Michael Siegel of the BU School of Public Health

This guest post is by Professor Michael Siegel of the Boston University School of Public Health. The text was also provided in an open letter to the Dean of SPH.

This is perhaps the most difficult note I have written in my career. It comes out of a deep love for the School of Public Health, a love that has been engendered by 25 years (as of six days ago) of being a part of an institution with a singular mission to use scientific principles and methods to think about public health problems, to teach our students principles to go out and improve the world, and to demonstrate our commitment to public health and social justice by doing – that is, implementing these principles in our own actions and policies as a school.

It is based on a careful analysis of these principles that I have reached the conclusion that led me to convey this message:

It is essential that we rescind the decision to hold in-person/hybrid classes and transition immediately to online-only classes, not merely to protect the health of the community and the public, but to restore our ability to carry out our mission as a school of public health. 

Our decision to hold in-person/hybrid classes was made in late April, long before any reasonable public health institution would commit to such a policy, given that the pandemic was raging at the time and we had no idea of the status of COVID-19 infection in the fall. From the start, we were violating the principles of public health that we teach our students: make decisions based on the facts and only after a careful weighing of potential costs and benefits. The decision was made for financial reasons only.

It is critical to acknowledge that the Learn from Anywhere (LfA) theme was merely a post-hoc justification for a decision that had already been made for financial reasons. The idea was to propagandize the illusion that BU’s primary concern was fashioning an educational system marked by choice: each student could choose the educational mode that serves them best.

However, the reality is that LfA is about anything other than choice. It is about providing separate and unequal education to two groups of students, those who are most advantaged and those who are disadvantaged, under the guise of providing improved pedagogy. But the reality is—and I think I have the expertise to state this based on being a student of didactics and someone who has been recognized for my teaching over the past 25 years—that in the current environment, the hybrid model is far inferior to simply holding online-only classes.

The hybrid approach places the community at serious risk of health harm and offers no pedagogical advantages. I have made some difficult public health decisions over the course of my career, but this one seems simple: option A has no pedagogical advantages and potentially serious public health harms; option B has pedagogical advantages compared to option A and avoids those public health harms. 

This is why our colleagues at both other institutions of public health in Boston decided early on to provide online-only education. Both of those school’s wrote letters to their students explaining that the health of the community must come above other concerns.

Harvard wrote: “What is clear is that the safety of the Harvard Chan School community is paramount, that we cannot ensure a safe return to in-person instruction in a way that would facilitate learning, and that, when the right time comes, we will bring our students and instructors together back on campus in carefully planned phases. Our students—U.S. and international—must be able to continue their education without fear for their health, and many have expressed wanting to avoid unsafe travel and the need to care for family members. Our actions cannot worsen the public health crisis.”

Tufts wrote“The School of Medicine has determined that all MPH coursework offered in fall 2020 will be delivered remotely. This decision was made after extensive research and consideration of many different options. As a program which requires no on-campus clinical training, the MPH program has the ability to take advantage of remote delivery without compromising course quality. By moving to remote instruction, we hope to provide you with the flexibility to decide when and how to relocate to Boston without compromising your health or your budgets. Since we are located in the heart of an urban center, this decision also allows for more effective social distancing and will contribute to city-wide efforts to mitigate the effects of COVID-19 and to protecting the health of the Tufts community.”

To be clear, at BU, it was financial concerns that over-rode public health considerations. Our letter was not: “We are going to protect the health of our community.” Instead, it was: “Look – we’re still offering in-person classes next fall. So there’s no need for you to take a year off or to enroll at a different school.”

Along the way to that decision, a number of basic public health principles were violated:

1. In public health, we don’t provide protection only to the least vulnerable.

One of the principles of public health practice is that when we develop policies to protect the population (whether it be a state, city, school, etc.) from recognized health hazards, we do not just protect the people who are least vulnerable to the hazard. We protect the entire population, including and especially those who are most vulnerable to the hazard.

Unfortunately, this is precisely the opposite of what BUSPH is doing in response to the COVID-19 pandemic. The School is basically saying: “We are going to protect only the members of our community who are not especially vulnerable to this infection. They will be able to attend classes in person. But the members of the community who are especially vulnerable to this infection can choose to attend classes online.” This is, in fact, precisely what we are doing. Let each person decide based on how vulnerable they are.

