By Tracy Beth Høeg, MD, PhD

Recently an article in the Swedish press by Johan Anderberg asked readers to imagine a scenario:

“We Swedes should play with the thought that it could have been us – that it could have been our kids that had had their schools closed, that it could have been our kids that for multiple quarters were forced to go to school with a mask… over the entire world, little children were forced to wear masks, eat their lunches outside in the cold and forced to take rapid tests.”*

*“Vi svenskar kanske ska leka med tanken på att det här kunde varit vi – att det kunde varit våra barn som fått sina skolor stängda, att det kunde varit våra barn som i flera terminer hade tvingats gå till skolan i munskydd… Över hela världen har små barn tvingats bära munskydd, äta sina skolluncher i kyla utomhus och tvingats genomgå upprepade tester.”

It is thought-provoking for us Americans to see someone from outside the US describe the harms inflicted upon our children during the COVID-19 pandemic.

I added a picture frame to the photo from the article because I imagine one day, in the not-too-distant future, a photo like this will be on display in a museum of Covid-19 mistakes and absurdities. Historians, social scientists, ethicists, film-makers, lawyers, economists, great-grandparents and many others will look back on the pandemic and ask “How was it that Sweden, and to a great extent Denmark and Norway, were able to get it right with children?”

Schools

Sweden never closed primary schools and Denmark and Norway had brief, transient closures; they never masked children under 12 and free childcare was always available. Children always had a safe place to go throughout the pandemic. Disruptions to normalcy were minimized.

I suspect we will learn Scandinavia’s compassionate decisions about child policies during the pandemic had less to do with science than cultural commitment. It was clear early on that children were mildly affected by covid and were not primary drivers of the pandemic. However, when Sweden chose to keep primary schools open and in Denmark and Norway reopened schools in April 2020, it was unclear exactly how well it would go.

Data from the Center for Global Development published June 12, 2020. https://www.cgdev.org/blog/back-school-update-covid-cases-schools-reopen

We then quickly learned from Europe’s experience in the Spring of 2020, “closure or not of schools had little if any impact on the number of laboratory confirmed SARS-CoV-2 cases in school-aged children”, and my own research and others showed this to also be the case in public and private schools in the US.

The below figure shows excess mortality (överdödligheten) in Europe in % by country in 2020 and 2021 with the country that dared never close schools, Sweden (Sverige), ending up near the bottom, above only Norway and Iceland.

The value of a normal childhood

In Scandinavia, the threshold for disrupting normal childhood seemed to be much higher than in the US and Canada.

In Sweden, it’s unconstitutional to close schools. They have a concept is called “skolplikt” where all children have the right to public schooling. The head of the ministry of education, Anna Ekström, referred to this in the Swedish decision to not close schools: not only that all children have a right to go to school but moreover “school plays a very important role in children’s lives.” Denmark had a 6-week closure of primary schools but then famously opened outdoor theme parks, such as Tivoli Gardens, for outdoor classes in April of 2020. A society-wide effort was made to avoid, as much as possible, the pandemic interfering with children’s lives. Something similar could have been done in the United States. Outdoor sports and playgrounds could have remained open all along. In some fashion or another, schools could have re-opened in the Spring of 2020. Even in times of fear and uncertainty, should we not feel an obligation to be creative for our children?

Betrayal of the precautionary principle

Recall: school closures, sports closures, masking, asymptomatic testing, school-based vaccine requirements. While some argued these were precautionary, the precaution was backwards. The harms from missing these events were not given due consideration. I believe the burden of proof should have always been on showing that the benefits of these interventions outweighed the harms. None of the above passed any sort of rigorous or thoughtful risk benefit analysis in the US or elsewhere. The way we viewed public health in children strangely turned upside down during Covid-19; children have always been an ethically protected group. This means they should not be subjected to unnecessary harms without known benefits. But in the US, they inexplicably faced the harshest restrictions of any age group.

The last couple of years, I have been extensively involved in researching school mask mandates. Although ongoing research from Spain, Finland and two studies I was senior author on failed to find benefit of student mask mandates, these mandates continued many places. This is despite the evident harms to communication and connectedness and learning. Many children will now also grow up with a distrust of public health because of being asked to mask for years for no evidence of benefit.

On September 10th, 2021, Denmark dropped all Covid-19 restrictions on society and Norway would soon follow suit. There was an article celebrating a return to normal school life and how important it was for children to thrive and have normal routines.

“It’s no longer about stopping the spread- children should thrive” read the Politiken headline on September 6th, 2021.

Vaccinating children

Scandinavia returned to normal schools without ever require children to be vaccinated to attend. Though a coronapas was temporarily adopted, Scandinavia now has now dropped all societal vaccine requirements. This decision was based on worldwide research that COVID-19 vaccines do not lower transmission risk and, at best, delay infections (by a matter of weeks to months).

