Voices: Containing Coronavirus?

By Charlotte West    //    Volume 28,  Number 4   //    July/August 2020
AGB Trusteeship Magazine: July/August 2020 with cover article "Reopening Amid a Pandemic"

“There’s nothing like being an epidemiologist in the middle of a pandemic.”

Trusteeship interviewed world-renowned epidemiologist Larry Brilliant about what trustees, college presidents, and other higher education leaders should know about reopening college campuses amid the novel coronavirus pandemic.

Larry Brilliant, MD, MPH
Founder and CEO of Pandefense Advisory, epidemiologist, and philanthropist

Larry Brilliant is a physician and epidemiologist, CEO of Pan-defense Advisory, and Chair of the Advisory Board of the NGO Ending Pandemics. He is also a senior advisor to Jeff Skoll and serves on the board of the Skoll Foundation. Brilliant was previously the president and CEO of the Skoll Global Threats Fund, vice president of Google, and the founding executive director of Google.org. He also co-founded the Seva Foundation, an NGO whose programs have given back sight to more than five million blind people in two dozen countries. In addition, he co-founded The Well, a progenitor of today’s social media platforms. Earlier in his career, Brilliant was an associate professor of epidemiology and international health planning at the University of Michigan. Brilliant lived in India for nearly a decade where he was a key member of the successful WHO Smallpox Eradication Programme for SE Asia as well as the WHO Polio Eradication Programme. More recently, he was chairman of the National Biosurveillance Advisory Committee, which was created by a presidential directive of President George W. Bush. He was a member of the World Economic Forum’s Agenda Council on Catastrophic Risk and a “First Responder” for CDC’s bioterrorism response effort. Recent awards include the TED Prize, Time magazine’s 100 Most Influential People, “International Public Health Hero,” and four honorary doctorates. He has lectured at Oxford, Harvard, Berkeley, and many other colleges, spoken at the Royal Society, the Pentagon, NIH, the United Nations, and some of the largest companies and nonprofits all over the world. Brilliant has worked on numerous films as a writer, producer and consultant including Contagion, Unseen Enemies, the award-winning HBO film Open Your Eyes, and the Grammy-nominated film about polio, The Final Inch. He has written for Forbes, the Wall Street Journal, the Guardian, and other magazines and peer-reviewed journals and was part of the Global Business Network where he learned scenario planning. Brilliant is the author of Sometimes Brilliant, a memoir about working to eradicate smallpox, and a guide to managing vaccination programs entitled The Management of Smallpox Eradication.

What are the things that colleges and universities should be thinking about as they start to roll out plans for the fall?

I have a good friend who is the chairman of the Department of Epidemiology at the University of California Berkeley; he has been working on his reopening committee. I have been really interested with how thoroughly, thoughtfully, and agonizingly, they’ve been dealing with it. I guess the first thing I would say is: if you are a university, and you have a school of public health and you have an epidemiology department, use them. If you’re a college, and you have a relationship with a medical school or school of public health, use them. Put together your team, including the people who both know you and know epidemiology. Sometimes it’s easier to find somebody who knows your particular university than it is to find somebody who knows the COVID-19 virus. The best you can find is that one person knows both of those things.

I was recently at the University of Michigan in December as my last trip before everything closed down, I got an honorary degree. So, I spent a lot of time with all the regents at their graduation. At a big university, regents are elected for a lot of things and epidemiology is probably not one of them. So use the experts that you already have: the school of public health, the medical school, and your alumni who may be epidemiologists because otherwise you’re going to end up talking to politicians who may not be as helpful.

I have a consulting group called Pandefense Advisory. We have worked with a lot of universities, even some private grade schools and public school systems. This is really a difficult moment. Because if you look at the epidemic curve, we’re really in the worst moment we could be. Because we’re guilty of premature celebration. It’s not the second peak that I worry about so much as why hasn’t the first peak gone down to closer to normal. We’re in June—it’s 10 days away from officially being summer [at the time of this interview]. If we were going to see an effect from the heat, and the sun and the outdoors of summer, we would have seen it already, but we’re seeing the opposite. We’re seeing “wavelets” in exactly those states that opened up in April, that were kind of stubborn about hoping that they could put this pandemic in the rear-view mirror and get on with life. God knows we all feel a great deal of sympathy for thinking that. I’m going to hope I’m wrong.

Do the number of COVID cases or hospitalizations in a particular locale have an impact on the health and safety measures campuses should have?