Make no mistake about it. LfA is not about giving students the choice to pick the educational mode that serves them best. At its root, it is about separating out students who are more vulnerable to respiratory disease and more anxious about it and those who are less vulnerable and less anxious.

This is not public health! In public health, we either offer a safe working and learning environment for our community, or we don’t. And if we can’t offer it, then we don’t offer it to some and not to others. In particular, we do not offer a safe working environment to the less vulnerable and force the vulnerable out of the workplace/classroom. 

2. In public health, we don’t provide separate and unequal services for different groups, especially in a way that is disproportionately associated with race. We don’t implement racist policies.

It’s unfortunate for us not to appreciate that many students have medical conditions, are taking care of vulnerable family members, or can’t afford to avoid public transportation options that would put them at risk. These students don’t really have a choice to learn from “anywhere.” So instead, we are providing them with separate and unequal services, depriving them of the opportunity to interact in person with their professors, for example. 

How is this different from deciding that because of severe financial problems, we will not be able to fix the elevator in Talbot, so we are implemented a Learn from Anywhere approach for Talbot classes? Students can choose the option that best meets their educational needs. If you are advantaged enough to be able to walk up the stairs, then you are welcome to join us in person. If you are disabled, then don’t worry – there is still the online option for you.

This policy is inherently discriminatory. And because we know that students of color are more likely to have all three of the above concerns (medical conditions such as diabetes, high blood pressure, asthma, and sickle cell anemia), vulnerable family members they need to take care of, and fewer financial resources), this now becomes a racist policy.

Implementing a Learn from Anywhere system of education this fall will disproportionately endanger the lives of Black and Brown people in our community — both the BU community and the larger South End community. As a school of public health, we should be doing everything we can to minimize the burden of COVID-19 in the South End and Roxbury communities with which we share our neighborhood. In the last two weeks, there were 691 cases in Boston, an increase from the prior two-week period. However, instead of doing our part by not bringing hundreds of students onto campus, we insisted on doing so, based on a decision that we forced upon ourselves way back in April.

Instead of speaking out throughout the summer to urge other colleges and universities to hold online classes instead of returning hundreds of thousands of college students back to campus, we remained silent because our hands were tied: we had already committed to bringing our own students back. 

In doing so, we required maintenance staff – also disproportionately employees of color – to put themselves in harm’s way by doing the meticulous, time-consuming, and exhausting cleaning work to make it possible for our students to attend classes in person. 

And finally, we implemented a racially discriminatory hiring policy for teaching assistants by which in order to be hired, you needed to be able to go into the classroom all semester, something that is not possible for those who are more vulnerable to the effects of COVID-19 (i.e., BIPOC). 

We can do all the self-reflection and self-learning that we want, but if we remain silent while the School implements a racist policy that threatens the health of neighborhoods made up predominantly of people of color, what good is that self-reflection doing? If the School mandates diversity and inclusion training on the one hand, but on the other hand, implements a racist policy that disproportionately disadvantages people of color, what good is that training doing?

“So basically what the school is saying through this policy – not intentionally obviously – but what we’re saying is that having racial justice in our classroom is not worth paying $250,000 for, that’s what they’re saying, they’re putting a price tag on racial justice so it makes us hypocritical right because on the one hand we’re going out there and saying, “Hey, this is a school that prides itself on social justice. This is what we do. This is our theme. This is what makes us special. This is what makes us different from other schools.” Except if it costs us more than $250,000. Then forget about that, we forget the racial justice, never mind. Right. That’s essentially what we’re saying.” (excerpt from my talk to the Academic Public Health Volunteer Corps)

3. We don’t put financial interests above health

Given the decision that the School of Public Health made back in April to hold in-person classes using a hybrid format, the safety and health of the full community is clearly not the priority. Nor is the priority to provide a safe and healthy work environment for all BU faculty, staff, and students.

Were that the case, the School would have either: (1) waited until later in the summer when it had a clearer idea what the situation would be in the fall to make any decision; or (2) followed the lead of both Tufts and Harvard’s MPH programs which announced in June that they would be online-only in order to most effectively protect the health of their entire communities.

I would respect the decision a lot more if we were simply honest with ourselves and admitted that it was made for financial reasons. But deceiving ourselves into thinking that this was first and foremost a public health decision is a disservice to our entire community. And it teaches just the wrong lesson to our incoming students.

