Reopening Colleges and Universities During the COVID-19 Pandemic
Authors: Mark S. Wrighton, Steven J. Lawrence
Journal: Annals of Internal Medicine (2020)

Editorials2 July 2020Reopening Colleges and Universities During the COVID-19 PandemicFREEMark S. Wrighton, PhD and Steven J. Lawrence, MD, MScMark S. Wrighton, PhDWashington University in St. Louis, St. Louis, Missouri (M.S.W., S.J.L.) and Steven J. Lawrence, MD, MScWashington University in St. Louis, St. Louis, Missouri (M.S.W., S.J.L.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-4752 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Reopening of schools for fall 2020 is a daunting challenge; indeed, zero-risk reopening is not possible. With no effective treatment for victims, no vaccine, and a highly contagious virus, bringing together students in traditional ways would be irresponsible. Plans for risk-mitigated reopening of educational institutions are being developed across America, after many schools abruptly ceased normal operations in spring 2020. Although the paramount concern remains the health of students, faculty, and staff, financial viability of residential schools is threatened by the possible decline in enrollment. America's higher education system has already lost billions of dollars because of the pandemic, and anxiety about safety may result in diminished enrollment and additional financial losses. How can a residential school provide a stimulating, in-person educational experience for students while implementing measures to ensure the health of students, faculty, and staff?Obviously, the entire world is affected by the pandemic, and schools everywhere face adversity. In Taiwan, with a large, diverse higher education system, strong measures to combat coronavirus disease 2019 (COVID-19) have been successful. As of 18 June 2020, Taiwan had a total of only 446 cases of COVID-19, with 434 recoveries, 7 deaths, and 5 patients hospitalized, according to Taiwan's Central Epidemic Command Center. Taiwan's population is about 24 million, and the higher education system has about 1.2 million students, including more than 125 000 from outside Taiwan (1). For Taiwan's higher education system, Cheng and colleagues (1) have presented a plan for reopening colleges and universities. Although there are important differences between Taiwan and other countries, residential colleges and universities function similarly, with students living in residence halls on campus, in-person classes, and campus events involving large crowds. Thus, considering how well Taiwan has managed COVID-19 overall, the plan for safely reopening colleges and universities in Taiwan (1) offers important principles for all.Reopening schools while preserving the health of students, faculty, and staff is the compelling objective. Thus, every institution should implement best practices, including symptom screening; diagnostic testing; contact tracing; isolation of cases and quarantine of contacts; use of masks; and dedensification of living arrangements, classes, and events. Transmission on campus must be swiftly identified and contained. Taiwan has responded to COVID-19 in a timely, effective manner overall, and the Ministry of Education of Taiwan has the authority to set policies and procedures for colleges and universities (1).In the United States, based on the latest data, more than 16 million (2) college students are expected to be enrolled in about 4000 degree-granting institutions in fall 2020 (3). As in Taiwan, the American system is complex and diverse, with world-class, comprehensive research universities, colleges, community colleges, and other higher education institutions. But the United States is larger and even more complex than Taiwan. Further, America does not have a central authority to implement policies and procedures applicable to all institutions. Local, state, and federal governments all play a role in public health policy, with leaders striving to do the best for their constituents. No single entity can mandate the best policies. Further, public and private colleges and universities all have a degree of autonomy that can undermine a set of policies and procedures that should be followed to safely reopen. Indeed, that autonomy should be used wisely to reopen with procedures unique to specific circumstances facing each institution.The United States was slow to respond to the COVID-19 crisis, and there has been no central, aggressively coordinated response. A challenge in achieving a uniform response stems in part from differing views of the balance of preserving public health versus the economy. Also, colleges and universities—perhaps especially private ones—may chart different courses on reopening. Many are