the data above to you that “schools are safe,” ask your school board: What is the plan beyond reopening? What if we are wrong? How will your district know that things are going well (or not well)? Don’t let the conversation stop at “data suggests that schools are safe.” Don’t let the plan stop with “symptomatic people should call their doctor.”

If we are going to open safely in the fall, we must have the capacity to know — quickly — when an outbreak occurs. Israel is an important cautionary tale. When Israel closed down its schools again, it had only identified two school-based cases, yet in the end it discovered that more than 100 students had been infected.

To do this well, and to do it safely, we must have school-based Covid-19 symptom screening, testing, contact tracing, and isolation. “School-based testing” does not mean that the test themselves must occur in school buildings. “School-based testing” means that students and teachers can easily access a test by contacting the school, and that the results of those tests are sent directly to the school district in real time.

That seems straightforward, but it is not. The community does not yet have adequate testing, contact tracing, or isolation. Schools currently have nothing.

It requires building new capacity in schools for testing and contact tracing. It requires a budget. It requires a formal plan. Ideally, that budget should come from the federal government and be directed to states and ultimately school districts, as part of a national Covid-19 testing strategy. Realistically, given the lack of any such national plan, the funds need to come from individual states.

Building such infrastructure comes at a cost and many districts are already facing budget shortfalls. Districts that rely only on their existing testing infrastructure will not have the real-time information they need to make good decisions. Imagine a child has a fever and cough in October and is told by the school to call the doctor for a Covid-19 test. Results are typically returned in two days to the doctor’s office. After another day (or two), the data might make it to the school district. So it will take at least four to five days for the district to have any information.

We need testing within the school system to shorten the delay at every step of the process and reduce the turnaround time for the test to only a day. With that kind of time resolution, we can increase awareness of the situation at our schools, along with the ability to react appropriately. Without it, we are flying blind and gambling with the health of our children, teachers, and community.

Ultimately, when I look at the decision about school as both a father and a scientist, I see a difficult decision that must be made despite uncertainty. The risks of opening are uncertain, but the benefits are clear. We need to try to reopen.

We have been wrong before about Covid-19. In March, the epidemiology world was quite confident that transmission could not occur before a person develops symptoms. Three months later, there is consensus that asymptomatic people were likely one of the main drivers of the pandemic. In March, the CDC and the US surgeon general told the public that masks play no role in controlling the spread of the disease. Now we see masks as a central component of our reopening strategies.

We could be wrong about schools, but we cannot afford to wait to find out for certain. We need school-based Covid-19 symptom screening, testing, contact tracing, and isolation. Opening without a plan to test is irresponsible and a gamble with our children’s health.

Benjamin P. Linas is an associate professor of epidemiology and an infectious disease physician at Boston University School of Medicine. Find him on Twitter @BenjaminLinas.

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Nuclear power has long been a divisive issue in the environmental community. The enormous momentum of anti-nuclear sentiment from the ’70s and ’80s has clashed in recent years with a new wave of advocates who claim that deep decarbonization — eliminating the greenhouse gases that drive climate change — requires the assistance of nuclear power.

The embrace of nuclear in climate and progressive circles has been hampered by two factors. First, nuclear has traditionally been a huge and highly hierarchical industry, peddling enormous plants that cost billions of dollars and produce dangerous waste, with a history of special pleading and corruption — not the kind of industry progressives naturally lean toward.

Second, nuclear advocates have traditionally been, well, men. And not just any men, but the kind of men highly prone to mansplaining why they are rational and you are an over-emotional hysteric. (“Nuclear bros,” in the online argot.) There is a cohort of nuclear advocates who seem to have chosen the issue mainly as a pretext for bashing environmentalists. Insofar as they’ve attempted outreach to climate advocates, the nuclear bros have met limited success.

This has caused quite a bit of angst among the small but growing number of progressives who have turned to nuclear advocacy out of progressivism — out of a concern over climate change and its impacts on the most vulnerable.

Those activists see opportunities in the new generation of nuclear plants, which are smaller, cheaper, and safer than their predecessors, more congruent with the general movement toward distributed energy, microgrids, and community ownership.

But they have struggled to change the tenor of the conversation because they are scattered and lack institutional backing.

Now they are launching a group of their own: the Good Energy Collective, which will develop and advance progressive nuclear policy.

Four of the five board members are women, as are the co-founders: Suzy Hobbs Baker (currently creative director at University of Michigan’s Fastest Path to Zero initiative) and Jessica Lovering (currently a doctoral student in engineering and public policy at Carnegie Mellon University).

