Schools, Sports, and COVID Through a Health Equity Lens
There are striking regional and political differences in proposals to reopen schools and resume sports. Some proposed approaches will widen health disparities. An analysis of schools, sports, and COVID, suggests that a hybrid model for reopening schools, and prioritization of education over football is our best hope for promoting health equity.
Reopening schools and resuming sports is associated with a degree of risk of increasing the spread of COVID along with the resultant illness, hospitalization, and death associated with this grim virus. There is much debate about the relative risk associated with COVID transmission and illness between children and adults. Although there is data suggesting elementary-aged children may not transmit the virus as much as others, it is certain that there is some degree of risk of transmission and illness in all ages.
Given some risk-benefit uncertainty, we need to find other ways to measure the relative value of various school and sports proposals. One important consideration is how do school reopening and sports resumption plans impact health equity. If health is not distributed equitably, we will find disparities between populations in health outcomes. That is exactly what we see now, with rates of COVID mortality several times higher for blacks than whites, and Latinos, who are over-represented in working at essential jobs in agricultural and food industries, facing similar disproportionate rates of illness.
To address disparities we must address the social determinants of health. Social determinants of health, according to the World Health Organization, are the conditions in which we are born and live that are shaped by money, power, and resources. School is perhaps the most momentous “resource” we offer to all children, so it is particularly important that we consider various school strategies in light of potential impact on health equity.
To tease out the impact on health equity of various reopening strategies, we must first be clear about what we mean when we say reopen schools and resume sports. Reopening schools can mean all students resuming education virtually, using online learning 100%, all the way to having all regular classes taught in person, with class sizes that averaged 20–30/classroom in pre-COVID times unrestricted.
There are also measures that can be taken to reduce risk in schools. These include face masks for students and teachers, screening for symptoms, social distancing at least six feet apart, and limiting classes to pods or cohorts of 10 or less. For older students, limiting in-person classes to labs or hands-on collaborative activities that can’t be done online, reduces risk. The reductions of class size and limits on lecture classes depend on a vigorous online remote learning program, bolstered child care resources, and hiring more teachers.
Opening schools without regard to class sizes or limitations on the number of classes offered puts all students and teachers at higher risk of transmitting COVID, because without limits on the number of students in each class or on the number of classes offered, students will be unable to social distance, with resultant congregation occurring in riskier indoor settings. Parents who are concerned about sending their children back to school (around 30% based on some polls) can elect some type of private schooling or online program-if they can afford it. If those who can afford it opt out, those who will get infected because of opening school without restrictions on class size or classes offered will be disproportionately poor, with strong racial and ethnic associations. This option exacerbates disparities and leaves us further from our goal of health equity.
If sending students back to school without limits on class size or classes offered will worsen health disparities, what does moving to online learning look like? Access to high end technology is expensive, and for many, complicated to learn and to master. Having better, faster equipment, and the money to pay for instruction will give you a head start. Again, students who are poor will be disproportionately impacted, once more leading to widening disparities in access to education and performance.
Can we reopen schools in a manner that does not widen health disparities? Lessons from around the world suggest the answer is yes, if we can reduce rates of disease in the community, and if we can institute accepted preventive strategies. The opportunity to reopen schools should be a strong incentive for a community to take the steps collectively and individually to reduce spread.
The preventive strategies to reopen schools more safely are also well known, including face masks for students and teachers, screening for symptoms upon entry, social distancing at least six feet, and limiting students to pods or cohorts of 10 or fewer students. For older students at the high school and college levels, limiting in-person classes to those that cannot be provided online substantially reduces congregation and the risk on spread on campus. These preventive strategies would reduce the likelihood of infection, while providing equitable access to the benefits of smaller class sizes.
As with schools, there are different levels of risk associated with various sports activities. All things being equal, exercise is good for us and should be encouraged, if it can be done safely with a low risk of transmission or infection. If all activity is limited, such as in a strict shelter in place policy, then outdoors and indoor sports activities are all but eliminated. At the other end of the spectrum is allowing even the riskiest sports.
What are the implications of these approaches on health equity? Similar to schools and education, if you have money, you have more access to alternative sources of exercise. It means you can purchase an elliptical machine for your house. Wealth means you are better able to afford a visit to a park, and given the racial breakdown of wealth in our country, more likely to feel comfortable amongst the overwhelmingly white clientele that frequent parks. Restricting access to sports and exercise widens health disparities.