When I look at the fall, when school should be reopening, I see a possibility of there being a lot of disease. I would say the ambient viral load—that is the incidence of coronavirus infections or hospitalizations around your campus—is the single most important factor in determining whether your campus can possibly be safe. Let’s say that your faculty are going to be spending eight hours a day on campus, they’re going to be spending 14 hours a day home in that area where the high case count is. The visitors who come to your campus, they’re going to be spending the time they’re not on your campus back in that area. Maybe they’ll go into town for lunch or dinner, or come for an event. Events are, in a way, the gasoline poured on the fire of a pandemic. These events are what create the biggest explosions of disease. Of course, by events I mean graduation, homecoming, parents dropping kids off the first day of school, and football weekends. If you’re talking about colleges, all of those things, every one of them, is peril. We haven’t even talked about fraternities and sororities…heaven help us.

Here’s what’s important to ask. First, what will be the status of the pandemic in the world and in the country and then in your state? Second, and far more important, if you draw a radius around your campus, what direction is the epidemic going there? You’re going to be importing that rate into your campus activities. And then third: Can you open up your campus for the minimum amount of in-person activity, so that you can create a kind of a campus experience while offloading the majority of the things you want to do pedagogically, to online and canceling those things which are obviously of the highest risk?

What aspects of campus life represent the greatest risks for transmission?

Let’s start with which parts of campus life reduce risk. Because if somebody is coming just to your campus, from a country that has a higher rate of COVID than you do, or if they’re coming from a family or a home, in a community there’s a higher rate, they’re coming might bring that higher rate to your campus, but the making up of your campus with people like that will be reducing their risk. Always think about this. Let’s take a campus that’s got 10,000 students. Those students are going to come from 50 or 100 countries. They’re going to come from 20 to 30 states. You’re going to be importing the epidemic risk of all those states and all those countries. And then later when the students go back, we’re going to be exporting the risk you have to all those places.

Campus life is an accelerator. Unless you do the things that reduce that acceleration, then you are part of the problem, not part of the solution. Now, we all want campuses to work. We know that the cultural, educational, especially at this time dealing with racism and forces that are pulling us apart, the kind of healing aspects of campuses, the community building parts of campuses, experiential basis is critically important to us.

But nonetheless, if you don’t take a line-item-by-line-item analysis of what are the risks that you’re exacerbating, you’re probably going to miss something. We just finished doing some serious computer modeling for the Directors Guild in Hollywood. We’re trying to decide if they can go out and make movies again. And the key is testing. The ambient viral mode is the most important factor, but it’s outside of your control. Testing is inside of your control. Nobody [should] come onto the campus in the beginning of the year, unless they’re tested for the virus, at least 48 hours before school begins. If they’re traveling from someplace, maybe they’re tested once before they leave the place they’re leaving to come to campus, and once again when they get on campus. If you do that, you will weed out the 3 percent, 4 percent, or 5 percent of people who are coming to your campus who are sick and don’t know it, and will be transmitting the disease. Then you have to isolate and quarantine them.

If you’re going to be open for business, with all the work that your president has, all the work that your faculty have, you’re going to have to add a new job, which is campus pandemic safety officer. And you’re going to have to figure out how to use testing, which tests, how fast you can get them done, how expensive they are, what can you afford.

Availability of testing was a huge issue in many places across the country, especially at the beginning of the pandemic. Is there enough testing capability now that this would be a feasible solution for institutions to implement?

This is a feasible solution. And there’ll be a little competition to get the most tests. You have to decide if you’re going to use a saliva test, which has advantages and that you can take the saliva yourself at home, put it in a box, and mail it in. One university, Rutgers, is doing a really good job of being the testing agency. There are other groups who use the Rutgers testing agency and they do telehealth in order to make sure that the person who’s sending them the saliva is actually the owner of that saliva.

It’s a bigger problem for athletics than you would think. But it’s a bigger problem for everybody else. If you’re about to get your doctoral thesis approved and you have a little fever, human nature is not always as good as we think it is. But yeah, there are enough tests. You should get those tests now on campus.

What measures can campuses take to help prevent an outbreak?

You should have a source of masks. For everybody you should know the difference between a one-way mask and a two-way mask. Maybe you put your campus logo on a cloth mask, give them away, and nobody can be on campus without one. But that’s only going to protect other people from you.

There are some people who should be wearing a two-way mask, which is an N95, which is the medical version, or KN95, which is the non-medical version. Those will protect people from you and protect you from everybody else. And they’re really only good for 8 or 10 continuous hours of use. You can clean them, it’s a little bit more complicated. But you’re going to have a lot of tests on campus, a lot of these masks. You have to have testing. You have to have masks.

You have to have sanitizer. And you have to source all this.

Your health department or your medical school is going to have to be geared up to be the provider of these things to all students and faculty.

People are going to have to be trained on day one in social distancing. Six feet apart in a crowded area is the minimum. What we’re seeing now, if somebody’s coughing, it could be 12 or 13 feet. And you’re going to have to wash your hands.