The reality is that we made a decision to place our finances above the health of the community. In doing so, it undermined the basis for our credibility in encouraging others to take actions that promote public health. In almost every public health issue, it comes down to a trade-off between financial concerns and health concerns. How can we as a School or members of this School community now go out into the field and tell other institutions that they have to place health above financial concerns when we ourselves have done the opposite?

The bottom line is that the decision to hold in-person classes this fall not only undermines public health principles, but it also takes us far from our mission as a School and makes it impossible to have credibility when trying to carry out this mission.

4. We don’t make decisions without knowing the facts

Public health decisions should be evidence-based. That is, they should be based on the best available scientific evidence. It also seems to me that public health experts agree that decisions regarding the opening of facilities during the pandemic should not be made based on the idea of setting a fixed schedule in advance, but should instead be real-time decisions that are made separately for each phase of opening at the appropriate time and based on actual parameters of the spread of disease, rate of change in new cases, trends in percentage of positive test results, hospital and ICU capacity, and so on. 

However, the School of Public Health made a decision last April to commit to having in-person classes this fall. I view this to be an irresponsible decision because we did not have the necessary evidence available to be able to make such a decision. At the time the decision was made, we had no idea how widespread the pandemic would be in September and no idea what any of the actual parameters would be. Without that information, how could we commit ourselves to holding in-person classes?

As soon as the marketing for the School of Public Health’s new Learn from Anywhere (LfA) system came out, it was already apparent to me that this was simply a post-hoc justification for a decision that had already been made.

The decision to offer hybrid classes, made before even considering the implications and ramifications (including the cost and use of resources) of implementing in-person classes this fall, was clearly made first, with the LfA propaganda coming second in an attempt to justify what was obviously a premature and irresponsible public health decision.

5. We don’t sacrifice our public health mission.

In the midst of the COVID-19 pandemic, the primary mission of the School of Public Health (SPH) should be to try to minimize the morbidity and mortality from this disease. However, the decision to hold hybrid (“learn from anywhere”) classes this fall does exactly the opposite. 

Of the choices available to the School (which were only two: hybrid or online-only), this choice maximizes the potential exposure of the SPH community. But it goes far beyond that. It also maximizes the potential exposure of everyone we come in close contact with, including our families, friends, and the general public. Given the tremendous toll that COVID-19 has already taken (more than 180,000 deaths in less than six months) and the extremely high level of risk that there will be a second surge of cases this fall, it is unconscionable that we would choose the option that maximizes the potential impact on morbidity and mortality in both the SPH and the overall community.

It is for this reason that I believe this decision forsakes the School’s primary mission, which is to save lives. Right now, the single most important thing we can do as a School to save lives is to minimize exposure to the virus to the greatest extent possible. With respect to exposure in the classroom, the only option that is consistent with the School’s mission would have been to move to online-only classes for the fall semester. 

Sacrificing your mission is substantial, so to what did we make this sacrifice? 

The answer is quite simple: money.

The only benefit of announcing back in the late spring that we were going to have hybrid classes this fall was a financial one. There was a concern that if admitted students believed that we were going to have online classes, many of them would have deferred their admission or chosen to attend a different school. It was the potential loss of these tuition dollars that the School’s mission was weighed against. And the decision came down clearly on the side of our financial interests, rather than on the side of being true to our mission and protecting the public’s health.

There is a second way in which the decision essentially forced us to abandon our mission. Because we had committed to opening our classrooms in September, we could not be a credible voice warning about schools opening up too soon in the fall. How could we be taken seriously if we emphasized the importance of delaying the decision to reopen schools until certain parameters were met when we had already committed to opening our own classrooms?

Where is the School of Public Health in countering the president’s message that schools must open, unconditionally, in the fall? We were nowhere to be seen because our own premature decision to open our classrooms forced us to abdicate our public health mission.

6. We don’t force people to put their health at risk.

A core principle of public health is that we create conditions under which people have the agency to make their own informed and voluntary decisions about what substantial health risks to take. While we certainly provided that option to students, we did not provide it to faculty members and certain staff, including maintenance workers and teaching assistants. Teaching assistants who indicated that they did not want to take the risk of exposing themselves to a potentially serious or even deadly infection were told that they were not eligible for the position.