The main benefit of vaccination is to reduce risk of severe disease. While the benefit seems clear in the average previously uninfected older adult, the benefits are much less clear in children. In fact, 1) we have no evidence that vaccination will lower the risk of severe disease in previously infected children and, 2)in healthy children without prior infection, the harm of the second vaccination dose from myocarditis alone may outweigh the benefits in healthy children. I want to acknowledge that the risks of myocarditis in younger kids <12 is lower than the risk to boys 12-28, for instance, but it is not zero, and a careful undertaking of risk benefit balance, particularly as kids have high prior immunity, as novel variants become de-coupled from mis-c, has not been undertaken.

Scandinavia more readily adapted policies that matched the evidence. Sweden never recommended mass vaccination of 5–11-year-olds. Norway has said prior infection should be considered equivalent to vaccination in children and always made child vaccination optional. The Director of the Danish National Health Institute (Sundedstyrelsen) in fact stated this June that vaccinating children under 16 was “a mistake.”

It is frustrating that the CDC and American media do not discuss Scandinavia’s differing policies for vaccinating children. Instead we are once again an international outlier in using highly uncertain data to recommend boosters in all children 5 and up and infant and toddler vaccines. This is another example of betrayal of the precautionary principle and there is no public health rationale to stifle discussion around weighing adverse vaccine effects vs benefits in children.

My experience as a dual citizen physician scientist mom

Through my personal lens as a physician epidemiologist extensively involved in researching many of the above topics: school transmission, sports closures, testing, masking of children and risks and benefits of mRNA vaccination in adolescents. With largely reassuring results about covid’s risk to children, or lack of effectiveness of school mitigations, the results of these studies have only been accepted very slowly in public health and academia. Perhaps it is my time living in Denmark that made me so incredulous our American society did not err on the side of allowing normalcy for children in the first place rather than waiting for conclusive evidence that it was okay to stop doing things to them.

It was likely a primitive mother instinct that prompted me to start sounding the alarm on the harm of school closures in the Spring and Summer of 2020. I witnessed Scandinavia successfully reopen their schools and simultaneously saw the way my own children and their friends lost so many things in life they loved including hope and a sense of what would come next. It was my background as a physician and scientist in Denmark that convinced me early on this was not just about the covid response but a much deeper issue in the way that America views and treats children.

My own experience as a young physician mom showed me first-hand the stark differences in the Scandinavian and American societies when it comes to policies around mothers and children. At age 28, I had matched into my first-choice ophthalmology residency program in the US but - 1 week before start - found out I was pregnant. My Danish boyfriend (future husband) had matched (before we had met) at a residency program in another state. I started my dream residency program, but having a child with only 15 days’ maternity leave, without family or help nearby was an incredibly overwhelming prospect. Someone in the program leadership suggested I have an abortion. I simply could not fathom this could be the best solution. I did what, to me, just one year earlier would have been unthinkable: I left the residency position, risking my entire medical career.

I was lucky because it worked out. I ended up moving to Denmark with my husband and was able to quickly start practicing medicine and went on to complete a PhD in epidemiology and public health, while having plenty of time to be a mom!

Mothers in Medicine

I wonder how many women physicians in the US give up their medical careers because of their children. Who are these mothers that never become practicing doctors or never even start training because they know how hard family life would be? I learned by moving to Denmark that medical training doesn’t have to be hard on new moms. You can have a respected career as a physician and scientist and only work around 37 hours a week and have 9+ months of maternity leave, free healthcare, 6 weeks of vacation, many holidays off and get paid to do a PhD on top of that (all you need to do is learn Danish and marry a Dane!). I think because of these options and support, physicians in Scandinavia have a more family- and community-centric way of looking at the world.

Though it may not be immediately obvious, this societal approach to supporting parents is tied to Scandinavia’s decisions about school closures. In most cases, it is in children’s best interest that their parents spend time with them when they are young. Further, remote school would mean a parent needing to stay home, but with around 80% of mothers working in Denmark for example, not having a place for children to go during the day was incompatible with both women’s and children’s rights and the entire Danish society. In the US, families with single or two working parents faced an incredibly tough decision during the pandemic: if their public school was closed and they could not afford an open private school, either a parent would stay home, a grandparent would be put at risk of covid, or the child would be at home alone. It’s not surprising in the US 45% of mothers were not working during the pandemic, which disproportionately affected women of color. Furthermore, children with parents who could not afford to stay home were less likely to be able to attend remote school. In Detroit, where Zoom school dominated for over a year, 70% of kids in public schools were chronically absent. School closures induced harm inequitably and for no clear benefit. The damage done to these children may persist for a generation or longer.