facing existential financial problems from lost revenue and the expense of implementing procedures to preserve the health of the community.As of 18 June 2020, the United States already had about 2 million cases of the virus and more than 115 000 deaths (4). According to the Centers for Disease Control and Prevention, about 17% (>330 000) of the cases are among persons aged 18 to 29 years, whereas deaths in this age cohort comprise only about 0.4% (390) of the total. A large fraction of college students, who by nature think of themselves as invincible, fall in this age cohort. However, the staff and faculty serving the students are largely in the age cohort of 40 to 74 years, which has experienced nearly 1 million cases and more than 35 000 deaths. Thus, campus outbreaks represent a real threat to older members of the higher education community. This is but 1 facet of the problem. Dedensification exacerbates financial problems and compromises aspects of what constitutes a rewarding on-campus experience, but dedensification and enforcing rules regarding masks and physical distancing are key strategies to mitigate the risk of reopening. Mass testing to identify asymptomatic cases has recently been proposed as a mitigation tool (5). Although promising, this intervention poses logistic challenges, and its value may be limited by false positives in low-prevalence settings; false negatives eluding detection; and the potential for a negative test result to be considered a "ticket to party," thereby undermining efforts to maximize adherence to proven mitigation measures (6). Efforts to have the lowest-risk reopening will depend on such adherence by all members of an academic community—a community that typically "pushes back" against authority and rules.There is no completely risk-free way to reopen. But reopen we must. For many new high school graduates, attending college has been a long-sought goal. Collins Agyeman, a first-generation college student becoming a freshman at Vanderbilt University in 2020, said it well in the title of his essay: "I worked my whole life to get into college. I can't not go" (7). There is a responsibility to the young to provide the best educational experience possible. As Taiwan and other regions of the world illustrate, mastering COVID-19 is possible, and the close-knit communities of colleges and universities can do it. But prudent reopening will require a degree of attention to detail and conscientiousness never seen in higher education. Not getting it right could have devastating consequences.References1. Cheng S, Wang CJ, Shen AC, et al. How to safely reopen colleges and universities during COVID-19: experiences from Taiwan. Ann Intern Med. 2020;173:638-41. doi:10.7326/M20-2927 LinkGoogle Scholar2. National Center for Education Statistics. Undergraduate enrollment. Updated May 2020. Accessed at https://nces.ed.gov/programs/coe/indicator_cha.asp on 30 June 2020. Google Scholar3. National Center for Education Statistics. Table 105.50. Number of educational institutions, by level and control of institution: selected years, 1980-81 through 2017-18. Accessed at https://nces.ed.gov/programs/digest/d19/tables/dt19_105.50.asp on 30 June 2020. Google Scholar4. Centers for Disease Control and Prevention. United States COVID-19 cases and deaths by state. Accessed at www.cdc.gov/covid-data-tracker/index.html on 30 June 2020. Google Scholar5. Murakami K. Whom to test and how to pay for it. Inside Higher Ed. 22 June 2020. Accessed at www.insidehighered.com/news/2020/06/22/differing-views-states-consider-whether-colleges-should-test-all-students-covid-19 on 30 June 2020. Google Scholar6. Lyu W, Wehby GL. Community use of face masks and COVID-19: evidence from a natural experiment of state mandates in the US. Health Aff (Millwood). 2020:101377hlthaff202000818. [PMID: 32543923] doi:10.1377/hlthaff.2020.00818 CrossrefMedlineGoogle Scholar7. Agyeman C. I worked my whole life to get into college. I can't not go. Chronicle of Higher Education. 18 June 2020. Google Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Mark S. Wrighton, PhD; Steven J. Lawrence, MD, MScAffiliations: Washington University in St. Louis, St. Louis, Missouri (M.S.W., S.J.L.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-4752.Corresponding Author: Mark S. Wrighton, PhD, Washington University in St. Louis, MSC 1020, St. Louis, MO 63130; e-mail, wrighton@wustl.edu.Current Author Addresses: Dr. Wrighton: Washington University in St. Louis, MSC 1020, St. Louis, MO 63130.Dr. Lawrence: Washington University School of Medicine, Box 8051, 4523 Clayton Avenue, St. Louis, MO 63110.This article was published at Annals.org on 2 July 2020. 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