7. We don’t make the absence of health conditions a prerequisite for employment.

This stems from #6 above. Teaching assistants who indicated that they did not want to take the risk of exposing themselves to a potentially serious or even deadly infection were told that they were not eligible for the position. Essentially, this means that teaching assistants with medical conditions that put them at high risk of COVID complications were systematically excluded from employment as TA’s this semester.

Conclusion

Fortunately, there is an easy way to correct all of the above. There is still time to announce a transition to virtual classes at SPH.

(For more detailed commentaries on many of the above issues, please feel free to go to my blog, entitled “Sacrificing Our Principles: Public Health and Social Justice Give Way to Money and Marketing.”)

BU’s Mask Policy is Inadequate

This is a guest post by Professor Nathan Phillips, Department of Earth and Environment, Boston University.

In light of national and Massachusetts trends in COVID cases, the wisdom of re-opening BU in three weeks is becoming increasingly questionable. But if BU is going to re-open this fall, among all the safety measures it is taking, it needs to address a big safety gap in its present approach: its mask policy.

To cut to the chase, BU should make a bulk purchase of properly-vetted KN95 masks for the university community, as a key part of a prudent strategy to reduce risk of airborne transmission. Institutionally-vetted KN95 masks are preferable to N95 masks for BU because of a shortage of N95 masks that is due to the need to prioritize the requirements of front-line healthcare workers and first responders.

Our current policy is inadequate because it takes a collective action problem, and views it simply as an individual matter. Choices regarding masks matter for indoor airborne transmission, and leaving this type of decision to tens of thousands of individuals will lead to highly uneven individual choices that will have bad effects on the whole community. Currently, for example, the use of bandanas would be allowed. Bandanas are effective at preventing ballistic transmission, but poor at blocking viral aerosols. Even those who might choose a KN95 mask could easily buy a faulty one by mistake, as this recent report makes clear. BU needs a community-level solution to a community-level problem. Masks must be considered not just PPE, but Community Protective Equipment, and part and parcel of the university’s ventilation strategy.

I appreciate that BU has begun to address concerns about building ventilation in light of mounting evidence of the potential for airborne COVID transmission. While this is laudable, these steps, which include increasing air exchange rates and installing HVAC filters, are missing both the very first and the last lines of ventilation defense: masks. Properly fitted and filtered masks inhibit aerosol transmission both at the source, and at the end point of potential infection. If we are investing time and expense in retrofitting rooms with improved HVAC filters, we should also be considering the quality of facial filters.

A recent Harvard-Illinois IT study of COVID transmission on the Diamond Princess Cruise Ship found that, despite good ventilation on this ship, airborne transmission was a likely major route of transmission. A NY Times review of this study states:

But good ventilation is not enough; the Diamond Princess was well ventilated and the air did not recirculate, the researchers noted. So wearing good-quality masks — standard surgical masks, or cloth masks with multiple layers rather than just one — will most likely be needed as well, even in well-ventilated spaces where people are keeping their distance.”

To be sure, the science is not settled and the cited study, a preprint, is one study, but the physical mechanisms posited as being involved make for a highly plausible causal account, and with the health and welfare of tens of thousands of people at BU on the line, as well as the lives of hundreds of thousands of people across greater Boston at risk, use of the precautionary principle is strongly warranted. If a bulk order can procure vetted KN95 at $2/mask, this is well worth an $80,000 university investment in community safety (supposing we need masks for 40,000 people). While there are risks with extended use of respirators like N95, they have been recommended for re-use under conditions of scarcity.  Compliance and enforcement is an important related issue, but due diligence would mean providing at least one properly-vetted KN95 mask to every member of the university community.  

The mask I wear affects you; the mask you wear affects me; the masks we all wear potentially affect everyone in the BU community. We need a community-level solution to this problem.

BU Today and BU Tomorrow

This is a guest post by Jonathan R. Zatlin, Associate Professor of History at Boston University.

A few weeks ago, in the midst of thinking about our future at BU, I invited BU Today to report on a letter to university leaders by the History Department, which you can find here. The letter asked the university president and provost, as well as the dean of CAS to rethink their approach to reopening the campus, and allow instructors at BU the same freedom as our students: the freedom to choose to teach in person or remotely based on each instructor’s own personal situation. To our surprise, we received answers from all three administrators, first from Dean Sclaroff, and then from President Brown and Provost Morrison. As far as I know, these two letters from the upper administration are unique; they have not responded to other letters or petitions from faculty or graduate students. I suspect there are several reasons that we received responses, all of which have to do with aspects of our letter.