I called Baker and Lovering on July 15 to chat about the new group, the values that distinguish it from other groups in the nuclear space, and the prospects for advanced nuclear plants to play a role in the climate fight.

Our conversation has been edited for length and clarity.

David Roberts

How did this organization come about?

Suzy Hobbs Baker

We saw a gap in the ecosystem — there was no place to do progressive nuclear policy. It just didn’t exist. And nobody was trying to build it.

David Roberts

What do you mean by progressive nuclear policy, as distinct from what other NGOs are doing?

Suzy Hobbs Baker

There are a bunch of policy shops in DC that do great nuclear work. Most of it has been focused on R&D. Under the auspices of innovation, there’s been a huge emphasis on a fundamentally technical issue: We have to figure out how to design and build reactors again.

Jessica Lovering

There are lots of moderates working on [nuclear], and lots of bipartisan efforts.

Suzy Hobbs Baker

Right. But just at the moment the climate movement was taking off, it became clear there wasn’t a progressive [nuclear] contingent, figuring out how to join forces with and work within the climate movement.

David Roberts

So you decided to make one.

Suzy Hobbs Baker

Yeah! We took stock: Who are the progressives in the nuclear sphere? Oh, there’s like five of us. So it wasn’t that hard to get everybody on the phone and ask, “Do you want to do this?”

David Roberts

Is there no progressive nuclear work going on in bigger environmental or climate groups?

Jessica Lovering

There’s nothing nuclear going on. Some of these orgs, they will acknowledge that nuclear needs to be part of the mix. There’s been some consensus around keeping existing plants open. And that’s great — that’s way different than it was five or 10 years ago. But no one’s really working on the policy.

You can see this in the Biden-Sanders Unity Task Force recommendations on climate. They mentioned advanced nuclear, which is amazing, but it’s kind of like … “and also, advanced nuclear needs to be in there.”

There’s a lot of work that needs to be done to actually make that a reality. That’s what we want to focus on.

Suzy Hobbs Baker

It’s different from a lot of the larger orgs, who might have a “nuclear person” who tracks the issue. There aren’t places in the environmental space that have deep expertise on nuclear.

Jessica Lovering

Another thing that’s different — and really couches us in the progressive movement and not in the energy think tank space — is that we are focused on community-level engagement. We want to develop tools and processes to help communities figure out what they want for their low-carbon energy future.

And we want a process where they can decide they don’t want nuclear. That’s fine. We’re not going around trying to sell advanced nuclear. We want equitable processes that people feel are fair and transparent so they can make their own choices.

I think that fits much better with the environmental-justice agenda inside these climate platforms, more so than the R&D/technology side, which a lot of other think tanks are focusing on. R&D still needs a lot of work, and we’re going to be plugged into that, but our focus is going to be more on social science.

Suzy Hobbs Baker

While a lot of think tanks are thinking about deployment, we’re thinking about the other side of the equation, which is adoption. There are folks in DC and private companies trying to figure out how to get the technologies out, and simultaneously there are communities across the nation trying to figure out how to reach their climate goals. We want to transition to working with more focus on the communities.

David Roberts

The nuclear space is notoriously dominated by a certain kind of male voice — left-brained, not particularly emotionally intelligent — and it has often posed a communications challenge for the industry. It’s notable that you’re a female-led organization, but is that tone something you think consciously about changing?

Jessica Lovering

I gave a talk on this topic in November at the [International Atomic Energy Agency conference], about risk perception around nuclear. It’s a talk the nuclear industry asks for all the time: Why do people think nuclear is so risky? And how do we fix that with, I don’t know, better PR?

The talk I gave, which made a lot of people uncomfortable, was about a phenomenon called the white male effect. It’s not unique to nuclear. Across a whole bunch of risks — car crashes, alcoholism, all sorts of things — white males rate things as much less risky than everyone else, even males of color.

A lot of studies look into the drivers of this, but one thing that really struck us is an explanation that comes down to differences in worldview. White males tend to be more hierarchical and individualistic in their worldview, on average, whereas women and people of color tend to be a more communitarian and egalitarian.

One thing that is unique about nuclear, the way it’s been done in the past, the way the industry has been run, is that it has been very hierarchical, very top-down, very arguments-from-authority. And even fancy new nuclear technologies that are safer and cheaper don’t fundamentally change that aspect.

You can’t fix that with better communications. You can’t fix that with a slogan. You need to change how the industry runs.