Encouraging scientific debate

Why did this happen? Debate was stifled and decisions were left in the hands of few. Those in charge may have been fearful of getting covid, unfamiliar with how to best manage this type of pandemic and faced political pressure to promote certain policies. Spreading a fearful message may have also resulted in more fame and attention. The entire news narrative was indeed more hopeful in Europe than the US. This was particularly striking to me in Danish news where fear mongering was nearly absent. This may have been a result of diverse voices of various political views being able to contribute to the conversation, while they were silenced in various ways in the US.

Unlike the recent trend in the US, debate is and was encouraged in medicine and the media. Recent debates in Danish newspapers have included pros and cons of vaccinating children for COVID-19 and whether or not the Swedish or Danish approach to managing the pandemic was better. I would love to see debates like these in the New York Times and other mainstream media. In Scandinavia, physicians and scientists don’t risk losing their research funding or jobs for questioning the dominant narrative. Indeed, many American physicians have reached out to me and my friends about feeling forced to express certain opinions they don’t hold.

Physicians as servants of the people

In Scandinavia, physicians are respected but simultaneously are seen as entirely normal (consistent with the Scandinavian concept of janteloven). As a result, medicine is much less patriarchal and public health more a partnership with all society.

Along with this has come an accurate representation of Covid’s risks to children which includes reporting deaths and hospitalizations in children due to covid rather than simply with covid. Risks of long Covid to children have not been needlessly exaggerated.

We have all watched the US become increasingly fearful of disease and reliant on expensive, and, at times harmful, medical and scientific solutions to complex problems. Hyperfocus on the avoidance of disease leaves less time for play, sports, music, art, togetherness and the outdoors, all of which can make childhood healthy if nt magical. Testing, quarantines and masks needlessly interfere with these. People do count on us physicians to not forget what health actually is. One need look no further than children’s physical activity levels during the pandemic to see a striking example of how much of the world has failed. There was, on average, a 20% decrease in physical activity worldwide in children during the pandemic, while there was no such decrease among children in Sweden.

The failed intervention of tying swings together would have been unthinkable in Scandinavia. It is the opposite of hygge or good public health. Photo by @politicalmath

In the end, much of the world unfortunately emulated the US and Canada’s school closure policies and attitudes towards children. As a result, 150 million additional children worldwide are now living in poverty and millions have not yet returned to school after many spent over a year not being allowed to leave their homes. Many more articles and books will be written on this topic: the unhealthy and inequitable actions imposed on children in the name of Health and Equity

It’s not over

California will likely soon be passing a bill into law which will require schools to continue covid testing in children. Estimated to cost $1.5 billion for just the first year, this law will keep children unnecessarily out of school, sports and time with friends for a third year.

Children 12 and older will be required to be fully vaccinated to attend school in Washington DC. Again, with only evidence of a brief possibility of reduction in transmission potential, and such a high rate of previous infection, why the choice for children to be vaccinated will not be an individual one. Some children will needlessly harmed by myocarditis or other side effects and others kept from school for not being vaccinated.

Children will still be required to mask in some districts again despite lack of good evidence of benefit. For some kids, there is no end in sight.

As Dr. Joseph Marine, Johns Hopkins Professor of Medicine, said : “Today I saw in my hospital lobby a woman struggling to put a useless cloth mask on a blind (resisting) 3 year old to comply with a Johns Hopkins mask policy. This policy has no rationale, no good evidence and no endpoint. A moment to be embarrassed for my profession.”

As this pandemic ends, doctors and public health officials should 1) speak out against ongoing policies that harm children more than help them in the ways that they can and 2) admit mistakes were made and be a part of defining what they were.

Norway, for example ,has found in their pandemic investigation that even the relatively brief school closures in their country did more harm than good, citing negative impact on children in terms of “less play, learning, attention and well-being”.

The Norwegian government interviewed children about how they felt about school closures and Live Sæther age 7 said the first day she went back was “probably the best day of [her] life”

If physicians and public health officials in the US remain silent and fail to admit past mistakes, harmful policies will persist or resurface in the next pandemic. Why wouldn’t they, without us defining what went wrong or creating an ethical framework to prevent the same mistakes?

I and other physicians and scientists are working to set an agenda for an investigation. Also, at Urgency of Normal, we are starting both a children’s rights group and a physician’s professional organization focusing on protecting children’s rights and well-being, free from political or special interest group influence. It will also be a place where we physicians see each other as allies, who are allowed, even encouraged, to disagree.

It is not the full answer to the complex problems above, but as Lao Tzu says, “a journey of 1,000 miles begins with a single step” and we owe it to our children to start with them.

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