Whatever those reasons, we were encouraged that our concerns were officially acknowledged. Given the administration’s reticence to discuss LfA and its perceived shortcomings, I thought it would be useful for the larger BU community to read our letter and the responses to it. To help apprise our colleagues and students, I invited BU Today to report on the letters and what they mean for BU tomorrow. I turned to BU Today because, according to their website, they are a source for “university news” and include “safety” as one of their reporting areas. I recognize, of course, that BU Today is more newsletter than news organization. Any news that conflicts with its mission to enhance BU’s reputation will present a serious challenge to its reporters. That said, I hoped that BU Today’s willingness to print an op-ed by graduate student Emily Chua represented a readiness to report on the actual news: what reopening BU’s campus will actually mean for teachers, students, and staff. One part of that story that needed reporting, I thought, was that History faculty wanted the same choice as is being granted students and the reasons that administrators continue to choose to deny us that choice. 

What I didn’t expect was BU Today’s response. The editor, John O’Rourke, rejected my suggestion that BU Today report on the letters. Worse, he responded by offering a non-solution that is at once telling as it is insulting: “If you wanted to post the letter with a short intro as a comment to the POV that we ran written by Emily Chua, we’d be happy to post the letter in the Comments section of the story.” The story by Emily Chua was published on July 9, and this suggestion was provided on July 20. I wrote, in response, “Placing our letter in the comments section… strikes me as problematic. I’m sure you didn’t intend to suggest it, but your offer … makes me worry that our concerns will simply be swept under the rug, tucked away in comments well after the publication of a different piece. I’d prefer that BU Today report directly on them.” Needless to say, O’Rourke did not take me up on this suggestion. I guess the helpful thing about O’Rourke’s response is that it clarifies BU Today’s institutional position for us: despite sometimes trying to present itself as a journalistic venture, BU Today is not a newspaper, newsletter, or even a newsfeed, for it doesn’t deal in news. Instead, it’s a public relations enterprise, and, as such, it uncritically reflects the views of the BU administration. 

See also these earlier posts on BU Today: On the Response to my Open Letter, An Open Letter to the Editor of BU Today, and Where are you BU Today?

Ventilation Issues and BU Classrooms

This is a guest post by Dr Sarabeth Buckley, a postdoctoral research fellow at Cambridge University. She recently received a PhD from BU’s Earth and Environment Department, where her research focused on ventilation and rooftop gardens.

Towards the beginning of the whole pandemic in early February, there was a story that came out of Hong Kong that was particularly frightening. In a large apartment building, one person on one floor initially tested positive for Covid-19. The virus was still primarily circulating in China at the time. What was scary was that someone ten floors away also then tested positive and that although they did not know each other and had not had any contact, their apartments did share some pipes and there was a leak in the second apartment. This was a very early indication that Covid-19 might be airborne.

WHO denied this, saying that the evidence overall suggested Covid-19 was not airborne. It took five whole months for this article, citing this paper to come out. The article says coronavirus is, in fact, airborne. We all need to take this fact seriously. When anyone coughs they release water droplets of different sizes. Some of these are large and they will fall right to the ground. Others are very tiny, around five μm, which is too tiny to see. Droplets of this size can travel tens of meters away from the person who exhaled them, which is a much longer distance than the length of a normal room, and definitely longer than the length of many of our small BU classrooms. Scientists had hoped that Covid-19 viral particles would not be able to survive in these tiny droplets and might only survive in the bigger droplets that people expel directly, next to themselves. If this had turned out to be the case, it would be enough to just stay out of spitting range of people while sitting inside.

The article states that Covid-19 can survive in these tiny droplets for three hours, which is longer than any of the classes I ever took at BU. This means that if you are in a room where someone who is infected with Covid-19 has been, even if you are on the other side of a large room, you could still catch the virus by breathing in air that someone, perhaps in an earlier class, breathed out a good couple of hours ago. I think about all the classes I took at BU and the little rows of desks a foot or two away. Even if half or more of those desks are removed and the ten people left coming to in-person classes all sit awkwardly, far apart, one person being infected means some portion of the air in the class is going to contain viral particles.

Before the July 4 article, the WHO’s official statement was still that the virus was only airborne in hospitals after medical procedures. It took 239 scientists in 32 countries writing an open letter, explaining the way in which Covid-19 is airborne, for this discovery to be taken seriously. 

