Masking in Schools: Stop Debating the Wrong Question

Finding the best answer to a problem starts with asking the right question. Anyone who has ever gotten into an debate about any trivial matter knows this truth. Scientists, lawyers, the best leaders and parents settling a sibling quarrel also intuitively know that the most meaningful solutions come from asking the right questions, which often have yet to be asked. Asking the wrong question may result in debate for the sake of being "right" or proving the other side "wrong", but, ultimately, the underlying problem remains unsolved. All too often, our society's debates and decisions surrounding COVID-19, have not adequately addressed, much less been centered on, the well-being of our children who are profoundly effected by these decisions.

The end of summer break is marked every year by first day of school photos of children with proud parents lamenting on social media that their kids are growing up too fast. Unfortunately, the start of the 2021-22 school year has been remarkable for the fierce internet debate whether masking school children prevents COVID infections. This debate is also playing out vociferously at school board meetings around the country. I believe we are debating the wrong question. At this point in the pandemic, I do not think the right question is "do masks on school children prevent COVID infections?".?We should be asking what is best for our children's health, development and overall well-being??I offer my perspectives, as a mother and a Pediatric Emergency Medicine physician why mandatory masking of young school children is our best solution to keep them healthy and learning in person at schools all school year. It may surprise you, that my practical reasons are only indirectly tied to COVID-19.

Let’s take COVID out of the equation. At a minimum, masks do reduce droplet spread of OTHER infections, which kept children remarkably healthy during the 2020-21 school year. I imagine the usual icky stickiness of elementary school surfaces had inexplicably disappeared for the most part. One of the most remarkable memories of the pandemic for me will be that I did not see a single case of RSV during its usual season between November and April. Normally, I would see hundreds of RSV cases. I only saw a total of two cases of influenza total during the winter, and it was not due to lack of testing. The patients just weren’t there to be tested. With fewer viral respiratory infections circulating among school children, there were much fewer secondary pediatric asthma exacerbations, secondary ear infections or secondary bacterial pneumonias.?

School districts in the Indianapolis metro and surrounding suburbs, employed various back to school plans for the 2020-21 academic year ranging from completely virtual all year, to completely in person all year with masks and social distancing. Most school districts offered some combination of options. Pediatric offices, pediatric EDs and pediatric hospitals in the Indianapolis area had historically low patient volumes for the entire 2020-21 school year. These low numbers were also true in pediatric EDs and pediatric hospitals around the country.

Another common theme among pediatric facilities all over the US since the beginning of the pandemic was a striking mental health crisis among our young patients. Our schools provide many supportive services beyond education for our nation’s children, including counselling, school nursing, medication administration, screening for mental health problems, and reporting of potential child abuse and neglect: these services can only be provided effectively in person. I recall entire 12-hour Pediatric ED shifts where patients with psychiatric complaints greatly outnumbered all others.??We saw innumerable children of all ages with depression, anxiety and suicide ideation/attempts. My observation was that these mental and emotional difficulties were worse and more frequent in kids who were doing virtual learning as opposed to those kids that were able to go back to in person school with masks. Of note, I did not care for a single child who was suffering mental health problems (nor skin problems, nor respiratory problems) due to wearing a mandated mask. The increase in pediatric mental health problems coupled with a long-standing severe shortage of pediatric psychiatry services, inpatient and outpatient, often resulted in all of our local inpatient pediatric psychiatric facilities being full, and these patients being boarded in emergency departments for hours (even days), and some children even being transferred to neighboring states for inpatient treatment.

As schools let out for summer break 2021 and local mask and social distance mandates were lifted, it became clear that children were once again acquiring and spreading many of the usual respiratory illnesses that come along with being around other children. This summer local pediatric EDs have been OVERRUN with winter respiratory viruses, especially RSV, but many other infections. Our daily total patient volumes over the summer have been three to four times higher than during the height of the pandemic in November/December 2020, and even higher than our usual summer volumes. There has also been a gradual but steady increase in pediatric COVID-19 infections since May 2021 (notable even though I am not writing directly about COVID in this article).?EDs, ICUs and inpatient hospital floors are full now and we should all be concerned that even small increases in current patient volumes will overwhelm the capacity of our healthcare system (including pediatric hospitals which are suffering from the same nursing shortages as adult hospitals).

As a mother,?I know that it is best for my children to be in school in person. As a pediatrician, I know that in person school is also best for most children. The difference in my own children’s educational attainment, mental health and overall development between the spring lock-down of 2020 with at home (not) learning, versus the entire 2020-21 school year with in-person and mandatory masks, was quite profoundly in favor of being in school with a mask as dictated by circumstances.

Now, schools are back in session for the 2021-22 academic year. During the COVID pandemic every sniffle, every sore throat, every headache, every cough, has to be sent home from school. Proof of a negative Covid test is required before return to school, unless you can keep the child home for ten days from the onset of symptoms. With many, if not most, kids not wearing masks the droplet burden (in the air and on surfaces) in classrooms will increase and even the masked kids will catch the virus-du-jour. Student absences, especially for elementary students, are going to increase multi-fold over an ordinary year. Without masks, there will be an increase in the number of students at all grade levels who will be required to quarantine when exposed to a COVID positive person. I understand parents’ concerns about “we can’t protect them from every virus“. Absolutely, our children should, and will at some point, be infected with many of the common cold viral infections and will build their immune responses. However, doing that now, in the middle of a pandemic which will cause a large number of school absences and quarantined children (not to mention the resulting parent work absences) and may eventually cause schools to go back to virtual learning which would be unconscionable and more harmful in the long run for our children’s education, mental and emotional health, and overall development. Mandatory masks, especially for elementary school children, is the right answer when we thoughtfully ask the right question.

Mercy Hylton, MD?is a pediatric emergency medicine physician in Indianapolis who finds essay-writing therapeutic. She is the married mother of three children. She is an aspiring physician leader, and the founder of Indiana Physicians Lounge, a virtual gathering place for hundreds of Indiana physicians to socialize and network.