To the Editor:
Following Dr. Hageman's discussion of safe school return and equity issues (“Can students safely return to school in the age of COVID-19?”)1 in the September 2020 issue of Pediatric Annals, I felt an expansion of the topic was necessary to more broadly discuss ways we, as clinicians, can better support the families we serve. As we continue to live through the coronavirus disease 2019 (COVID-19) pandemic, new clinically useful information about COVID-19 infection and its management in the pediatric population is available almost daily.1–3 From COVID-19 data, a few key points are clear: the morbidity and mortality of pediatric COVID-19 cases are much lower compared to the adult population; the disease continues to disproportionately affect both adult and pediatric minority populations, and children are subject to multiple risk factors while not in school.1,4–6
Nations around the world are now distributing the first COVID-19 vaccines. However, we've reached another issue with these new developments, which is that current vaccine trials likely do not include representative numbers of people of color; yet, we expect the same populations to trust medical providers when they say that the vaccine is safe.7
So how do vaccines and safe school return somehow fit into a conversation to be had by the clinician with their patient? Let us first begin by discussing and further understanding just how staggering the disproportionate impact of COVID-19 is on communities of color. The percentage of racial/ethnic minorities in the total US population is 40%,8,9 but they account for 47.3% of all COVID-19 cases,4 and 42.3% of all deaths.4
Now let us better understand how COVID-19 affects the pediatric population as well as what children may be at risk for during home schooling. Pediatric COVID-19 cases comprise 10.1% of total cases in the United States and 0.76% of deaths.4 Pediatric risks (specifically concerns of equity) from COVID-19 include homelessness, abuse or neglect, food insecurity, mental health issues and lack of social supports, isolation, exposure to weapons in the home, and environmental exposures such as disinfectants, dust, or mold.6,10
From these data, it may seem obvious what the next steps should be in supporting our pediatric patients and their families. We must encourage the adults within families who have risk factors to get the COVID-19 vaccine, and we must support children's safe return to school. We must consider that it might be safe for children to return to school even without pediatric COVID-19 vaccinations, given that the vaccine has yet to be approved in children younger than age 16 years.4,6,11,12 Several local school districts and cities are using overall COVID-19 statistics (not pediatric statistics) to determine school return.13 For example, New York City's case rate of more than 3% is used to determine school closure.12 Although most children may not be at significant risk for severe symptoms if they contract COVID-19, it is their adult guardians, teachers, and family members that assume higher risk; more specifically, their adult counterparts within minority populations.3 If the administration of the COVID-19 vaccines do decrease the overall infection rates, that will support a safe return to school.
From a US perspective, our prevalent history of systemic racism, disregard for the health of Black communities and other people of color, and a history of events such as the Tuskegee Syphilis Study have created general distrust of the medical community.14 So, from the perspective of a pediatrician in Chicago, IL, whose patient population is near to a majority Black, how do we move forward to protect the very population who is understandably slow to trust the medical establishment? Although many changes to combat systemic racism and distrust of the medical community exist on a longer timeline than that of COVID-19, there may be things we can do as clinicians to be proactive and promote equity in the midst of a new vaccine. In the short term, we must ask ourselves how we are creating environments of vaccine confidence and empowerment—perhaps by motivational interviewing, answering questions, and providing vaccine information long before vaccines are offered to the public. How are we listening to specific concerns of the communities we serve rather than talking at them? What is our plan for best supporting these families in a general sense over the next several months? Perhaps through community outreach and in strengthening existing bonds with our hospital and clinic neighbors, or perhaps by using our platforms as clinicians to speak out regarding greater and earlier vaccine availability specifically populations with risk factors, such as racial and ethnic minority groups.
COVID-19 has altered lives, modified medical practices, and has caused loss of some sort in every individual I've encountered. But as privileged individuals, it is easy to remain comfortable within our bubble. As Atul Gawande said in Better: A Surgeon's Notes on Performance, “Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”15 Whether we see COVID-19 as a wake-up call or as inspiration to better serve our pediatric patients, there are clear disparities in both risk for COVID-19 infection and adverse events for children while not in school. We must work to do better. We must be willing to try.