Masks certainly help, but they can’t prevent you from breathing in particles. They’re not sealed. When you breathe in while wearing a mask, you can feel the slightly cooler air rushing in through the little areas on the sides of your nose where the mask isn’t quite flush with your skin, and this air hasn’t gone through the cloth. What masks do help with is preventing your own water droplets from being sent off to mingle in the air. Therefore, if everyone wears a mask the entire time they are around other people, then, hypothetically, all of the viral particles infected people breathe out should be caught on the inside of the mask fabric and stop their journey there.

There are a few other things that can be done. Classrooms can be cleaned very frequently with cleaning implements like ultraviolet lights, for example. But one of the most important things that can be done is ensuring that rooms have good ventilation. If potentially contaminated air is being continuously pulled out, recycled air is heavily filtered, and new fresh air without Covid-19 is pushed in at a fast enough rate, this should help get rid of the viral particles twirling about above our heads, threatening to infect us.

This is basically about trying to create a situation reminiscent of an outdoor environment, where the air is moving around so much that it fairly quickly whisks away any viral particles just hanging about (unless you are within direct firing range). This is where some of my work comes in. The recommended ventilation level for removing Covid-19 particles is thirty cubic feet per minute per person (Allen and Macomber, 2020), but how do you know what the current ventilation rate is?

A primary method for testing what ventilation rates actually are is measuring CO2 concentrations in rooms with multiple people in them. This is because, as everyone knows, people are constantly breathing out large amounts of CO2 that build up in confined spaces like classrooms; the more people, the more CO2 builds up. If CO2 concentrations get too high, this indicates that ventilation is not sufficient. Governing bodies set limits for CO2 concentrations in rooms. Generally these are:

5000 ppm – Upper limit of what should ever be found (ACGIH, 1999; OSHA, 1997)

1000 ppm – Suggested limit for classrooms, in particular (ASHRAE, 1989)

800 ppm – Suggested limit in Massachusetts (MADPH, 2020)

As part of my PhD research, I took CO2 measurements in BU classrooms to understand how well ventilation there is working. You can see for yourself how well some of the rooms in the College of Arts and Sciences building did on this test.

Macintosh HD:Users:Sarabeth:Desktop:MY DOCUMENTS:Personal:Activism:Covid19:BU:CAS Classroom CO2.png


Each color is CO2 measurements taken in a different classroom over the course of a week. They obviously go far above the 800 and 1000 ppm limits.

From one perspective, CO2 can affect how well you perform mentally, meaning high concentrations can make you a bit slow and sleepy, and you have probably experienced this first hand. High concentrations are also known to be associated with other pollutants, such as particulate matter, sulfur dioxide, or, as is critical in this case, biological contaminants. This is usually referred to as Sick Building Syndrome, but in the present context, you might as well just call it Covid-19.

What I found was a sign that current ventilation, at least in CAS classrooms, is far from efficient enough to deal with even normal contaminants, let alone something as contagious and virulent as Covid-19. This is good and bad. It means BU is not ready for normal classes at this point, but it highlights a clear step BU must take in order to make the campus safe in the fall. At this point, BU has said they will be doing “a comprehensive review of all HVAC systems, upgrading filters as needed.” This must include increasing ventilation rates and actively monitoring CO2 concentrations in these rooms, in order to keep tabs on whether or not ventilation is actually functioning at a high enough level. There are even third parties who BU could hire to help them test building ventilation and set up a system that will keep everyone safe. They just need to make this a priority and let us know what their plan is.

– ACGIH (American Conference of Governmental Industrial Hygienists). (2011). TLVs and BEIs. Cincinnati, OH: American Conference of Governmental Industrial Hygienists.
– Allen J. and J. Macomber. Healthy Building: How Indoor Spaces Drive Performance and Productivity. Cambridge, Massachusetts: Harvard University Press, 2020.
– ASHRAE. 1989. Ventilation for Acceptable Indoor Air Quality. American Society of Heating, Refrigeration and Air Conditioning Engineers. ANSI/ASHRAE 62-1989.
– MA EOHHS (Massachusetts Executive Office of Health and Human Services). (May 8th 2020). Massachusetts Environmental Public Health Tracking: Ventilation. https://matracking.ehs.state.ma.us/Environmental-Data/indoor-air-quality/ventilation.html
– OSHA. 1997. Limits for Air Contaminants. Occupational Safety and Health Administration. Code of Federal Regulations. 29 C.F.R 1910.1000 Table Z-1-A.