The steps we can take to safely participate in sports activities are similar to the steps we can take to make schools safer, including face masks, social distancing, small pods of 10 or less, and avoiding gyms and indoor facilities. The most extreme example of a high risk sports activity is football. Football, along with wrestling and cheer-leading, are considered high risk sports because of the extended periods of direct contact between participants, as compared to medium risk sports such as basketball, softball, and volleyball, and low risk sports such as swimming and track and field as well as individual and small group conditioning.
There are multiple issues surrounding football that are most dramatically illustrated in the planning for the 2020 college season. Our health equity calculations are complicated because a disproportionately high percent of football players are black. Postponing the football season may adversely impact their ability to improve their draft status and potentially to make money in the future, and takes away the pride and satisfaction of being on a football team. You hear these sentiments in the calls from many athletes to let them play. At the same time, the same disproportionate percentage of black athletes will be exposed to the highest risk activity for transmission we can imagine. There is frequent direct contact, with yelling and shouting at close quarters that creates the aerosols that lead to higher rates of transmission, while social distancing in huddles and at the line of scrimmage is impossible.
It is possible to offer sports inside bubbles like the NBA and NHL have created, and we could theoretically do the same for college football players. These bubbles depend on strict sheltering and frequent testing. One major issue with this approach, is the social isolation of living in a bubble for months on end. It’s one thing to accept social isolation when you are paid millions of dollars, it is another when you are an amateur and others are making the millions, while you shoulder the risks to your mental well-being as well as the real possibility of catching COVID at the bottom of a football scrum. Even with the exceptional measures that may be associated with keeping players COVID free, it is hard to escape the gladiator-like appearance of sending disproportionately black football players into games when we know they are engaging in a sport that puts them at the greatest risk of contracting the virus and damaging their health.
Testing has been proposed as a way to have a more normal school and sports environment beyond the rarefied air of professional sports leagues. The willingness to embrace repeated, expensive testing of entire football teams stands in contrast to the testing expectations for schools to reopen-which in most cases are none. Using this measure, we are more willing to expend resources to play sports then we are to open schools safely. Prioritizing resources for sports over schools will disproportionately impact those who rely on public schools, further exacerbating health disparities.
Not that testing is a guarantee of success. There are various types of tests, but none of them can tell you whether you will have COVID in a week, or a day, or even in an hour. As the CDC notes, “You may test negative if the sample was collected early in your infection and test positive later during this illness. You could also be exposed to COVID-19 after the test and get infected then.” The bottom line is, we should all assume that we are potentially infectious even if we test negative, and follow the preventive strategies that are good not only for schools but for each of us in our everyday lives.
Our approach to reopening schools and sports varies between regions and political ideologies. These approaches reflect our priorities. Policies at both end of the spectrum can impact health equity, either by limiting access to critical school resources, or by putting disproportionately poor and racially and ethnically diverse populations at risk from higher rates of COVID. A hybrid school model, where universal preventive strategies including face masks, screening for symptoms, coupled with social distancing and small pods of 10 or less students, limits health risks and provides access to educational opportunities. Similarly, implementing these measures and limiting in-person classes to hands-on experiences that can’t be done online reduces risk for older students.
At the same time, providing funding to resume college football prioritizes a narrow band of highest risk sports activity over the needs of our educational systems. It also endangers the health of disproportionately black participants, and limits support for physical activity to a very select few. A more equitable approach to sports would expand access to physical activity by building outdoor facilities and walking trails in underserved communities. Encouraging conditioning individually or in groups of 10 or less would also align the degree of risk we accept for physical activity with the degree of risk associated with a hybrid education model that embraces the same preventive measures, in stark contrast to the high-risk activities during a football game.
If our priority is health equity, we will invest in a hybrid model of education, and prioritize educational funding over playing football. To be more equitable, we will tackle related issues including funding for day care, investing in technology so that there is equal access to virtual and remote learning experiences that are critical in any school reopening scenario, creating and maintaining access to physical activity in underserved communities, and expanding and paying for the pool of teachers who can do more one on one teaching in socially distanced and smaller classes. These steps will not only support health equity in both schools and sports during COVID, they will also be important strategies to achieve a more just society for years to come.
Dr John Zweifler is a family physician with decades of experience in medical director roles, patient care, medical education, and managed care. He now works part-time as a medical consultant with the Fresno County Department of Public Health. He is also a physician consultant with The Terry Group, and is the author of the e-books, “Tipping Health Care in the Right Direction” and “Pop Health”
He can be contacted at The Terry Group John.zweifler@terrygroup.com
