Our Arizona schools closed for in-person instruction on March 13 when there were 12 known COVID-19 cases and no known deaths. As of October 7, there were 222,538 cases and 5,733 known COVID-19 deaths. In reopening in-person education, there was natural anxiety for students, parents, educators, and school leaders.
After calls for written statewide evidence-based benchmarks, Governor Ducey then tasked the Arizona Department of Health Services (ADHS) to come up with such metrics by August 8, with many schools set to open on August 11. On July 23, physicians and educators again called for evidence-based benchmarks as a prerequisite to opening. On July 26, a copy of evidence-based metrics compiled by local physicians was delivered to ADHS Director Cara Christ, MD, MS, and Arizona Superintendent of Public Instruction Kathy Hoffman, MS.
Several days later, Dr. Christ and Superintendent Hoffman presented three very weak guidelines: a two-week decline in the number of COVID-19 cases or two weeks with new case rates below 100 per 100,000, two weeks with less than 7% positivity of COVID-19 diagnostic tests, and two weeks with hospital visits due to COVID-like illness below 10%. A three-tiered threshold system was outlined: red for substantial community spread, yellow for moderate community spread, and green for minimal community spread. ADHS recommended “county-specific public health benchmarks fall within the moderate or minimal spread category in all three benchmarks for two weeks in order to provide hybrid learning.” None of the metrics were firm thresholds that must be met but rather voluntary suggestions.
Though little had been done to ensure a safe transition back to school, the school districts’ insurer added another complicating factor. The AZ School Risk Retention Trust (“the Trust”) struck the phrase “foreign or exotic disease or illness” from coverage. Districts would be uncovered for pandemic liabilities. The Trust then released strongly worded waivers or “acknowledgments of risks” for parents to sign to reinstate minimal coverage. Additionally, many districts required employees to sign waivers of risk. Some districts even mandated non-disclosures to prevent staff from sharing their COVID-19 positive status. These legal maneuverings have further increased distrust from parents and students alike.
Today, many districts have opened for in-person education despite being in the yellow zones or red zones because parents are desperate to get their children back to school. As students returned, many districts found themselves short staffed as teachers were understandably reluctant to return. Almost one thousand teachers resigned as of August 31. This loss of teachers means that 28% of Arizona classrooms do not have a certified teacher.
Higher education has also been affected. Arizona State University reported only active cases of COVID-19 students and staff. Once the isolation period for these students was over, ASU removed them from the case count. ASU has reluctantly agreed to start reporting the standard cumulative numbers again. ASU also shortened the semester and will be virtual only after Thanksgiving. Maricopa Community Colleges are mainly virtual. And the University of Arizona instituted a shelter in place mandate due to a surge of positive cases on campus.
Despite the available CARES Act funding, most districts in Maricopa County are having to finance their own options for testing and tracing. In other cases, some school communities like Tucson have health department support for no-cost testing and tracing. It is hoped that continued advocacy can get the local health departments to require more robust testing and tracing.
The most important metric, percent positivity rate, has also come under fire because of inconsistencies. ADHS elected to count only the electronically reported numbers, leaving 25-30% of tests uncounted. Some higher risk populations were part of the unreported cases, such as indigenous communities and predominantly Hispanic or Black communities. Additionally, the ASU Biodesign Institute started to report percent positivity as the number of positive cases divided by the number of the entire ASU population as opposed to the standard positive cases divided by number of people tested. These inconsistencies leave citizens with little certainty as to the real level of risk.
As physicians, we should support our school leaders as they make the difficult but courageous decisions to open only when truly safer. Educators are not public health experts, just as we should not be put in charge of educating thousands of students. It is impossible to make it 100% safe for all. The goal needs to focus on making it safer while knowing that at least 40% of educators are high risk. Returning to the basics of epidemiology would include control of community spread, enforcement of robust mitigation systems with free accessible testing, contact tracing, isolation, and quarantine. We can, with personal responsibility, as well as holding our school leaders and elected officials accountable, have a thoughtful plan for safely reopening the school that is evidence-based with intentionality for equity.