Healthy people as young as 45 at greater risk from Covid-19 than people deemed “at increased risk” by the CDC

This is a guest post by Michael Otsuka, Professor of Philosophy at the London School of Economics

A study just published in Nature reveals the following: even for someone with no underlying health conditions, the increased risk associated with being 45 years of age, rather than 30, is greater than the increased risk associated with various health conditions the CDC deems sufficient to render a person “of any age” at “increased risk of severe illness from COVID-19”.

I. Quantifying the risks the CDC recognises

According to the CDC:

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html

The aforementioned study in Nature — which is entitled “OpenSAFELY: factors associated with COVID-19 death in 17 million patients” — quantifies the risks associated with the above health conditions. It indicates that, when one adjusts to control for age, gender, level of income deprivation, and other health conditions, the CDC-listed conditions are associated with increases in one’s risk of death from Covid-19 by the following factors (see righthand column of Table 2 on p. 10):

  • Those who have kidney disease (GFR <30) are at 2.52 times greater risk of death than those without kidney disease
  • Those who have COPD are at 1.63 times greater risk of death than those without respiratory diseases
  • Those who have an organ transplant are at 3.55 times the risk of those without a transplant
  • Those who are obese (BMI of 30 or above) are at 1.05-1.92 times greater risk of death than those who are not obese
  • Those who have chronic heart disease are at 1.17 times greater risk of death than those without heart disease
  • Those who have Asplenia, including sickle cell disease, are at 1.34 times greater risk of death than those without this condition
  • Those who have uncontrolled diabetes are at 1.95 times greater risk of death than those without diabetes

Whatever one’s age — and therefore even if one is as young as 30 years old — having any of the above conditions is sufficient for classification as “at increased risk of severe illness from COVID-19”. The increased risks associated with these conditions range from 1.05 to 3.55 times the risks to those who lack these, as well as any other, health conditions.

Table 2 also indicates the following strikingly dramatically increasing risks associated with advancing age, even among those who are “healthy” insofar as they lack all of the above, as well as any other, health conditions. Compared with a healthy 30 year old:

  • a healthy 45 year old is at 5.00 times greater risk of death
  • a healthy 55 year old is at 16.67 times greater risk of death
  • a healthy 65 year old is at 40.00 times greater risk of death
  • a healthy 75 year old is at 101.33 times greater risk of death

II. Why are those who are older at such increasing risk?

The “OpenSAFELY” study does not address this question. Elsewhere, the hypothesis that Covid-19 involves impairment of the immune system has been offered as an explanation for why increasing age appears to be such a great risk factor:

Many T cells apparently die, and so the body’s reserves are depleted — particularly in those over age 40, in whom the thymus gland, the organ that generates new T cells, has become less efficient.

…The new research may help answer another pressing question: Why is it so rare for a child to get sick from the coronavirus?

Children have highly active thymus glands, the source of new T cells. That may allow them to stay ahead of the virus, making new T cells faster than the virus can destroy them. In older adults, [as mentioned above] the thymus does not function as well.

III. CDC has removed its age 65 threshold for increased Covid risk

In light of findings such as those reported in Nature, it is unsurprising that the CDC has recently “removed the specific age threshold” of 65 which it once affirmed. “CDC now warns that among adults, risk increases steadily as you age, and it’s not just those over the age of 65 who are at increased risk for severe illness” from Covid-19 infection. The CDC also maintains that “Age is an independent risk factor for severe illness, but risk in older adults is also in part related to the increased likelihood that older adults also have underlying medical conditions” (my emphasis added). Sensibly, and in line with the findings of the “OpenSAFELY” study, the CDC now says the following about “Older Adults” under the general heading of “People Who Are at Increased Risk for Severe Illness”:

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html

The data simply does not support an age threshold of 65. As I have shown in Section I above, even those who are 45 years old and healthy are at greater risk than 30 year olds whom the CDC classifies as “at increased risk of severe illness from COVID-19” because of underlying health conditions. If any employer attempts to adhere to the now-discarded age threshold of 65, there will be a glaring lack of consistency and parity in the protections it extends to their workers who are at higher risk.