If there’s a case of coronavirus on campus, what steps can institutions take to minimize the risk to everyone else?

The first thing is you have to isolate, quarantine, or hospitalize that case, depending on what their health status is. The second thing you have to do is called contact tracing, which is what we used to call good epidemiology—and that is to find out every place that person was for the previous two weeks, and every person who was in contact with that person, and where they’ve gone to. A contact-tracing system has several parts: human beings who ask the questions, digital add-on systems, which will be valuable on a campus because almost everyone will have smartphones, and then the connective tissue, which is a contact tracing system like Sales-force. We keep track of everyone, all the people who are sick in the hospital, who their contacts are.

One case doesn’t mean you have to close down the campus. But a couple might, so you want to stop it with one. If your campus has 10,000 students, then there are probably 50,000 people in the larger ecosystem. And that’s the art of case finding, detecting, testing, and contact tracing.

What triggers should universities look for to make the decision to switch back to remote learning?

First of all, I wouldn’t frame this in terms of sending students back home because implicit in sending them home is the fear that they have been exposed to a pandemic disease—and sending them home is an act of spreading that disease. So, the first thing I think about as an epidemiologist is, “they probably ought to be quarantined or sheltering-in-place.”

I am personally really worried that by the time we get to September, or whenever classes begin, this conversation will be moot. Because in many parts of the United States, the burden of disease will be so great even colleges that thought they were going to open up might not be able to do so. Of course, it may not happen that way, and I hope that doesn’t happen, but I’m looking at Georgia, Alabama, Mississippi, Louisiana, Arkansas, and parts of Texas that opened up prematurely and the disease there is doubling every couple of days. I’m looking at parts of Florida. I’m looking at parts of California, mostly in the Los Angeles area. There’s one spot or two in Kansas, around meatpacking factories. There’s places where there are campuses near jails that have outbreaks.

And New Jersey and New York have had a victory, but that doesn’t mean they’re still safe now because even if you take all of the people in the United States who’ve been exposed to COVID, and in theory have some immunity, we’re probably talking about 4 or 5 percent nationwide. And that is just people who have some immunoglobulins and antibody tests show that they had the disease. Probably only half of those people are really immune. So, we might be in a situation where 95 percent, 96 percent, or 97 percent of America is still susceptible to this virus.

Which means if the fire gets lit again, there’s not that much [we can do] to stop it. What we’ve done by social distancing and flattening the curve, we postponed well over 5 million cases in the United States. We only reported a little under 2 million. And all of the loss of life that goes along, we’ve saved that. But this has come at a great cost—35 million jobs lost.

With schools closed and all the cultural issues have come out of it, so now we’re thinking about how we can balance that and the pendulum right now is in favor of trying to open where we can. However, that opening is going to cast the seeds of its own destruction in places that were more eager to open than the science permitted back in April and May, and if I’m looking at those states today, I don’t see a reason to open them. We don’t have a single state that has fulfilled the very first criteria that CDC has right now, which is they have a declining number of cases every day for 14 days. The only place in [the United States] where that’s probably true right is in New York and New Jersey.

Those states are on the way to recovery. Whereas the rate of infection in every other state, even though it’s starting from a lower base, is going up. And this disease spreads exponentially. And while the exponent, that by which spreads are in the range of 2–2.5, there are certainly places that it spreads as if it had an exponent of 5, 6, 7, or 10. And the college experience has places like that. For example, think about a basketball arena, even more so than a football field, because it’s indoors. I don’t see how you can open up a basketball arena. You would have to re-engineer the seating. I just can’t even imagine colleges being able to afford that. Outdoors, yes. I can understand if you could sit with two or three seats in between each other.

Do you think that large systems like California State University that have said the majority of their classes will be online have made the right decision?

It’s the smartest route for a university system as large and complicated as that. There may be smaller systems with a higher ratio of staff, family, money, and resources [that could make a different decision]. I would like to see what the major universities that have great public health schools, like Michigan, Johns Hopkins, North Carolina, Harvard, are doing. Because they’re getting really good advice from people who know their campus really well.

What advice do you have for presidents and trustees as they navigate this uncertain and unprecedented public health crisis?

If you haven’t already done it, I would put together a task force with a minority of regents and the majority of scientists. It’s never too late. Identify people from the university who really should be on that task force and have them really customize a plan for your university. And be absolutely certain that you get it right. Because there are consequences. This is not like an athletic contest where we build your team and if you lose you just don’t go to a ballgame. This is a matter of, literally, life and death for a lot of people. And not even the people on your campus, but also the people to whom people on your campus take it back to.

Charlotte West is a freelance education reporter. Her work has appeared in the Hechinger Report, USA Today, the Washington Post, and International Educator, among others.