The Hard Covid-19 Questions We’re Not Asking

02 September 2021 12:38:11

By Joseph G. Allen and Helen Jenkins

While the availability of vaccines refocused the U.S. response to the pandemic, many policy questions remain. Should vaccinated people get boosters? Does everyone need to wear a mask? Are unvaccinated children safe in schools?

We think much of the confusion and disagreement among scientists and nonexperts alike comes down to undefined and sometimes conflicting goals in responding to the pandemic. What are we actually trying to achieve in the United States?

If the goal is getting to zero infections and staying at that level before dropping restrictions, one set of policies applies. If the goal is to make this virus like the seasonal flu, a different set of policies follows.

Let’s use masking of children in schools as an example.

The Centers for Disease Control and Prevention pegged its masking recommendation for vaccinated adults to local transmission rates. If high, all people should mask indoors. If low, no need. But, it did not set similar metrics for children and masks in schools when it recommended universal masking. In failing to do so, it avoided not just the obvious tough question — When can kids stop masking in school? — but also an even tougher, fundamental one: What is the purpose of Covid-19 precautions now?

One often discussed timeline for ending masking in schools is the date that a vaccine is approved for children under 12. That seems reasonable, but it raises yet another question: What happens if vaccines for children younger than 12 are approved at the end of the year but only 35 percent of this age group get vaccinated? That is exactly what we see now for 12- to 15-year-olds, who have had access to vaccines for months.

If it’s conceivable — and even likely — that in March most children will still be unvaccinated, does this mean masks should come off then anyway? Or would masks be recommended indefinitely?

To answer those questions, it must first be considered that there are several possible aims of any policy addressing whether children should wear masks in schools. Those goals could include the protection of immune-compromised people; reaching zero infections, zero deaths or even reducing transmission of other respiratory pathogens — and achieving these aims might require indefinite mask mandates. But if any of these are part of a school’s rationale, its leaders need to say it clearly and have an open discussion about the pros and the cons.

Any organization setting a mask mandate at this point in the pandemic in the United States must pair that mandate with an offramp plan. Sleepwalking into indefinite masking is not in anyone’s interests and can increase distrust after an already very difficult year.
What if the stated goal is simply, “Kids need to be in school, period.” Considering the devastating costs of having children out of school last year, including dramatic and quantifiable learning loss in math and reading, this is a very reasonable and defensible goal. How might that then drive policy? Setting that goal would mean deploying more tools to keep children in school, like using rapid antigen tests and allowing kids who test negative to go to in-person class rather than mass quarantining hundreds or thousands of children who had close contact to people with the virus, as is happening now. Or, we accept that there will be more cases in children, recognizing that disease severity for a vast majority of kids is low.

Another hard question that is most likely also causing confusion and disagreement is how we define “severe” disease in children. Children can get Covid, but their death and hospitalization rates are much lower than for adults. The inflammatory syndrome MIS-C is rare. Long Covid has gained wide attention, but recent studies have shown that rates are low among children and not dissimilar to effects caused by other viral illnesses.

We’re not being cavalier by raising these points. Consider that in Britain the government doesn’t require masks for children in schools, and it’s not clear it will advise kids to get vaccinated, either. Britain has experts, as we do, and they are looking at the same scientific data we are; they most assuredly care about children’s health the same way we do, and yet, they have come to a different policy decision. Schools were prioritized over other activities, and the risks of transmission without masks were considered acceptable.

This reveals the crux of the problem in the United States. It’s not just the C.D.C., but everyone — including us public health experts — who is not always connecting our advice or policy recommendations to clear goals. The conflict is not about masks or boosters, it’s about the often unstated objective and how a mask mandate or a “boosters for all” approach may or may not get us there.

We use schools as the example here, but much of the same applies to broader societal questions over mass gatherings, live entertainment and returning to offices. There are questions around how vaccinated people should live their lives if the vaccines reduce the likelihood of spread but don’t absolutely and completely prevent breakthrough infections and transmission, which was never going to be the case.

If the goal is zero spread, which we think is not realistic, then the country would need to keep many of the most restrictive measures in place — an approach that has serious public health consequences of its own. If the goal is to minimize severe disease, some states with high vaccination rates might already be there. Low-vaccination states would still have work to do before loosening restrictions. Treating the country as a whole just doesn’t make sense right now because of the widespread differences in vaccination rates.

The emergence of the Delta variant has, understandably, caused many Americans to step back and use caution. But the same questions will be there when we emerge from this Delta surge, whether in a few weeks or next spring. We shouldn’t let ourselves off the hook with “easy” decisions today. At some point, the country needs to have an honest conversation with itself about what our goals really are.


Joseph Allen is an associate professor and the director of the Healthy Buildings program at Harvard T.H. Chan School of Public Health and the chair of the Lancet Covid-19 Commission Task Force on Safe Work, Safe School and Safe Travel.

Helen Jenkins is an associate professor at Boston University School of Public Health and an infectious-disease epidemiologist.