College campuses can't open safely

College campuses can't open safely
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As a physician, I believe in science and rely on evidence. But as a parent, I’ve learned to listen to my gut. My son’s plans to return to college in a “red zone” state leave both my head and my gut at odds. My gut tells me that my son needs to be back in an educational environment that also fosters his social relationships as a young adult. 

To open those educational environments safely, colleges will need to rapidly master the delivery of public health infrastructure and health care at scale. Based on the evidence, I don’t know if they can safely do this in time. 

A recent survey showed that over half of U.S. colleges are planning to open for in-person classes this fall. A third is planning a hybrid model, with only 10 percent planning solely for online-only education. The loss of tuition, athletics, room, and board, coupled with the increased costs associated with COVID-19, leave all schools, even elite schools with large endowments, with a financial conflict of interest in inviting students back to campus.

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With limited guidance from traditionally trusted sources like the CDC, colleges planning to do anything beyond online education need to ensure protocols for public health and health care delivery are in place. It’s unclear that they can do this. Healthcare isn’t their primary mission. Their clients are primarily young, healthier people, which is why many college health services get away with not being able to provide high-quality health care for their students. Only a minority of college health centers are accredited

The problem is that, historically, college campuses don’t handle infectious outbreaks very well, including those with effective vaccines like mumps, measles, and meningitis, for reasons that include delays in recognition, the inability to effectively execute isolation and quarantine protocols, limited cleaning of communal spaces, and the social behaviors of college students. 

COVID-19 presents a steeper challenge than any of these diseases. Colleges are planning widely disparate protocols, with some proposing aggressive screening regardless of symptoms and others planning only to test symptomatic individuals. Frequent, routine testing of everyone on campus, regardless of symptoms, every few days, is critical to preventing COVID-19 infections on campus. Models suggest that with testing every three days, a campus with 5,000 students could see 234 infections in a semester. Testing every seven days would result in 3,662 infections; most of the campus could become infected with the weekly strategy.  

If 25 percent of these young adults develop symptoms of COVID-19, campus health services would need to provide supportive care to 59 - 916 people under these two screening strategies and then would need to successfully triage and transfer the 9 - 146 young adults who may ultimately require hospitalization. That’s more than college campuses are used to, even in the worst flu seasons.

It seems like weekly (or less frequent) testing won’t work. That strategy may result in 4 deaths among the 5000 students in the model scenario. Considering that there are 20 million U.S. college students if even half of them go back to school and college campuses are tested weekly, they’re potentially risking 8,000 deaths. I don’t know how many college parents are willing to sacrifice their children to this risk. While these estimates pale in comparison to the number of deaths that we see daily in the headlines, as a parent who believes the evidence that more frequent testing will prevent infection, the only acceptable number of deaths is 0.

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Early reports - before most campuses have opened for the fall semester — suggest that there are already at least 6,300 COVID-19 infections linked to college campuses. Not surprisingly, several of these outbreaks are related to athletics and Greek life and are concentrated in “red zone” states. Because there is no standard reporting required for COVID-19 infections, hospitalizations, or deaths on campuses, this initial report underestimates what we will see in a few weeks and underscores the need for mandatory, standardized reporting of infections, deaths and infection control protocols.

Moreover, conducting testing, contact tracing, and isolation the right way is going to be expensive. If schools are already COVID cash-strapped, the testing may be prohibitive. Perhaps well-endowed schools can dip into their savings for this. Still, less wealthy institutions, including community colleges and Historically Black Universities and Colleges, may not be able to and, without federal and state resources, this inability will only exacerbate the disproportionate impact the disease has on students of color.

It’s overly optimistic to expect campuses to succeed where we have failed at the city, state, and federal levels. Right now, we need testing to be less expensive and more available for the entire country, but we don’t have it. I don’t see how colleges and universities will be able to do this on their own.

As a country, we need our colleges and universities open, and as a parent, I dream of having my son safely in school. But doing this right is more important than doing this now. 

Campuses that can’t implement regular and frequent testing, contact tracing, isolation, and care for infected individuals should start the semester remotely and then bring people back to campus in October or January. If they don’t, parents would be wise to be wary of colleges and universities that think they can guarantee students' safe experience.

Jennifer Haas is a primary care physician and director of research for the Division of General Internal Medicine at Massachusetts General Hospital, a Professor of Medicine at Harvard Medical School, and a Public Voices Fellow with The OpEd Project.