Can you make nuclear appeal more to communitarians and egalitarians? I think you can, but it’s going to look very different. And that’s where we, who have strong progressive values, consider ourselves part of the left. We need to change the industry from the ground up.

So that comes back to your question about a women-led organization. There have been a lot of efforts in the past to find women who work in nuclear and prop them up as a spokesperson. “Okay, we have a woman talking about nuclear, this is going to change people’s minds.” It doesn’t, because it’s still the same industry and the same business model.

It’s because we have progressive ideals that it tends to be women leading this effort. We don’t just want policies that appeal more to women and progressives, we want to build up a younger generation of diverse leadership that allows people to live their values while working in nuclear, helping to build the case for nuclear in the broader climate change agenda — but really empower them, not just as props.

Suzy Hobbs Baker

It’s not an exaggeration to say that we had to build the organization we needed to move forward in our own careers. In order to move forward into leadership and have a healthy work environment, a new third space — we’re going to have to build it.

David Roberts

Where do you want to focus your policy work?

Suzy Hobbs Baker

We’ve seen this huge shift, with the growth of renewable energy sources in the last 15 years, of much more participatory decision-making in communities around the question of energy. We see where this is going. And a lot of the developers of these new [nuclear] technologies see where it’s going.

But it’s one thing to say we’re committed to a community-based approach, and a whole other thing to build the policy agenda and the infrastructure.

Jessica Lovering

There’s a big movement toward community ownership and community lead on energy projects, with distributed generation and microgrids, and there’s an assumption that nuclear can’t be a part of that because of the scale. But moving toward much smaller nuclear and factory-fabricated nuclear opens up those markets.

The industry just has no idea how to do that, how to approach small towns to see if they’re interested in nuclear. They’re used to dealing with big investor-owned utilities. So we need to develop those processes. How do you do have a community-ownership model or municipality model [for nuclear]? That’s really exciting to me.

David Roberts

Are these new plants ready?

Jessica Lovering

Almost.

Suzy Hobbs Baker

This year, the Department of Energy, mandated by Congress, stood up a new program called the Advanced Reactor Demonstration Program. They have the slightly bananas mandate to construct two [advanced nuclear] demonstrations in the next seven years, and then support a whole host of other demonstrations over the next five to 10 years. There are folks preparing sites for potential demonstration units.

This is a big piece of my research at Michigan: how we demonstrate best practices for community engagement at the demonstration phase with these new reactors so that it’s baked into the way that everybody’s doing business. We’ve been thinking a lot about the lack of institutions, the lack of training and professionals to help make this happen.

Jessica Lovering

It’s no longer paper reactors that’ll be ready in 20 years. Nuscale submitted their license application two years ago. [Editor’s note: Nuscale submitted its design certification application, which is short of a full license application.] Oklo submitted in December. Oklo is only 1.5 megawatts for the off-grid market, so they’re hoping to get licensed in two years. They can start planning their supply chains and their first build in the meantime. They could start construction in the early 2020s.

We need to get the rest of the supporting infrastructure ready to go before then — not on the construction/engineering side, but in terms of community engagement and everything that goes along with it.

David Roberts

Is there a short way to explain the different kinds of advanced nuclear?

Jessica Lovering

When we say advanced nuclear, there are two big categories.

There are small modular reactors, which are water-cooled like traditional nuclear but manufactured a more standardized way and much smaller. That’s a more gradual improvement.

The other big category is non-light-water reactors that don’t use water as a coolant. There are salt-cooled, called molten-salt reactors; there are gas-cooled, often referred to as high-temperature gas-cooled reactors (the gas is usually helium or CO2); and there are fast reactors, usually metal-cooled with sodium or lead. Those are less common, but there are some groups working on them. They can be really tiny.

David Roberts

Which are the ones that might actually be built soon?

Jessica Lovering

Nuscale is a small-modular light-water reactor of 50 megawatts, and Oklo is a micro-reactor, a sodium-cooled fast reactor — very different than what we operate today, and also very small. [Editor’s note: technically, Oklo’s “Aurora” mini-reactor is a fast reactor cooled by heat pipes, not sodium.] The whole power plant fits in about two shipping containers. It’s 1.5 megawatts, which is less than a standard wind turbine today.

David Roberts

Are the new designs meltdown-proof?

Jessica Lovering

Nuscale is water-cooled, more similar to traditional nuclear. It has a lot of passive safety features, but I wouldn’t say it’s meltdown-proof. For the other ones, the salt- or sodium-cooled plants, they really are meltdown-proof. You could never get temperatures hot enough to melt the fuels. And the fuels are much more heat resistant.